Paediatric General Surgery Model of Care

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HMI
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The new Paediatric General Surgery: A model of care for Ireland 2024, for the sustainable delivery of paediatric general surgery in Ireland outlines a comprehensive framework to enhance surgical services for children close to where they live, ensuring access to a high standard of surgical care with clear oversight and governance.

CORE RECOMMENDATIONS BY PRIORITISATION

  1. All complex paediatric neonatal surgery should be performed in Children’s Health Ireland (CHI) hospitals.
  2. Children less than 1 year of age (or a minimum age agreed locally) should only have surgery in the Regional Paediatric Surgical Facilities (RPSFs) if the workforce, skills, and surgical volumes erre appropriate.
  3. Acute surgical admissions for children under 2 years of age can be under the care of either a general surgeon or a paediatrician. Admission policies and consultation arrangements must be clearly documented and agreed locally in line with this Model of Care guidelines.
  4. The national standard for paediatric surgery should be set at 2 years of age, where local surgical, medical, and nursing skill mix competencies are in place to ensure safety and equity of access.
  5. It will be necessary to provide General Paediatric Surgery (GPS) through the new Health Regions. Managed clinical networks will require additional paediatric surgeons to be appointed in CHI and appointed locally at the RPSF centres
  6. The staffing in RPSFs and Local Paediatric Surgical Facilities (LPSFs) must be appropriate to perform both the emergency and elective paediatric surgery as defined in their respective ‘bundle of cases’.
  7. Defined governance groups with designated lead surgeons and anaesthesiologists in GPS should be identified locally within Hospital Groups/Health Regions to oversee GPS care and must conduct regular multidisciplinary meetings with analysis and review of surgical outcomes.
  8. Each RPSF will need a minimum of two adult surgeons with a special interest in GPS.
  9. Clear clinical pathways are required in RPSFs with core paediatric surgery expertise in urological conditions, as available and agreed locally.
  10. Clear transfer pathways and guidelines between CHI, RPSFs and LPSFs must be in place to facilitate safe care and transfer in the event of unexpected complications. Senior clinicians must be closely involved in any pre-transfer stabilisation within managed clinical networks.
  11. As defined in this Model of Care, IT connectivity between CHI and the RPSFs and LPSFs require development to allow NIMIS and other data sharing, such as single EHR between units.
  12. Outreach network surgeons from the CHI will need to have regular and scheduled access for dedicated paediatric surgery clinics and day surgery in RPSFs.
  13. There will be a variable requirement for additional anaesthesiologists, paediatricians, radiology and interventional radiologists, quality assured laboratory services, paediatric emergency medicine consultants, paediatric sonographers, and nursing and health and social care professionals to support the development of GPS in each of the RPSF sites. These support services should be determined and agreed locally based on workload requirements.
  14. Emergency departments within RPSFs and associated LPSFs that treat children should have access to consultant-led paediatric emergency medicine (PEM) teams.
  15. RPSFs must identify GPS needs when appointing general surgeons to ensure each centre has an adequate number of surgeons with the required special interest in GPS. Such appointments should be highlighted in applications to the Consultant Application Advisory Committee (CAAC).
  16. Newly appointed surgeons with a commitment to GPS taking up posts in RPSFs will need to have undertaken GPS training in CHI of at least one year at Specialist Trainee Level 6 (ST6) or above or in an equivalent hospital abroad. Proleptic appointments should be enabled where necessary to support GPS posts.
  17. With the development of surgical services in the RPSFs, a significant portion of low acuity GPS should be redirected to the regions from CHI.
  18. Paediatric Regional High Dependency Units in RPSFs should be developed in keeping with the standards of care outlined in the Paediatric Model of Care.
  19. A HSE National Implementation Strategy will require a gap analysis to be conducted in each Health Region in order to establish whole time equivalents (WTE) and infrastructure requirements to support this Model of Care with oversight from a national accountability group.
  20. The key performance indicator suite should present a visual and easily understood means of presenting the activity in the hospital or health region and may include number of patients seen and within what timeframe, waiting lists, and average length of stay, readmission rates and morbidity and mortality outcomes.
  21. Each regional hospital undertaking GPS must have one designated lead anaesthesiologist who has a subspecialty interest in paediatric anaesthesia.
  22. For the transfer of the critically ill paediatric patient with time-sensitive surgical conditions, senior clinicians must always consider the logistics of transfer, as any delay needs to be balanced against the advantages/disadvantages of local or regional treatment.

Ireland would need to double the size of its Consultant Paediatric Surgical Workforce from 12 to 24 to meet the  British Association of Paediatric Surgeons (BAPS) recommendation of  a consultant workforce ratio of 2.4 per 100,000 paediatric population, according to the Model of Care for General Paediatric Surgery.

“Towards reaching this target, an expansion of the size of the consultant workforce to 17 by 2028 had been recommended by the National Doctors Training and Planning (NDTP).To reach this figure, five additional surgeons will need to be appointed in CHI to complement the current 12 WTE-funded posts.”