Birmingham Children's Hospital has improved services but further progress is required, according to regulator

Birmingham Children’s Hospital NHS Foundation Trust (BCH) has made significant improvements in the quality of some areas of specialist care, according to the Care Quality Commission (CQC)'s report published today .

The report examines the hospital’s progress in implementing recommendations made in March 2009 by the regulator’s predecessor, the Healthcare Commission. A review at that time found the trust was struggling to meet rising demands, resulting in delays in treatment, less than optimum care, and children being redirected to other services.

CQC completed its assessment of the progress made at the trust in November 2009. It commended improvements made in making services more accessible, creating and improving management systems, purchasing more equipment and recruiting and training additional staff. The remaining challenges to be faced are in managing long-term demand for services and ensuring that all local NHS bodies work together to provide the best possible specialist care for children, according to the regulator.

The trust had fully met six of the 12 recommendations made in March 2009 and had made progress in the remaining six. CQC commended the progress made in:

• Recommendation 5: Access to interventional radiology, a minimally invasive diagnostic procedure. Concerns were raised that poor access to these services meant children were undergoing more invasive procedures than necessary. The trust has now recruited two additional interventional radiology consultants and allocated more time for elective treatments. No open procedures have been performed when interventional radiology would have been more appropriate and the waiting time for treatment has decreased from over a year to six to ten weeks.
• Recommendation 6: Support for surgeons conducting urgent renal transplants and neurosurgery. This has included additional trained nurses available to work in theatres.
• Recommendation 7: Working with the University Hospitals Birmingham NHS Foundation Trust (UHB) to resolve concerns about lack of specialist equipment. Concerns were previously raised by consultants from UHB who carry out surgery at BCH. Additional equipment has been bought.
• Recommendation 9: Agreeing a clear plan to ensure craniofacial patients will be treated at the appropriate age and that any delays will be minimised. The trust checked its waiting list to give an up-to-date picture of numbers and waiting times, informing a workforce and capacity plan. The National Commissioning Group then agreed funding to clear the waiting list of 18 patients.
• Recommendation 10: Agreeing and clarifying the level of input the trust requires from UHB staff, enabling greater and formal involvement of its consultants in clinical governance and management structures at the trust. The trust is holding regular meetings with senior managers and clinicians where these arrangements are reviewed.
• Recommendation 11: Creating job plans and accounting for the time spent by UHB consultants at the trust. The trust has clarified and agreed with UHB the level of input it requires from UHB staff and job plans have been developed.

CQC also commended progress made in the following areas but said they still require improvement and will continue to be monitored:

• Recommendation 1: Monitoring demand and capacity for children’s services, including information about patients the trust has not been able to admit. The trust has recruited extra ward clerks to improve accuracy of its data, added indicators to its performance report and some individual specialities are collecting their own performance data. But at the time of assessment, the trust had not yet developed a system for collecting, aggregating and monitoring speciality and trust-wide data around unmet demand, including assessing delays in admissions.
• Recommendation 2: Reviewing strategies and policies to improve management of admissions and beds. The trust has a programme to improve its bed management and patient flow. While it has undertaken a range of initiatives, CQC has not yet seen sufficient evidence that the trust has improved its ability to admit neurosurgery and liver patients in a timely way.
• Recommendation 3: Managing demand and provision of services at the trust. The trust has involved NHS Interim Management and Support to better understand its capacity, demand and complexities around case mix, patient flows and length of stay. Regular meetings are now held between the trust and clinical leads to review demand and provision. But there remains concern that there is a shortage of beds in the neurosurgery ward.
• Recommendation 4: Reviewing the way the trust organises capacity and prioritises cases within theatres. To increase capacity, the trust is to build new theatre(s). But construction time means it could take up to two years before there’s more theatre space. Some surgery cases are being cancelled to allow urgent and emergency surgery cases timely access to theatres, but performance has recently improved with cancellations decreasing.
• Recommendation 8: Reviewing the arrangements for Hospital at Night with senior clinical staff to ensure any concerns are addressed. Specifically in relation to liver patients, consultants felt registrars would not be suitably familiar with these specialist conditions. Two additional surgeons and a fellow from the Royal College of Surgeons have been recruited. Most liver patients are now taken as surgical patients for the first three months, and thus subject to greater levels of observation.
• Recommendation 12: The trust and UHB agreeing and implementing a model of care for delivering high-quality paediatric services, in line with the requirements of the foundation trust regulator, Monitor. The trust, UHB and Monitor have agreed a set of outcomes that the two trusts will work towards. Progress on the action plan devised to lead to these outcomes is communicated to Monitor via monthly reports.

The review covers paediatrics tertiary care services in the specialty areas of renal transplant, liver transplant, craniofacial surgery, neurosurgery, interventional radiology and cardiac services.

Andrea Gordon, West Midlands regional director for CQC said:

“ Birmingham Children’s Hospital faces real challenges in meeting the rising demand for services. That's why it is so important for it to work effectively with neighbouring trusts to manage demand and ensure children receive urgent specialist care when they need it. There is no question that the trust has made significant progress, particularly in the way it works with University Hospitals Birmingham and in providing more staff for some specialist services. But there is more to do in managing capacity and improving the way it prioritises children needing urgent surgery.

We will continue to monitor the trust through our tough new registration system, which requires the NHS to meet essential standards of quality and safety. So far, we have been satisfied with the progress at Birmingham Children's Hospital and I want to be clear that we have not identified any breaches of the standards. This is about managing long-term demand for services and ensuring that all local NHS bodies work together to provide the best possible specialist care for children."

About the CareQuality Commission: The Care Quality Commission (CQC) is the independent regulator of all health and adult social care in England. The CareQuality Commission inspects health and adult social care services in England, whether they're provided by the NHS, local authorities, private companies or voluntary organisations. It also protects the interests of people detained under the Mental Health Act. (Until 31 March 2009, this work was carried out by the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection.)

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