In this paper we identify and evaluate arguments for and against offering assisted reproductive technologies (ART), specifically IVF, to HIV discordant couples (male partner HIV positive, female partner HIV negative). The idea of offering ART to HIV discordant couples generates concerns about safety and public health and raises questions such as: what is an acceptable level of risk to offspring and should couples who want this assistance be subject to selection criteria; should they undergo scrutiny about their suitability as parents when those who are able to conceive naturally face no such scrutiny and people with other illnesses are given access to ART? We conclude that offering ART to HIV discordant couples is likely to produce more benefit than harm and violates no ethical principles. Nevertheless, a decision to deny treatment need not constitute unjustified discrimination.

AimsTo assess the value added to patient care by the input of the paediatrician following referral to a general paediatric outpatient department.MethodsThe authors received 200 general practitioner (GP) referral letters from the Primary Care Trust (PCT) over a 2-year period. The authors excluded letters to other hospitals and to non-medical specialties, such as paediatric surgery or ENT. A group of paediatricians reviewed both the referral letter and the return correspondence, and made a judgement on the relevance of the referral to hospital.Results70 pairs of letters were analysed. In 45, patient care was improved by referral to secondary care. In 25 it was felt the referral could have been avoided.The referrals which enhanced patient care: ▸ suspicion of serious underlying conditions▸ unclear diagnosis▸ treatment instituted by GP had not resolved the problem▸ further hospital investigation and management required However, there were instances in which improvements could be made: ▸ lack of information on the referral▸ incorrect diagnosis on the letter▸ referral being directed towards the wrong individual Other letters highlighted education and training issues: ▸ knowledge or confidence gap in the GPs' training▸ lack of confidence in treating children▸ lack of confidence by the GP in his own diagnosis This carries a cost implication—if 36% of the 1268 referrals to general paediatrics last year were potentially avoidable, this would represent a saving to the PCT of £110 000.ConclusionsThe authors advocate an integrated approach to healthcare for children in which GPs have easy and ready access to advice from paediatricians. There is a shortage of paediatric resources, partly due to different working patterns after the introduction of the European Working Time Directive. We must ensure the most appropriate use of scarce resources. With improved communication, the numbers of children requiring hospital review can be reduced. The authors feel that better links between primary and secondary care will improve patient satisfaction and GP education. In addition, parental confidence in GPs will increase as they become more confident in managing the child's condition. This will result in fewer avoidable referrals to secondary paediatrics.

IntroductionThere has been a recent shift in government policy towards ensuring that healthcare services for children are more child and family-centred. Ideally, any admission should be as short as possible, with aftercare supported by the “hospital at home” model. The authors studied the process of discharge in our unit to identify possible areas of avoidable delay and measures that may overcome them.MethodThe time and action course leading to a patient's discharge was process-mapped. Five domains were identified: ▸ discharge medication▸ completion of electronic discharge summary▸ patient reviews▸ patient transfers▸ bed being cleaned and prepared for the next patient. Data were collected 24 h per day, over 8 days, from the time decision was made to discharge (TDD).ResultsData on 34 discharges were collected to completion. The average time from TDD to the patient leaving the ward was 4.5 h, and 6.6 h for the patient's bed to become available for the next patient. Discharge medication took 3.3 h to organise. The family took 6 h to organise transport with 70% of patients waiting for this by their bedside. Only 53% of patient discharges were discussed and organised prior to the ward round, leading to trainees often leaving the ward round to coordinate discharges.DiscussionThis study has demonstrated multiple areas for improvement. We recommend that discharge should be discussed at admission. This will enable timely generation of discharge summaries and the families given an idea of potential discharge time so that they can make appropriate preparation. Dedicated discharge coordinators/nurses should join the ward round to ensure that the process runs seamlessly, and reduce the need for trainees to leave the ward round. Children requiring review should have a clear plan for discharge, which could be nurse-led. Every paediatric unit should identify waiting areas for children who have been cleared for discharge to ensure more efficient bed utilisation.ConclusionWith these measures in place, the new process-map of patient discharge generated 156 h of increased bed availability. This equates to almost an extra bed/cubicle per day, and could significantly reduce waiting times in A&E.