Paediatric General Surgery and Urology

Use the newly established Operational Delivery Network (ODN)-based model of care in children's surgery to ensure that all children requiring surgery are treated by experienced teams with the right infrastructure and support. a GIRFT to support NHS England and NHS Improvement in the development of a paediatric surgery service delivery model, which is informed by the findings in the GIRFT paediatric surgery report. b GIRFT to support NHS England and NHS Improvement to develop and implement ODNs across England, including defining KPIs and ensuring neonatal surgery is fully integrated with network governance processes. c NHS England and NHS Improvement, ODNs and trusts to work together to deliver the model of care, by ensuring: • Expertise and resources for children with the rarest surgical problems are concentrated into, indicatively, 10 centres; • Specialist centres managing less rare conditions are able to provide appropriate care for urgent conditions; • Staffing arrangements are in place to ensure common surgical emergencies can be managed promptly in local hospitals close to home.

Reduce the mortality rates in premature babies with necrotising enterocolitis by encouraging breast feeding, use of probiotic nutritional supplements and rapid surgical review of babies with suspected NEC. a Trusts to encourage maternal breast feeding for premature babies, drawing on evidence from the East of England Perinatal Network and elsewhere as helpful, with a view to maximising breast feeding/donor milk rate at discharge. b GIRFT and NHS England and NHS Improvement to develop plan aimed at provision of probiotic nutritional supplements in all neonatal units. In the interim, trusts are encouraged to expand use of supplements and share implementation experiences with GIRFT. c Trusts and Operational Delivery Networks to ensure rapid surgical review of babies with suspected necrotising enterocolitis.

Increase the use and scope of day case surgery in paediatric surgery and urology by taking action within trusts across Operational Delivery Networks (ODNs). a Trusts and Operational Delivery Networks should routinely monitor day case rates compared to their peers using Model Hospital/ GIRFT data to identify opportunities to increase day case rates. b Where opportunities appear to exist trusts and Operational Delivery Networks should identify local improvements, review variations in trust policies on day surgery, review how consistently trust policies are followed, and review list utilisation using theatre productivity data Monitoring day case theatre productivity to ensure efficient list utilisation. c GIRFT to work with professional bodies to review and establish any new or amended clinical guidance needed.

Improve the care of children requiring emergency paediatric surgery for appendicitis and testicular torsion. a NHS England and NHS Improvement, Royal College of Surgeons (RCS), Royal College of Paediatrics and Child Health (RCPCH), Royal College of Anaesthetists (RCA) and Royal College of Radiologists (RCR) to produce a model appendicectomy pathway which includes: • ED to diagnosis (ultrasound, assessment decision units) • preoperative care • surgery • postoperative care b Trusts and Operational Delivery Networks to reduce the incidence of negative (normal) and complex appendicectomy rate by employing shared care between paediatricians and surgeons and adopting the appendicectomy model. c GIRFT and Public Health England to investigate regional variation in the rates of complex appendicitis. d Operational Delivery Networks to review capacity as necessary to ensure that all boys with suspected testicular torsion are assessed promptly and treated close to home to reduce the incidence of testicular loss.

Reduce unnecessary surgical procedures through Operational Delivery Networks by applying evidence-based surgical decision-making. a Trusts and Operational Delivery Networks to continually review and improve surgical decision making, based on the priorities outlined in box A. b GIRFT and NHS England and NHS Improvement to consider paediatric procedures for inclusion in the Evidence Based Interventions Programme.

Provide patients with a clinic review if necessary, after routine low risk procedures, without requiring routine out-patient follow-up appointments. a Trusts and Operational Delivery Networks to review existing practice against this goal, and change processes as necessary, for the following procedures: circumcision, inguinal or umbilical herniotomy.

Drive improvements in patient outcomes by strengthening how clinical data is collected, shared and analysed. This includes exploiting innovations in health data analytics by using the National Clinical Improvement Programme to monitor outcomes at clinician, provider, network and national level. a GIRFT and specialist societies to review existing paediatric general and urology surgery registries and audits. Review to include understanding the gaps and barriers (eg; participation) and where data collected from HES can support monitoring of outcomes. b GIRFT, specialist societies and NHS England and NHS Improvement to develop a plan based on action a, which includes how NCIP can support in developing data tools in paediatric surgery and linking with existing data sources to drive improvements in outcomes. c Updated guidance to be sent to trusts and ODNs to support participation and advise on how the tools can enable continuous improvement.

Take steps to improve the environment of care for children and young people undergoing surgery. a Trusts and Operational Delivery Networks to review facilities compared to expectations for child-friendly environments as described or referenced in health building notes and children's RCS standards for children's surgery consider business case for any improvements apparent, and implement as appropriate.

Improve how we gather and respond to the experience of children and their families / carers while in hospital. a Review what mechanisms (including Friends & Families Test and CQC Children and Young Person's Inpatient and Day Case Survey), are available to enable the capturing of children, young people's, and their families/carers' experiences. b Based on action a, liaise with NICE, NHS England and NHS Improvement, ODNs and trusts to produce and implement a plan to enable the improvement in how we gain and use children's and their families' experience of care at hospital-level.

Ensure the children's voice is heard in hospitals by implementing ward to board representation of children's services, and by trusts active participation in Operational Delivery Networks. a Trusts to review their governance arrangements compared to the goals described by RCS Children's Surgical Forum, consider any possible improvements and implement as appropriate, sharing experiences in doing so with GIRFT. Operational Delivery Networks should also share experiences across trusts in the network. b GIRFT and NHS England and NHS Improvement to consider any further policy development based on action A.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and by sharing best practice. a GIRFT to use sources of procurement data, such as SCS and relevant clinical data, to identify optimum value for money procurement choices, considering both outcomes and cost/price. b GIRFT to identify opportunities for improved value for money, including the development of benchmarks and specifications. Locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes. c Trusts, STPs and GIRFT to use Category Towers to benchmark and evaluate products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs.

Reduce litigation costs by application of the GIRFT Programme's five-point plan. a Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts would have received this information in the GIRFT litigation data pack. b Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk. c Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support. d Claims should be triangulated with learning themes from complaints, inquests and serious untoward incidents (SUI) serious incidents (SI)/ patient safety incidents (PSI) and where a claim has not already been reviewed as SUI/SI/PSI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all frontline clinical staff in a structured format at departmental/directorate meetings (including multidisciplinary team meetings, morbidity and mortality meetings where appropriate). e Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT we will be asking national clinical leads and regional hub directors to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit.