Published: 22/04/2002, Volume II4, No. 5902 Page 26 27

Play specialists are rapidly growing in number and credibility but are underpaid and often forced to raise their own funds, writes Ann Dix

Few would describe meeting accident and emergency waiting time targets as child's play. But the use of hospital play specialists at Leicester Royal Infirmary is helping the trust to meet its four-hour targets, say the hospital's A&E consultants.

Play is being used to calm waiting children, to give them information and help prepare them for procedures.

Play specialists are even offering children and their families support and assistance in the resuscitation room.

'They are helping us to meet our four-hour targets because everything can be done more quickly and easily, ' says Dr Ffion Davies, consultant in emergency medicine.

'If children are feeling happy, they will be more co-operative.'

For example, fewer children are sent back and forth because they are too stressed to undergo simple procedures such as x-rays.

So convinced were staff of the benefits that extra funding was provided two and a half years ago to increase the number of play specialists from 1.5 to 2.5 whole-time equivalents. The play service is now available from 10am to 10pm seven days a week.

A&E is one of the biggest growth areas for hospital play specialists, according to the National Association of Hospital Play Staff. But NAHPS chair Judy Walker, who is also play services manager at University of London College Hospitals trust, says the number of hospital play specialists is burgeoning in all areas.

Recently, the national service framework for children specified that the 'basic need for play' should be met for all children and their siblings attending hospital. It recommends that children staying in hospital have daily access to a play specialist and are offered play interventions at each stage of their journey through the hospital system.

It adds: 'Play may also be used for therapeutic purposes, as part of the child's care plan, and as a way of helping the child to: assimilate new information; adjust to and gain control over a potentially frightening environment; and prepare to cope with procedures and interventions. There is evidence that play hastens recovery, as well as reducing the need for interventions to be delivered under general anaesthesia.'

Judy Walker says: 'The need to give children the right information for them to understand and participate in treatment decisions - that whole area of informed consent - is now in fashion, precipitated, unfortunately, by the [heart babies scandal] events at Bristol'.

'Play specialists are trained to work with where the child is at in a particular moment in time, ' she adds.

And that might mean pitching information at the level of an eight-year-old for a 14-year-old teenager terrified at the thought of a hospital procedure.

But the news is not all good. A NAHPS survey back in 2000 showed most UK hospitals appearing to meet DoH recommendations at that time of one play specialist for every 10 children's beds. But, as Judy Walker points out, appearances may be misleading:

'The ratio looks very good on paper. But not all are fulltime and not all are qualified.'

Some posts are funded by charities, often on a temporary basis, and many have no cover for sickness or maternity leave.

While a snapshot survey by NAHPS last year showed an 11 per cent growth in UK posts in the past two years, feedback from local play managers suggested the increase needed to be nearer a third to meet requirements. The NSF will increase demand further, says Judy Walker, as it requires all hospital departments, not just children's wards, to give children access to play services.

To qualify, play specialists have to take a one-year diploma in hospital play specialism, on top of at least three years' experience of working with children and a qualification in an appropriate discipline, such as nursing, teaching or nursery nursing. They are also required to re-register every five years.

But as Ms Walker says, a national shortage of qualified play specialists is exacerbated by large variations in pay and conditions, with salaries that are frequently 'appalling' -£14,000 is not uncommon - and few opportunities for career development. Added to this, most play specialists are forced to 'operate on a shoestring', and have to raise their own funds to buy essential equipment.

But things may be set to change. NAHPS is working towards establishing a national pay scale under Agenda for Change, which Ms Walker says would result in about half of hospitals having to pay their play specialists more. Registration with the Health Professions Council is also on the cards - although it is probably 'about two years away'.

University Hospitals of Leicester trust, which has a children's hospital, gets around the shortage of qualified hospital play specialists by training its own.

This is relatively easy to achieve in a play department with nearly 30 staff and its own budget, says Tina Clegg, trust service manager for support services and projects. Salaries range from£12,000 for a trainee with recognised childcare qualifications, to£18,000 for a senior play specialist.

Ms Clegg, the trust's children's NSF lead, believes the framework will 'be the driver to increase staffing levels'.

Hospitals that do not have large play departments could link up with trusts such as Leicester to create coaching and mentoring opportunities for new recruits, she says.

Leicester also lays claim to the first community play service delivered by play specialists for children with life-threatening and degenerative conditions.

Dot Gillespie, service manager for the Diana Children's Community Services, says play specialists help children at home prepare for hospital admission and provide palliative care pre and post-bereavement for children and their siblings. The one-and-a-half wholetime equivalent posts are funded from Lottery money, and 'demand has been high', she says.

Ms Clegg would like to see community play services that include rehabilitation or transitional care for children leaving hospital. For children requiring frequent hospital admissions, 'there may be something we can do to keep them out of hospital longer, such as increasing compliance', she says.

Help could also be given to children who are fearful about going into hospital. 'We had one child post-September 11 who refused to come into hospital because they were frightened of being in a tower block, ' she says.

To contribute articles to HSJ 's clinical management section, please e-mail ann. dix@emap. com

Evidence base: reducing the need for general anaesthetic

Helping children get through painless but daunting hospital procedures without a general anaesthetic is one of the benefits claimed for play services.

This seems to be borne out at University of London College Hospitals trust, which employs a full-time play specialist in radiotherapy.The latest figures suggest a reduction in the number of children over four requiring a general anaesthetic for radiotherapy and for investigative procedures since employment of the play therapist in 2000.

Play specialist Rhonda Holden explains that children undergoing radiotherapy for a brain tumour have their face and often their whole head enclosed by a plastic mask that secures them to the bed.They must remain completely still and be alone in the room at the point of treatment, which is given every working day for six weeks.

The process is so daunting that many children cannot manage without a general anaesthetic, which often requires an overnight stay.Ms Holden works with the child at all stages, using books, photos and puppets to explain what is going to happen, to allow them to act out their anxieties.Children can take their puppets for a CT scan.

Key points

There is evidence that hospital play hastens children's recovery, increases compliance and reduces the need for general anaesthesia.

The children's national service framework recommends that all children in hospital have daily access to a play specialist.

A survey showed an 11 per cent rise in the number of play specialists in the past two years, but more are needed.