The National Service Framework for Children

Children and young people make up approximately a quarter of the total population. In England alone there are around 3 million children under 5 years of age, 6.4 million aged between 5–14 years and 3.1 million young people between 15–19 years (DoH, 2003a; DoH, 2003b). Out of these there are a total of:

• 600 000 live births a year.
• 400 000 children in need. 
• 59 700 children looked after by local authorities. 
• 320 000 disabled children. 
• Approximately 1 million children with mental health disorders.

The number of children and young people developing diabetes is increasing rapidly. Diabetes can affect children of all ages and effective management can increase life expectancy and reduce the risk of complications. Two of the 12 standards of the NSF for Diabetes (DoH, 2001) were specifically related to the clinical care of children and young people as illustrated in Figure 1. The Scottish Diabetes Framework identified similar issues to be addressed (Scottish Executive, 2002). One of the key action points related to the development of an educational video for children with diabetes and their families.

Background
The development of national level standards for children was announced by the Secretary of State for Health in response to the Bristol Royal Infirmary Inquiry in July 2001 (Kennedy, 2001). Kennedy found that children were treated as if they were simply mini-adults and that service providers failed to acknowledge their special needs. Facilities were designed with a lack of acknowledgement of the differing needs of children, older children, adolescents and parents. Staff who provided care lacked the appropriate training and skills to meet their differing needs.

The Department of Health established six external working groups in 2002 to lead the development of standards around the following key areas:

• Acute and hospital services. 
• Maternity services. 
• Vulnerable children and children in special circumstances. 
• Disabled children, including children with complex healthcare needs. 
• Mental health and emotional well-being. 
• Universal services, including health promotion and illness prevention.

Standards related to the care of the child in hospital were to be ‘fast-tracked’ and available by the end of 2002.

Scope of the NSF for Children
Unlike many of the other NSFs for England which are disease or condition specific, the full NSF for Children will cover all aspects of the healthcare of children and young people. (Standards for Wales are also currently being developed. Drafts are available at www.wales.nhs.uk/nsf). The breadth of the task is enormous. The NSF for Children covers from birth to a person’s nineteenth birthday, and encompasses interfaces with other services, including education.

Overall the aims of the NSF for Children are to:

• Improve the lives and health of children and young people.
• Improve their experience of and satisfaction with healthcare (DoH, 2003a; DoH, 2003b).

Every child comes into contact with healthcare and/or social care services at some point in their early life and these experiences can influence their attitude and the use they make of services throughout their lives. Nurses, midwives and health visitors therefore have an important role in the achievement of the standards and in the promotion of children’s and young people’s health and well-being.

The hospital standard
The hospital standard of the NSF for Children is the only standard that has been published so far. It is in three parts and applies to every department and service within a hospital that delivers care to children and young people, including accident and emergency department, outpatients and recovery areas. The three parts are child-centred hospital services, quality and safety of care provided and the quality of setting and environment.

Part one: child-centred hospital services
Part one focuses on the provision of integrated healthcare provision centred around the needs of children, young people and their families.

Part two: quality and safety of care provided
Part two emphasises that children and young people should receive high quality, evidence-based hospital care, which is appropriate for meeting their specific needs and delivered by staff who have the right knowledge base, expertise and skills.

Part three: quality of setting and environment
Part three ensures that children and young people receive care within an appropriate location and in an environment that is safe and appropriate to their age.

Three separate versions explaining the standards have been produced for children (8–11 years), young people (≥ 12 years) and parents. All hospitals are urged to introduce:

• Separate facilities for adolescents to ensure privacy and confidentiality.
• Designated play areas for children and recreational facilities for young people.
• The provision of education so that children do not fall behind in schooling when in hospital. 
• Dedicated children’s units in accident and emergency departments. 
• Specific menus to encourage children to eat while in hospital, encourage good eating habits, meet nutritional requirements and offer choices that are culturally appropriate.
• Security reviews to ensure that access to children’s wards and departments is limited.
• Training for all staff who come into contact with children and young people in hospital to ensure that all staff who treat and care for children have appropriate clinical and communication skills and are able to identify children with mental health problems.
• Written policies for managing pain in children and new-borns in neonatal units and a transition policy from children’s to adult service provision.
• Employment of play specialists within all areas where children and young people receive care and treatment

Emerging findings
The publication of the Hospital Standards (DoH, 2003a) was accompanied by the release of other documents, including Getting the right start: National Service Framework for Children – Emerging Findings (DoH, 2003b). The latter document highlights common themes and the direction of likely standards to be encompassed within the full NSF for Children. These include a focus upon:

• Prevention of ill-health and health promotion.
• Early identification and intervention. 
• Empowerment, self-management and family support.
• Child-centred care. 
• Transition and growing up. 
• Safeguarding.

Implications for diabetes services
People who provide care for children and young people with diabetes have to ensure that those accessing their services receive care in an appropriate and safe environment, whether on an inpatient or outpatient basis. Services for children and young people need to be provided by healthcare professionals who have had specific education and training. Support staff such as receptionists and porters working in areas that children access also need specific training, in aspects such as child protection and communication skills.

There will need to be an increase in the number of paediatric DSNs, as the full NSF for Children is likely to advocate an expanding role for such nurses, as well as an increasing proportion of care provision within the child’s own home or on an ambulatory basis. Admission for diagnosis and initial treatment is likely to become the exception rather than the norm, as is currently the case in some parts of the country.

Like the NSF for Diabetes, the NSF for Children emphasises the specific needs of young people. Standards encompass requirements related to the transition of young people to adult services. In the case of paediatric diabetes services there are already good examples of transition policies and young people’s clinics run jointly by paediatrics and adult services. However, these are not necessarily as widespread as they might be.

Conclusion
The development of the NSF for Children has focused on promoting health and preventing ill-health, as much as the provision of services for those who are ill. It will provide a policy focus so that services will be explicitly required to meet the specific needs of children and young people, as well as to ensure that staff treating them have the right training, knowledge and skills. The NSF for Children therefore offers a major opportunity to improve the lives and health of children and young people by developing effective, evidence-based and needs-led services. Local champions will be crucial to ensure that the standards are implemented at local level. Nurses have a key role to influence developments by ensuring that they become actively involved in local decision-making forums.