Published: 30/09/2004, Volume II4, No. 5925 Page 12 13

Putting young people at the heart of health services was never going to be controversial, but a lack of targets could hinder the new framework for children, writes Alison Moore

'There is a remarkable consensus across the professions caring for children in hospital about the standards which should apply in the provision of children's healthcare. The problem lies in action, in translating the words into deeds.'

The determination of Professor (now Sir) Ian Kennedy to ensure that future generations of children were accorded a higher priority than those who went before is made clear in the 2001 Bristol inquiry report into children's heart surgery.

As he pointed out at the time: 'The chapter on children was written with some anger.'

But the central question - how to translate fine words into a change in behaviour - is now about to be tested. Earlier this month, the government's long-awaited national service framework for children, young people and maternity services was finally published.

But this is the second NSF to come without specific targets attached.And given that the move towards standards and away from targets is something that Sir Ian - now in his role as chair of the Healthcare Commission - has championed, it will be a crucial test of how far a framework without targets can create the action he so passionately demanded.

How high a priority will children's services be given when some of the biggest drivers of the NHS - targets, workforce shortages, legislation and financial pressures - have the potential to constrain improvement? And could targets for other services divert resources from an area without targets?

Even children's czar Professor Al Aynsley-Green says: 'We have very serious issues around workforce capacity.We do not have the numbers of nurses, doctors and therapists we would like.'

Key parts of the NSF, such as offering women choice in maternity services, depend on having the staff in place. Some trusts are not offering home births, for example, because of a shortage of midwives.

And paediatrics is one of the areas hardest hit by the European working-time directive restricting junior doctors' hours. This is causing some trusts to ask whether they need to reconfigure services to meet the directive - which could affect accessibility of maternity and children's services.

Maidstone and Tunbridge Wells trust, for example, is going out to consultation on how its services - currently largely offered at both of its locations - could be provided in the future.

Some of these problems are not restricted to the NHS but also affect potential partners in local government, such as shortages of appropriately qualified social workers, for example.

NHS Alliance chair Dr Michael Dixon points out that even targets which carry penalties for individuals and organisations are being missed.

'Targets are more likely to be met than standards simply because people's jobs depend on them being met, ' he says. 'But targets are blunt instruments... we are in the age of standards and we just need to see how it pans out.'

Professor Aynsley-Green believes the approach has a better chance of bringing about sustained development than a targetdriven one, but says the standards approach is difficult to get across in the service.

But will all this be enough to put the NSF up there on senior managers' 'must-do' lists - especially when it has to compete with such concrete targets as reduced waiting times and patient choice?

Professor Aynsley-Green admits that services may remain patchy during the 10-year life of the NSF, although he hopes that all services will improve from the current baseline.

National Children's Bureau chief executive Paul Ennals also sees a gap enduring between the better primary care trusts and local authorities and the 'lousy' ones that will struggle, even years down the line, to reach the standards outlined in the NSF.

There is a need for it to be translated into a vigorous performance protocol by the inspection bodies in health, social care and education, and for all involved to see it as more than 'just' a health document, he says.

Royal College of Paediatrics and Child Health vice-president Simon Lenton says: 'I think a lot of people were expecting a 3-D model. It is almost like the NSF is a building specification plan: 'We want to do this'. It is not a blueprint of the building.'

Professor Aynsley-Green points out there are still some targets - for example, to do with the establishment of child and adolescent mental health services which are meant to be 'comprehensive' by 2006. But the emphasis on standards instantly puts a lot of power into the hands of the Healthcare Commission, which is likely to look at how such standards are being met as part of its inspection process.

It is already working on this.

Head of children's strategy Kathryn Tyson says: 'NSFs and National Institute for Clinical Excellence guidelines will be some of the key specifiers of standards of service. We will expect to use them and we will expect to find that trusts are using them.'

The NSF - which is a joint document between the Department of Health and the Department for Education and Skills - also moves away from an approach that looks at one organisation and says what it needs to do, towards a 'pathways' approach tracking children's journeys through the NHS, social care and education. It might measure progress across all these services.

This raises the question of whether it is pathways and the way they work that should be quality assured rather than specific services - and, if so, how the different regulatory bodies can work together. The Healthcare Commission is already meeting with other regulators affecting children to look at this process.

No-one questions the underlying principles of the NSF - although a few murmur they are a bit too much 'motherhood and apple pie' - but putting children's services high up the agenda seems challenging.

Dr Dixon says PCTs are already grappling with a wide agenda, including such controversial subjects as out-of-hours provision, but he has no doubt PCTs will be behind the thrust of the NSF.

In some respects, the evidence so far is not encouraging; despite the requirement in the hospital section of the NSF - published well over a year ago - for PCTs, strategic health authorities and trusts to appoint a senior member of staff responsible for children's services, not all have done so.

Professor Aynsley-Green is impressed with what SHAs have done - he has visited every SHA area and around 350 NHS organisations - but says there have been great difficulties among PCTs, where children's leads may be too junior or have children's services as one part of a wide portfolio.

And he freely admits children's services need to be pushed up the agenda. 'There is a major lack of understanding of children's services in the minds of people who matter. I have been to places where neither the chair nor chief executive have ever been seen in children's services.'

At a recent accident and emergency conference, for example, he asked who had read the hospital section of the NSF. Out of 500 people, only a handful indicated they had.

Getting the NSF read and understood beyond traditional 'children's services' so its effects are felt throughout the hospital is vital. He wants to see chief executives and trust boards actively involved - and staff demanding that the issues are addressed.

The Healthcare Commission is already piloting work on how the hospital NSF - published nearly 18 months ago - is affecting services.Kathryn Tyson says it has had 'a slow-burn effect'. 'Most places we are going to now are saying: 'We use this, that or the other benchmarking tool and we have drawn up a plan where we have identified our priorities'.'

A key player in much of this should be children's trusts. But while ministers are thought still to be committed to the idea of a children's trust in every area, its format may be changing. Increasingly the talk is of them as commissioners of services rather than of having a role in delivery - and of them not needing a massive structure to fulfil this.

Paul Ennals describes this as 'an approach rather than a legal entity'. Government guidance on children's trusts is due shortly; it may include a longer timescale for the setting up of such trusts rather than the swift roll-out to all areas as was first envisaged.

There is still much suspicion of children's trusts on the ground, with some critics unhappy at any attempts to hive off children's commissioning from the general commissioning done by PCTs.

So will the healthcare of children shift fundamentally? Professor Aynsley-Green admits to a long list of potential obstacles but remains optimistic: 'We have the best chance for 50 years to make it better. There is no plan B.'

How the NSF was born Britain may have had a health service for over half a century but children's services have often been treated as an 'add on' to adult services rather than being based around the child.

There has been growing recognition both of the difference in health needs between adults and children, and that many of the long-term factors affecting health can be influenced for good or ill in childhood.

But this recognition might not have led to dramatic changes had it not been for two reports that Professor Aynsley-Green describes as 'cataclysmic'.

The Bristol inquiry - which looked not just at the specific treatment of children with heart problems in Bristol but also at wider issues around children's treatment - put children's health at the centre of the agenda. It also raised the tricky question of how children's services could be both local and accessible, and also expert.But the Laming report into the death of Victoria Climbié showed that the failure of agencies to share information and talk together could also have tragic consequences - and highlighted the point that children were rarely asked for their views or stories.