The Bristol affair has raised, yet again, the question of how best to provide specialist care for ill children. So will it lead to a reconfiguration of children's services?
Should a child with a rare illness be treated close to home by a paediatrician with a limited knowledge of their condition, or 100 miles away in a centre of excellence by an acknowledged specialist?
That is the sort of tricky question underlying the reconfiguration of children's health services - and one which politicians are understandably reluctant to debate.
For every clinical voice arguing for a smaller number of specialist centres, there are many voters calling for 'local' services - most evidently when retired doctor Richard Taylor was elected as the MP for Wyre Forest on a 'save local hospital services' platform.
'We have consumer expectations that they should have easy access to high-quality services on their doorstep, ' says Sue Burr, Royal College of Nursing paediatric nursing adviser. 'Our first concern is the interests of the child - which means that in some cases, units will have to close and some will have to become a different kind of service.'
Dr Keith Dodd, the Royal College of Paediatrics and Child Health's health services committee chair and a consultant at Derbyshire Children's hospital, argues the Bristol affair has focused attention on ensuring children are cared for in an appropriate setting by paediatric specialists.
'Inevitably, that will mean a degree of centralisation at the highly specialist end of the service and also in secondary services, ' he says. 'I think that various pressures, not least quality and safety, lead to more centralised services.
'If you are looking after children who have had major surgery, not only do you need paediatric intensive care but also neurological services and nephrology - There is a lot of work going on at the moment to achieve that degree of coterminosity.'
The ideal is likely to be tertiary specialist services concentrated in a small number of centres, where expert diagnosis and treatment is on hand. The government has already set up a committee to look specifically at paediatric cardiac surgery, and it is in this area that the process may start.
But it is not always easy just to strip out one specialist service from a children's unit. Removing, for example, paediatric cardiac surgery can affect the viability of other services, especially paediatric intensive care, as Professor Bob Anderson, president of the British Paediatric Cardiac Association, points out.
'The feeling in the profession is that there should be five or six centres for paediatric cardiology - at the moment there are 13 centres in England and Wales, ' he says.
'The impact this would have is colossal.My own belief is that the case for centralisation is overwhelming, but those working in the peripheral centres are not convinced that centralisation will bring advantages.'
In some specialties, the changes may be more dramatic. Sir Barry Jackson, president of the Royal College of Surgeons, expects high-risk surgical procedures to be carried out in regional centres in an acceleration of a trend which is already happening. In some specialties, this concentration could have significant effects:
he suggests that cleft lip and palate surgery will eventually be carried out in around a dozen centres rather than the 70 that do it now.
But these changes are not without their opponents. Sue Burr believes some surgeons are fighting a rearguard action to keep cleft lip and palate surgery in their centres. 'They do not see why they can't do two a year, ' she says.
And although it is generally accepted that success rates for procedures to correct biliary atresia are far higher in some centres than others, there are a number of middle-ranking centres which have argued their results are close to those of the 'leading edge'.
Preserving surgery in their centres allows more local and convenient care for some children - but is this at an acceptable cost in terms of outcomes?
One answer may be specialist children's hospitals, though not necessarily stand-alone centres.
There has certainly been a renaissance in children's hospitals - Bristol has a newly built one and there are plans in the pipeline in Manchester and Birmingham. But most have been built beside large district general hospitals so facilities and support services can be shared. This not only reduces the cost but allows access to a full range of departments and equipment.
Whatever happens, one important factor is likely to be workforce - the availability of specialist paediatricians, surgeons who specialise in children, and paediatric nurses. The reduction in junior doctors' hours - and the move from rota systems to shifts - is probably helping the argument for centralisation. A reduction in the number of paediatric specialist registrars could also affect cover. If specialist staff are in short supply, concentrating them in a large unit or specialist hospital may make better use of them.
'Five or six years ago, you could run a registrar tier with three doctors. Now you are looking at five - and six-and-a-half if you want to meet the European working-hours directive, ' says Dr Dodd. 'It is workforce limitation which is going to run the configuration of the NHS.'
This has already been seen in Accident and Emergency, where government money has enabled special facilities for children to be set up at some hospitals.However, staffing has been problematic - such units need nurses with paediatric experience and A&E doctors with an interest in children's problems - and in some cases, the units have not been kept fully open.
There has also been increasing specialisation among surgeons, so children are likely to be treated by, for example, an ophthamologist or an orthopaedic surgeon who concentrates on paediatric work.
But if DGHs will not be doing complex and uncommon surgery, what will their role be? The Royal College of Paediatrics sees one option as a dissolving of barriers between primary and secondary care, with GPs who have an interest in paediatrics working alongside consultant paediatricians in community-based polyclinics.
Primary care trusts may take a bigger role in running paediatric services - possibly as a community-based service with admitting rights to hospital wards.
Huntingdonshire PCT is consulting on plans to run children and young people's services in its area. The setting up of care trusts could push this process forward, and allow for better co-ordination between health and social services.
DGHs would still have a role in treating paediatric inpatients - but perhaps far fewer. Better community services - especially nursing - could reduce admissions.Dr Dodd points out that only around 15 per cent of paediatric patients need high-dependency nursing.
'What we should be moving towards is that they should only be admitted if they are likely to need high-dependency care, ' he says.
Sue Burr sees what is perhaps a brighter future for children's services in DGHs where they work more closely with tertiary centres, perhaps providing shared care to common protocols, paediatric nurses have training sessions in the tertiary centre and there is a general sharing of skills and information.
This already happens to some extent in paediatric oncology, where children may visit the tertiary unit when first diagnosed but much of their care may be closer to home - or even at home. 'If we set up managed networks, then we would have the benefits of the expertise of tertiary units, with the added benefit that DGHs would not feel out on a limb, ' she says.
Change will probably take years:
some impetus may be provided by the national service framework for children's services which the government is currently developing, and by the modernisation taskforce which is looking at children's services. Bristol will give the process some momentum - but in the long run, workforce considerations may be more important.
The future of children's services:
The Bristol inquiry report calls for a national director of children's healthcare services. Health secretary Alan Milburn has appointed Professor Al Aynsley-Green, Nuffield professor of child health at London University and director of clinical research and development for the Institute of Child Health and Great Ormond Street Hospital.
He is president of the Association of Clinical Professors of Paediatrics, and in January was appointed chair of the NHS children's taskforce charged to implement the NHS plan and create a national service framework for children.
The report asks for consideration to be given to the creation of an office of children's commissioner in England, with the role of promoting the rights of children in all areas of public policy.
It wants the national service framework for children to be implemented as a matter of urgency.Mr Milburn has told the Commons that standards for children, including children with congenital heart disease, will be ready next year.
The report suggests children's acute hospital services should ideally be located in a children's hospital, which should be physically as close as possible to an acute general hospital.In the case of existing free-standing children's hospitals, particular attention must be paid to ensuring that children have access to 'facilities which may not routinely be found in a children's hospital'and specialists.
The report continues: 'Consideration should be given to piloting the introduction of a system whereby children's hospitals take over the running of the children's acute and community services throughout a geographical area.
'Children should always (save in exceptional circumstances such as emergencies) be cared for in a paediatric environment.
'National standards for care and the treatment of children with congenital heart disease should stipulate the minimum number of procedures that must be performed in a hospital over a given period of time.Paediatric cardiac surgery must not be undertaken in hospitals that do not meet this minimum.'
The report suggests surgeons should undertake a minimum of four sessions a week if performing in this area.
It calls for an investigation, as a matter of urgency, to ensure that paediatric cardiac surgery is not being carried out where the low volume of patients, or other factors, make it unsafe to perform such surgery.