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`... it is manifestly the case that children should be looked after by children-trained staff ... we have to break through barriers of small people needing fewer staff to the understanding that these are whole-time people, these children and babies, who require whole-time staff and the sicker they are, the more complex the health care techniques, the more dedicated completely preoccupied attention [is needed] from the nursing staff attending, therefore the more are needed in the whole staff of the hospital and that produces tremendous difficulties, both in having the budget to employ the staff, but downstream or upstream to have enough nurses coming through that training.' 
47 The acceptance that children are distinct from adults requires, in turn, the acceptance of the need for the care of children to be provided by appropriately trained staff. We have said this already. What this means is that all healthcare staff who treat children must have training in caring for children. This is especially so in relation to paediatric intensive care. For nursing in acute hospitals, there are very clear standards as to the number of nurses trained in the care of children who should be available: they are set down by the DoH in its 1991 guidance. The standards require that at least two Registered Sick Children's Nurses (RSCNs) (or nurses who have completed the child branch of Project 2000) be on duty 24 hours a day in all children's departments and wards in the hospital and that there be an RSCN available 24 hours a day to advise on the nursing of children in other departments. These standards should serve as the minimum standards and should apply where children are treated (save in emergencies) to take account of changing patterns in the provision of acute healthcare services. We also believe, however, that the standards should be reviewed as a matter of urgency.
48 According to a recent RCN survey of acute healthcare provision for children, around seven in ten trusts met the DoH's standard for the level of paediatric nursing.  Those trusts which did not meet the standard mentioned cover for night duty as a particular difficulty. We were told that, although there is no shortage of people applying to qualify as children's nurses, there is a pressing need for well-trained and highly-skilled nurses to cope with the growth in paediatric sub-specialties, which are amongst the most technologically advanced and labour intensive areas of nursing. We were also told that turnover among staff often leads to a lack of continuity of staff with the appropriate level of knowledge and expertise.
49 As with nursing so with medicine and surgery, there is no place in the NHS of today for occasional paediatric practice. Children deserve better. We are convinced from the experience of Bristol that all doctors who treat children, both in hospital and in primary care, should receive appropriate training and continuing professional development in paediatrics.
50 In terms of surgery, in the light of what we have previously said about the particular characteristics and needs of children, we believe that surgery, of whatever type, on children should be a sub-specialty, carried out by designated surgeons who have undergone appropriate training. This is not to say that there is no scope for mixed adult-paediatric practice. To argue this would be impractical and, in any event, there is no strong evidence to suggest that a mixed practice in itself is unsafe. Moreover, it ignores the fact that children grow up and, to the extent that they need further surgery, the paediatric cardiac surgeon, for example, familiar with responding to congenital heart defects must be able to care for them. What matters is that surgeons who operate on children, no matter that they also operate on adults, must be trained to care for children, and they must undertake sufficient operations on children to maintain their skills. The report of the Paediatric Forum of the Royal College of Surgeons of England recommends specific paediatric training for all surgeons who operate on children. It suggests that a minimum of one paediatric operating session  a fortnight be performed. We endorse the principle underlying this proposal: that there must be a minimum level of regular operating sessions. We doubt, however, that it is advisable to have a generic minimum level: the minimum level is likely to vary according to the particular paediatric surgical specialty. As a matter of priority, the GMC, the body responsible for the revalidation of doctors, should agree with the Royal College of Surgeons of England the appropriate number and range of procedures which surgeons who operate on children must undertake to retain their validation. Some areas of expertise may require more sessions than others. In the case of PCS, based on our experience of events in Bristol, we believe that one session a fortnight is probably too infrequent an engagement with children to maintain competence. While we do not stipulate the required number of sessions we are persuaded that an average of four sessions a week should be the minimum number required. Clearly this must be agreed as part of the process of revalidation as a matter of urgency. We express no view as to whether this should also apply to other paediatric surgical specialties. We recognise, however, that, over time, implementing this approach is likely to have consequences for the way in which general surgery on children is organised.
51 As regards medical care, clearly what was said about the surgeon applies also to the anaesthetist and others: if they are to care for children they must be trained to do so and periodically demonstrate that they have maintained their skills. And there must be enough of them. It may also be appropriate here to point out that with the growing influence of primary care groups and trusts, there is a strong case for saying that the expertise of GPs in paediatric care could be improved. A number (two or three) of GPs on a primary care trust (PCT) should be required to undergo additional professional training (with appropriate support) in paediatrics and then become the `children's experts' within the PCT. This would take us a step further towards integrating children's healthcare into all aspects of the health service. A still further step which we recommend is that each health authority and primary care group/trust should designate a senior member of staff to have responsibility for commissioning children's healthcare services locally.
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 Royal College of Nursing. `Children's Services: Acute Health Care Provision'. London: RCN, June 1999
 We take the term `session' to mean half of a working day