The Pharmaceutical Journal
Vol 270 No 7245 p539-540
19 April 2003

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Starting out right: the Children's NSF

The first part of the National Service Framework for Children has now been published. Clare Bellingham (on the staff of The Journal) finds out what it says

Related websites
Children's National Service Framework (more)

CHILD-CENTRED care is the catchphrase of the new National Service Framework (NSF) for Children which was published on 10 April. It is not the entire document: so far, the standards expected in hospitals have been set and a consultation document called "Emerging findings" has been published. It outlines the "direction of travel" that will be taken in the final NSF. Publication of the remainder of the framework — called "Getting the right start: NSF for Children" — is not expected until winter 2003/04.

The NSF adheres to the Government's aim of designing services around people who use them rather than around the organisations that provide them. "This NSF is crafted around the journeys that children take, through life as they grow up, and through services when they are ill, injured or vulnerable," this first part states.

Sharon Conroy, chairwoman of the Neonatal and Paediatric Pharmacists Group, comments: "It is a positive document in terms of children and their care. The NPPG wholeheartedly supports its aims of improving services, tackling inequalities and enhancing partnerships." She adds that it is good for pharmacy in that both the use of medicines and the role of pharmacists are acknowledged.

Why is an NSF for children needed? The hospital standard explains that children are healthier than ever before. But this is marred by health inequalities across different ethnic groups, different geographical areas, different neighbourhoods and differences in income. Furthermore, children are different from adults, so "they need distinct and tailored services". It is not just the physiology and range of diseases and disorders that differ in children. Children's level of understanding and their vulnerability is different, as is their legal status in terms of consenting to treatment. And this is something that perhaps has not been recognised in the past.

It is clear that lessons from the Kennedy report, including making the distinction between the needs of adults and children, were influential in the production of the NSF for Children. Pharmacists at Bristol today highlight this. Steve Brown, director of pharmacy services at the Bristol Royal Infirmary, comments: "We need to recognise the special needs children have and not treat them as mini-adults. They are a high-risk group of patients so the challenges for pharmacy are significant."

Hospital standards

One of the reasons the standards for hospital services were published in advance of the rest of the Children's NSF is the fact that it aims to meet the Government's commitment to the Kennedy report. Standards of care for children in other settings will be covered in the full NSF.

The over-arching hospital standard is: "To deliver hospital services that meet the needs of children, young people and their parents, and provide effective and safe care, through appropriately trained and skilled staff working in suitable, child-friendly, and safe environments." This applies to every department within a hospital that delivers a service to children, including pharmacy.

The standards document covers design and delivery of hospital services for children, safety of children while in hospital, quality of services for children in hospital and suitability of hospital settings to meet children's needs.

Emerging findings

The NSF "Emerging findings" report is a consultation document and comments can be made on it until mid-July. The Department of Health says that it was published both to seek views and to help with local planning in advance of the full NSF. It is likely to give a fairly accurate picture of what the eventual NSF will contain.

The NSF will have three aims (see also Panel left):

1. To improve services

2. To tackle inequalities

3. To enhance partnership.

Steve Brown comments: "A number of key themes from the Kennedy report are clearly reflected in the NSF for Children. These include putting patients at the centre of health care delivery, investing in staff, improving children's health care services, ensuring the safety of care, and including the public in decision making in the NHS."

The hospital standards recognise the fact that many children have conditions that require a range of services across specialty boundaries. This includes pharmacy services. Such services need to have "robust arrangements for timely access" to care when it is needed, the document adds.

Medicine use

Both NSF documents tackle use of medicine in children. This is clearly an area of priority for pharmacists, particularly in terms of changing practice to meet the standards set by the NSF.

Dr Ian Wong, director of the Centre for Paediatric Pharmacy Research in London, comments: "The NSF takes a significant step towards facing the challenge of medicine use in children." He notes that the NSF reinforces recommendations of the EU document "Better medicines for children" to increase the range of licensed products for children. "The NSF gives great responsibilities and challenges to pharmacists, and I believe the pharmacy profession is ready to take up these challenges," he says.

The final NSF is expected to include advice on how to manage medicines effectively for children. Medication reviews are recognised as a method to ensure optimal use of medicines. The document suggests: "The introduction of supplementary prescribing by pharmacists and nurses will provide greater flexibility, improved access and overcome some of the barriers that currently exist in the provision of holistic care to children. Appropriate use of patient group directions can also be helpful."

A major issue identified in "Emerging findings" is use of medicines prescribed for children that are "off-label" or unlicensed. Such use results from situations where a manufacturer has not applied for a licence for use of a medicine in children or where there are insufficient data about safe and effective use in children. "This is recognised as being an unsatisfactory state of affairs and steps are being taken to increase the range of products and formulations which carry licence for use in children across the age ranges," the document states.

Ms Conroy says: "Personally, I think these documents show a shift in the Government's attitude towards use of unlicensed medicine. It first recognised the problem in 1997 but laid the issue firmly at the door of the pharmaceutical industry. Now it is accepting that it carries some responsibility to address the problem and this is welcome."

The hospital standard covers this issue in more depth. It says that a variety of steps are being taken to tackle the problem. But "in the meantime, the use of unlicensed and off-label medicines has particular implications for clinical governance", the document says. "Standard information leaflets packaged with the medicine may not cover its use in children which can be a potential source of confusion. Using a medicine designed for use in adults may mean that very small amounts must be measured, or the medicine has to be diluted, adding to the potential for error." It goes on to highlight the role pharmacists have in this area. "Pharmacists should, when handing out medicines for children, reassure parents and children about the contents of the accompanying patient information leaflet produced by the manufacturer. It is important that clinicians and parents have appropriate information about these medicines and that hospital trusts have a policy covering their use." Ms Conroy adds that there is a need for proper parent- and child-focused information leaflets.

Partners in decisions

Concordance is a priority. First, there is the problem of children who do not want to take a medicine. "It is important that medicines are available in the most suitable, and palatable, formulation," the document says. Children may also find it difficult to take a medicine as prescribed. "Involving parents, carers and children in decisions about their medicines and supporting them to take their medicines effectively could have considerable benefits for improving their health," it suggests. The NSF will also consider when it becomes appropriate for the responsibility for taking a medicine to be transferred from parents to children.

"Children should be active partners in decisions," says Ms Conroy. "For instance, some children prefer tablets to a foul tasting liquid." She suggests that giving them the choice can improve compliance.

On top of concordance, there is also the issue of how appropriate a medicine is. It is hoped that children's medicines will be underpinned by the best possible evidence for their use. The hospital standard states: "The use of medicines in children should be guided by the best available evidence of clinical effectiveness, cost effectiveness, and safety, ideally derived from clinical trials conducted with children." It is because clinical trials tend not to be conducted in children that off-label use is a problem.

Information provision will also be key. "Emerging findings" recognises the pharmacist's role in this area and promises the NSF will explore ways to extend it. "The community pharmacist who sees well and unwell children and provides easy access to advice on self-care, minor ailments, and over-the-counter and prescription medicines has a valuable role to play in empowering parents of chronically ill children to help them administer their medicines effectively," it states. "Their role in providing advice on healthy lifestyles, responding to symptoms, differentiating major disease versus minor illness and when to refer to a GP, is important as they are often the first point of contact for ill children; the NSF will evaluate how this role can be enhanced."

The use of medicines in schools is a substantial problem, but one where pharmacists can ease the difficulties. For example, Ms Conroy suggests pharmacists could dispense mid-day doses in a separate, well-labelled container for the child to take to school.

She also points out that better communication between hospital and community pharmacists could solve some problems. For example, hospital pharmacists could telephone a community colleague and tell him or her what to expect when a patient is discharged, particularly in cases where the child has been prescribed unfamiliar extemporaneous preparations. All it takes is asking the family which pharmacy they plan to go to.

The hospital standards set out areas where "safe medicines practice" policies are needed. These include:

• A need for sufficiently trained pharmacy staff to cater for children's needs, to ensure medicines are managed effectively and to play an active role in the multidisciplinary team caring for children

• Central preparation in controlled conditions in the pharmacy of intravenous formulations for children

• Reporting and monitoring of medication errors

• Controls assurance standards relating to the specific needs of children

• Ensuring the formulation of medicines is appropriate to the age and ability of the child

The NSF sets out a large number of changes. These will not happen overnight, but they will happen, so pharmacists need to be prepared for them.

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