RCPCH news Royal College of Paediatrics and Child Health
Leading the way in children’s health
Taking a closer look: Research special 8
4 New groups for Academic Paediatrics and Young People’s Health 5 Article 14 update 6 Comparing Modelling the Future and Our NHS Our Future 7 Spring Meeting 2008: PREVIEW
Examples of research involving the RCPCH, relevant to everyday practice
13 Exams: “Fit for Purpose” 14 News for Trainees
Editorials Winter 2007
In the news 4 New voice for Academic Paediatrics Young People’s Health – a new Special Interest Group for the RCPCH 5 Application for CESR under Article 14 UNCRC training day Palestine programme 6 Comparing Modelling the Future and Our NHS, Our Future 7 Spring Meeting 2008: Preview 8&9 Research Special: Helping paediatricians to practice evidence based paediatrics 12 SASG News The effects of cancer treatment on reproductive functions: Guidance on management Workforce Census 2007 13 Exams: “Fit for Purpose” Advocacy Committee News 14 Trainees’ column 15 Media update Meetings
From the Registrar “I had been told that the training procedure with cats was difficult. It's not. Mine had me trained in two days.” BILL DANA
It was a Saturday night, two months into my gynae SHO job, and well before induction for junior doctors had been invented! There had been a riot on a local estate, and within minutes almost every doctor in the hospital had converged on A&E, without the slightest clue what to do. The surgical registrar seized the initiative and began emptying the general surgery ward onto the ENT ward to make space for incoming casualties. If only he had known that the ENT ward was the designated major incident receiving area! The Senior Nurse – the one person who did know what to do – was completely bemused; as fast as she cleared ENT, the beds refilled with a mysterious stream of displaced and irritable post-op patients. Fortunately there were few real casualties to treat. Within an hour a cocktail party atmosphere had supervened in A&E, as 40 doctors and nurses stood chatting over coffee and sandwiches, watching an unseemly fight between the surgical and A&E consultants over who should be wearing the Major Incident Officer tabard. Traditionally, doctors have never been terribly good at systems and processes. To make matters worse, junior doctors move rapidly, and need constant induction into local policies. So it is at the College. Officers come and go, but the staff remain, and must hold the continuity and organisational knowledge. Someone recently asked me whether the staff have the same passion as the doctors – who after all are the ones with the ‘sharp end’ experience. I believe they do – but it is a different kind of passion, driven by a focused engagement in their particular area of expertise – be that publications, training, finance, research or a host of other functions. We have a great staff team – some with interesting degrees, others with direct health service experience,
and still others who are parents or service users. They bring a different and sometimes more objective view, which we meld with our own experience, and that of our lay group and newly formed Youth Advisory Panel. All these perspectives coalesce to help us deliver the strategy set by Council. One danger for complex organisations is that departments can slip into silo working. So what happens when we are dealing with cross-cutting themes like obesity or child protection – or when there are advances in the management of diabetes or sickle cell disease? We need to ensure that these are built into our curriculum, exams and CPD programmes, that guidelines reflect latest evidence, and that we adapt policy and standards accordingly. The officers do their best to make these connections, but they are not in the College every day, so communication can be difficult. As you know, we will shortly have a new College building. This will bring our staff onto one site, provide a modern open-plan environment, and help them to work together more effectively to facilitate these important links. This will be my last Registrar’s column since I will shortly be demitting office to take up post as the first Head of the London School of Paediatrics, which is a joint Deanery-College appointment. It has been a particular privilege to work as Registrar to an extraordinary and very special College President, as well as with a fantastic team of officers and colleagues across many committees. I will look forward to continuing to work with many of them in my new capacity. I end with a very fond note of thanks to the staff - confident that the transition will be seamless and they will have my successor whipped into shape in no time at all.
Hilary Cass RCPCH REGISTRAR
Editorials From the President I have bought and sold a few properties in London over the years, and have found that there are infallible rules. Firstly, you begin to despair; secondly, as soon as you find somewhere and commit yourself to it, the property market stalls and/or mortgage rates rise precipitately. The survey then comes back saying how remarkable it is that the property had not fallen down years ago and the buyer you thought you had for your own place, having finally decided they can overcome your taste in decoration, discovers that the house is sitting immediately above the Northern Line. All these things and more happened in our recent building transaction but were resolved. The toll on my blood pressure and gastric epithelium has been considerable, but we are all relieved not to be pouring money away in rent – and not under threat of being on the streets when various leases end. Finally, we exchanged contracts – and can start the equally stressful but also exciting process of moving. We will not be in until March 31st but in the meantime will be working to make the members’ areas and the staff areas as attractive and as functional as possible. This is a great opportunity to bring all the staff onto one site and to make sure that departments can easily cooperate with one another. We are confident that this will make the College more efficient and effective. Members will benefit from this but also from the enhanced areas specifically for them – the education suite, the informal meeting-coffeeconversation area and the quiet area for working or reading. The meeting rooms will be functional and our architect will ensure that the Council chamber reflects the importance of the work we will do in it. I do know that many are concerned that we are spending money on a building in London – but I hope that everyone will visit it at least once. We are especially thinking of those of you further away and we will have lots of video-conferencing facilities. I hope you have noticed the 4 flagpoles that adorn the facade. These will demonstrate that we fly the flag literally as well as metaphorically for paediatricians in Wales, Ireland and Scotland as well as England. Meanwhile, work goes on. I was invited to speak at the European Society of Ambulatory Paediatrics to defend the British system of primary care for children before nearly 300 delegates, all primary care paediatricians, many believing our system to be near criminal.
I knew that I was on a sticky wicket. It is quite clear that UK primary care services are not always working well for children and families. The increasing number of parents bringing their children to Emergency Departments (EDs) testifies to this. The number of admissions for less than a day is rising and the greatest proportions of these are referrals from GPs. Most of the admissions are children less than 1 year old. It is not hard to speculate that changes in primary care are at the root of this. Only 40% of GPs have any formal training in paediatrics, and changes in out of hours services mean that parents come to ED rather than to their GP. But it is not fair to lay all this at the GPs’ door. Other factors play a part – parents know that if they go to the ED they will be seen within 4 hours and may well see a paediatrician. We traditionally put our least experienced doctors at the front line, which means that referrals there easily translate into admissions. Evidence from hospitals where more senior doctors see these children show that fewer are admitted for very short stays. Changing morbidity means that children present with conditions such as behaviour disorders that parents and GPs alike find challenging. Many recent immigrants know no other way of accessing doctors than via EDs. NHS Direct often directs parents to the ED. We have had to put more staff on acute rotas so fewer are available to provide longterm conditions or services closer to home. There is some evidence that this is translating into poorer outcomes for children. Our outcomes for solid tumours, control of diabetes and infant mortality rates are all worse that those of our European counterparts. Immunisation rates in London are shamefully low. So what is the answer? The immediate options seem to be either to develop GPs who specialise in paediatrics, or paediatricians who specialise in primary care. There are disadvantages to both options. The General Practitioners and their College feel they should remain family practitioners and that they should remain generalists. Tooke recommends that their training should be extended to 5 years and we plan to persuade them to include mandatory training in paediatrics. There has been variable support for GPwSIs – with reservations from
specialists and generalists about their training and re-accreditation. Would a primary care paediatrician need to be trained for 8 years – i.e. as long as our specialists in general paediatrics? If not – would they have a different pay scale or would there be “status” problems? Would they be prepared only to see the more routine aspects of paediatrics? More importantly would this meet the needs of children and families? Would there be an out of hours service? How would they keep up to date if they were working in an office based system? We would not like to see them isolated from colleagues or multidisciplinary teams. We would need very high numbers of paediatricians to provide a primary care service. Perhaps, however, we should target deprived areas to try to tackle the inequities that are so prevalent in the UK. Perhaps we should look at what skills are needed by the first contact professional – and what support services are needed. We need to talk to parents about what they want. We can identify the conditions that need to be seen urgently. Lord Darzi left children out of his first review but we, amongst others, objected and in the next stage– Our NHS, our Future – each SHA has a children’s clinical care pathway group whose task is to identify good practice, the needs and the barriers to change. This is a golden opportunity to examine the primary – secondary care interface. Hopefully we can learn from good practice – where erstwhile secondary and primary care professionals network in locations closer to the patient’s home and where generalists and specialists are doing away with what is perhaps an outmoded concept altogether. Finally, we say goodbye to Hilary Cass soon. She has been an energetic and excellent Registrar and brought new ideas to the College from which we have all benefited. She will remain a good ambassador for us in her new post as Head of the London School of Paediatrics, and we thank her and wish her well.
Patricia Hamilton RCPCH PRESIDENT
News Young People’s Health – a New voice for Academic Paediatrics new Special Interest Group The Academic Paediatrics Association (of Great Britain and Ireland) was founded earlier this year in response to the perceived threats to academic paediatrics and particularly to recruitment and retention of academic paediatricians (see Winyard et al., Arch. Dis. Child. 2006: 91; 1027-9). Its purpose is to promote academic paediatrics and specifically to facilitate and support paediatric academic careers. Its wider aims and objectives include: • Engaging in advocacy. • Developing a strategy for recruitment to and retention. • Mentoring trainees and providing career advice. • Supporting and developing academic training. • Providing a forum for the exchange of ideas and information. • Contributing to the maintenance of undergraduate and postgraduate academic standards by providing advice to educational, professional and regulatory bodies. • Acting as a nominating body for Clinical Excellence and Distinction Awards. Membership is open to all levels of clinical and non-clinical staff, and those with NHS appointments, who are actively involved in research related to paediatrics and child health. In spite of its short history, the Association already has more than 130 members, drawn from all grades and most paediatric subspecialties. The current president, Professor Richard Olver (firstname.lastname@example.org), and secretary, Professor Nick Bishop (email@example.com), provide academic representation on the Academic Board and Council of the RCPCH. A very successful inaugural meeting, attended by 75 researchers at the Institute of Child Health in London on the 25th April, comprised an eclectic mix of fascinating short research presentations, ranging from kinaseology in CF to HIV population studies on the China/Burma border, and several topical academic training presentations. The guest lecture was given by Dr Mark Walport, Director of the Wellcome Trust, entitled “Funding the best research”, which, in spite of its somewhat dry title, managed to be provocative, informative and entertaining. By the time you read this, the Association will have held its second meeting, this time at the St Mary’s campus of Imperial College, which looks like being every bit as good as the first. The programme includes talks on “Clinical Research Networks and what they mean for paediatrics” (Prof Rosalind Smyth, Alder Hey) and “Women in Medicine” (Dr Helen Budge, Nottingham) and, as before, the programme includes a number of top quality research presentations. Professor Stephen Holgate, lead on the MRC’s translational research initiative, is giving the guest lecture “Medical Translational Research”. The next meeting will be in April/May 2008 and details will be circulated with papers for the College’s Spring Meeting. For membership details, please contact Mrs Mary Hargan (firstname.lastname@example.org) and for further details about the Association please go to www.academicpaediatrics.association.googlepages.com/
for the RCPCH
Richard Olver PRESIDENT, ACADEMIC PAEDIATRICS ASSOCIATION
Dr Gill Turner and Dr Naomi Jones ON BEHALF OF THE YPHSIG STEERING GROUP
Young people, aged 11 to 19 years, haven’t always been well served within paediatric practice. There is now increasing awareness of the particular needs of this group for confidentiality, appropriate communication and consultation skills and attention to transition to adult services. With the support of the DH and Dr Pat Hamilton, a team of interested paediatricians have established a group with the aim of raising the profile of young people’s health within the RCPCH and encouraging the development of high quality health services for young people in the UK. Work has already commenced in a number of specific areas including: • Implementation of the “You’re Welcome” quality criteria. (www.dh.gov.uk/en/Publicationsandstatistics/DH_073586) • Supporting a monthly young people’s health e-bulletin. • Supporting implementation of good practice guidance on transition. • Developing good practice guidance on participation of young people in paediatric practice. The Young People’s Health Special Interest Group (YPHSIG) will officially launch at the next Spring Meeting on Tuesday 15th April 2008, starting at 6.15pm. The location is to be confirmed but full details will be available in the Spring Meeting programme. We would be delighted for anyone with an interest in young people’s health to attend. If you are interested in joining the group or would like to find out more about the YPHSIG, please contact us: email@example.com or firstname.lastname@example.org
Application for CESR under Article 14 Since September 2005, doctors unable to obtain a Certificate of Completion of Training (CCT) have been able to apply instead for a Certificate of Eligibility for Specialist Registration. This allows experience gained outside approved training programmes to be taken into account. The majority of applications are under Article 14(4) which requires evidence that qualifications, training and experience together are equivalent to a CCT programme. A small number of doctors who have had training outside the UK in a non-CCT specialty may apply under Article 14(5) for which the requirement is a “level of knowledge and skill consistent with practice as a consultant in the National Health Service”. Applications are made to PMETB, which passes them to the appropriate Royal College for evaluation. Within the RCPCH, each application is independently assessed by at least 2 assessors. An evaluation report for PMETB is then prepared by College staff and ultimately considered and amended by the Article 14 Chairman or a separate senior assessor (in discussion with the initial assessors where necessary). The final decision is made by PMETB based on the College recommendation.
Up to July 2007 the RCPCH had received 110 applications. 102 were under Article 14(4) alone, of which 26 were recommended for approval, 34 for rejection, and 42 were awaiting assessment. Some applications were from specialists outside the EEA but the majority were from SASG doctors in the UK. Requirements for Article 14(4) include demonstration of CCT-equivalent competence in general, neonatal and community paediatrics. Acute skills must have been maintained up to the time of application. Avoiding submission of applications which do not meet these standards will save applicants money, save time for PMETB and the College, and allow potentially successful applications to be processed more rapidly. Common reasons for rejection are: lack of sufficient general or neonatal experience in community doctors, lack of sufficient community and child protection experience in general paediatricians, and general lack of submission of sufficient appropriate evidence. When considering evidence to be supplied, applicants are advised to bear in mind whether their submission shows that they have gained the knowledge and skills to the breadth and depth required of a UK trainee
UNCRC training day: Wednesday 20 February 2008 ‘This training day will be of great value to all College members in all branches of paediatrics, and to trainees’. Dr. Tony Waterston, CHAIR, ADVOCACY COMMITTEE
environment in which children’s development can flourish. • The right to be listened to and taken seriously.
The day will provide an introduction to children's rights including the impact of discrimination on children’s health and healthcare, the structure and content of the UNCRC, and how it can be used to combat rights violations and solve value conflicts in the best interests of children. The day will explore how the UNCRC is relevant to the work of paediatricians, the College and its Committees. There will be a practical focus on the role of the UNCRC in everyday paediatrics.
Children are entitled as of right to be consulted about decisions that affect them, in particular: • Rights to express their views and freedom of expression. • Rights of disabled children to integration. • Right to privacy and confidentiality. • Protection from discrimination.
UNCRC issues for paediatricians include: • The right of every child to life and optimum survival and development. • This right imposes obligations not only to actively provide health services to protect the lives of children, but also to create an
Comments from a previous course: ‘Excellent thought provoking day that I would recommend others to attend’. ‘Very enjoyable and important day. Highlighted child centred approach’. To find out more please see the flyer with this newsletter, or contact the Policy and Standards Administrator on 020 7307 8017.
applying for a CCT in full. Structured reports from referees are essential supportive evidence but insufficient in themselves. Additional concrete evidence must be supplied. Examples of useful items are appraisal documentation, anonymised written communications including child protection reports, reflective entries, and evidence of leading clinical governance activities. A clear indication of linkage of evidence to specific GMP criteria is also helpful. The timescale for processing applications, both by PMETB and the College, has regrettably been much longer than originally envisaged and the resultant frustration for applicants is fully understood. Reasons have included the large number of applications and unavoidable changes of staff within the College. We are constantly striving to streamline the process. For further details go to the CESR page on the College website (www.rcpch.ac.uk/cesr) and follow links from there. Dr Andrew Cottrell CHAIRMAN OF RCPCH ARTICLE 14 COMMITTEE
Palestine programme The pilot teaching programme for the Palestinian Certificate in Child Health (formerly Child Health Development Programme) finished in August 2007 and all seven candidates (five doctors and two nurses) graduated in October at a ceremony in Ramallah overseen by the President, Dr Patricia Hamilton. The course they completed was a comprehensive programme in child health aimed at GPs and nurses working in primary care and delivered by local paediatricians with the support of UK College tutors. The course consists of 11 modules and a high standard was maintained throughout, the nurses in particular were impressive in their diligence and high standard of performance. Issues which have arisen from the course which require to be addressed are the need for an organising partner in Palestine. We value our partneship with the Palestinian Paediatric Society, Jazoor and the Al Quds Medical School.
News Comparing Modelling the Future and Our NHS, Our Future Both Our NHS, Our Future 1 (ONOF) and Modelling the Future 2 (MtF) are currently out for consultation, so it seemed timely to compare and contrast their two approaches. Central to both documents are: • The promotion of patient involvement and empowerment. • Designing services around patient pathways. • Developing systems for continuous improvement to achieve excellence. Table 1 outlines some of the key similarities and differences in terms of remit, drivers, keywords, ideology, and solutions. Given the similarities in both the drivers and the ‘destination’ the differences are more about the ideology of how they are achieved. Our NHS, Our Future proposes continued implementation of the NHS Plan. Central to this plan is patient choice and contestability between services, supported by performance measures. Improvement is driven by a market-driven approach assuming a range of provision to enable choice to the consumer. Modelling the Future proposes pathways of care, delivered by teams working collaboratively in a managed network, improvement being learning itself driven by ‘measures that motivate’ clinicians. Our NHS, Our Future makes reference to clinically driven reform, importing models of excellence from overseas, but the absence of need for significant reform of NHS management structures. Modelling the Future recognises that services need to improve using a variety of methods from small-scale innovation to multiorganisational reconfiguration. In particular it recommends that commissioning, delivery, inspection and regulation need to align with each other to reinforce patient pathways as the building blocks for the design of services. This type of approach would inevitably mean changes in management structures to achieve the outcomes envisioned in both documents. Both Modelling and Our Future emphasise the need to improve primary care. The Darzi approach is to build new health centres in areas of poor provision and extend GP working hours. Modelling proposes staff development and an erosion of the primary-secondary care divide with teams which may be community or hospital References 1 Department of Health (2007) Our NHS Our Future. www.nhs.uk/ournhs 2 RCPCH (2007) Modelling the Future. www.rcpch.ac.uk/modellingthefuture
based working across this boundary all delivering safe care as close to home as possible within that network. There are many examples within children’s services that are good practice and could be replicated for adult services – and hopefully children’s models will be able to
influence the NHS Review positively. This is the time to influence the future of your services – please read and respond! Dr Simon Lenton VICE PRESIDENT, HEALTH SERVICES
Table 1: Comparison of the two documents
Remit and context
Modelling the Future
Our Health Our Future
• Consultation paper • For paediatricians • Children’s services • UK wide
• Interim report • NHS staff, patients and the public • All services • England only
Drivers • Changing disease patterns • Increasing inequalities • Unacceptable variations in health outcomes • Needs to become more patient focused • Engaging with clinicians • Working with other organisations • Undervalued staff
Modelling the Future
Our Health Our Future
• EWTD drivers
• Comparisons with other countries
Modelling the Future
Our Health Our Future • Fair • Personalised • Effective • Safe • Locally accountable
• Family friendly • Pathway based • Continuously improving • Sustainable • Equitable
Ideology • Promotion of patient involvement and empowerment • Designing services around patient pathways • Developing systems for continuous improvement
Modelling the Future
Our Health Our Future
• Family focused • Collaboration driven • Feedback of measures that motivate • Focus on learning
• Condition focused • Competition driven • Targets and performance measures • Focus on innovation
Solutions • Localise where possible, centralise where necessary • Prevention and early intervention
Modelling the Future
Our Health Our Future
• Teams working across boundaries • Managed networks • Align commissioning, delivery and regulation • Reconfigure to enable integrated care
• Driven by safety and effectiveness • More health centres, longer GP hours • No change in management structures • International comparisons.
Spring Meeting 2008 Get the dates in your diary! 14 -17 April 2008 – these are the dates of the meeting that offers something for everyone in paediatrics. The specialty groups provide both CPD and research updates by mixing lectures with scientific papers. Plenary talks will focus on ‘Learning from your mistakes’, ‘How small is too small?’, ‘Modifying the outcome of childhood type 1 diabetes’, ‘Should wheezy infants be given inhaled steroids?’, ‘How the GMC can support paediatricians in their practice’ and ‘The historical context of child abuse’. Professor Gregory Holmes will give the 2008 Windermere Lecture on the ‘Developmental consequences of early seizures’ In personal practice sessions you can discuss the management of conditions ranging from hypertension to constipation via epilepsy, headache, cerebral palsy, UTI, cystic fibrosis, neonatal seizures and sleep disturbance. There are guideline sessions and symposia. Whatever your interests you should come and meet old friends, make new ones and participate in the evening sessions. You can attend College Question Time, listen to the orchestra, join the College dinner at the Merchant Adventurers Hall or drink in one of the bars on the York campus. This is your meeting. We hope to see you there. Dr Chris Verity CHAIR, ACADEMIC BOARD
Annual General Meeting 2008 In accordance with Bye Law 8 (ii) the College wishes to serve notice to the membership that the next Annual General Meeting of the College will be held on Wednesday 16 April 2008 at 6.15pm at the University of York, during the College’s Spring Meeting. Motions and items of business should be submitted in writing to the College Registrar not less than 10 weeks before the date of the meeting (Wednesday 6 February 2008), accompanied by the signature of 15 Ordinary Members or Fellows.
Research Helping paediatricians to practice evidence based paediatrics Four examples of research involving the RCPCH, relevant to everyday practice In the Autumn Newsletter I wrote about the new College research strategy. I have had some very helpful feedback from members and as the strategy continually evolves, I am still happy to hear your views – you can contact me at email@example.com I have been asked to provide some specific examples of our research work in this Winter newsletter. I want to showcase in detail four topical projects so that you can see the range of work which the research division is involved with on your behalf. Many of these projects are collaborative efforts with other Colleges or stakeholders – here I am flagging the RCPCH contribution. These four are chosen from a total of approximately 20 ongoing projects to reflect the fields of community child health, the district general acute sector and tertiary care, and provide examples of primary research, trials, guidance and audit. One is nearing completion, two are just starting up and one emphasises particularly how the RCPCH can support other organisations and initiatives which promote research for children. A recent Newsletter gave information on the ‘Medicines for Children Information Leaflets’ project – an example of advocacy and parent and child involvement.
1. Guidance on diagnosing Child Sexual Abuse Led on behalf of the RCPCH by Neil McIntosh & Rita Ranmal The Child Sexual Abuse project to review the evidence base behind the physical signs of child sex abuse is in its final stages. The draft 180 page handbook on the physical signs of child sexual abuse was sent out to stakeholders, paediatricians and forensic physicians in July 2007. By the close of the consultation period we had received over 1000 individual comments from over 50 individuals and organisations. Since the consultation period
closed the working groups and the research team have been working at full capacity to address the comments. There is a very tight timeline between now and the date when the book has to go to the printers to be ready for the proposed launch in Spring 2008.
2. Scoping a national audit of urgent and emergency care Led on behalf of the RCPCH by Ian Maconochie & Louise Youle
• • •
The College has been awarded the contract to scope a National Clinical Audit of Emergency Care for Children. Some examples of the questions the RCPCH has been asked include: Recommend topics which are most important and most feasible for a National Clinical Audit. Recommend topics to be most likely to lead to improvements in patient care. Determine whether a particular type of child is to be audited. Determine whether a particular disease or condition is to be audited.
Standards for generic emergency clinical care for children are scarce but the ‘redbook’ specifies some clinical standards which could be measured: • All children, attending emergency departments must be visually assessed within the first few minutes of arrival to identify an unresponsive or critically ill child. • All children should have a brief clinical assessment within 15 minutes of arrival. • All attendances of children must be notified to their primary care team. • All parents should be offered an appointment with a consultant 3-4 months after a child dies. We also need to decide whether to audit: • All Children seen in A&E departments.
• All children admitted to hospital following A&E attendance. • Just walk-in patients (i.e. excluding ambulance patients). • Every child or a subset (i.e. only those with specific conditions). If so, which conditions? Meningitis? Serious injury? Other? This scoping exercise is ongoing. Ultimately, we would hope to be awarded the substantive contract to perform this national audit.
3. Medicines for Children Research Network Led by RCPCH members Ros Smyth & David Edwards
Most paediatricians recognise that treatments available for children in the NHS often lack the evidence to inform their safe and effective use. The government has established a large national programme with substantial funding to address this. They have established a national network, the Medicines for Children Research Network, to assist the testing of drugs for children. The RCPCH is delighted that children feature as one of the five ‘topic-specific’ networks (the others are diabetes, stroke, dementia, cancer) and is very supportive of this initiative, coordinated by the centre in Liverpool. New research ideas for medicines research are generated ‘bottom-up’ from Clinical Study Groups covering the breadth of child health (eg. neuroscience, respiratory etc.). Examples of the 40 studies already adopted include the MENDS study of melatonin in children with neurdevelopmental disorders and impaired sleep; the TWICS study of oral
Research steroids for pre-school wheeze; the P3MC study of propranolol or pizotifen to prevent migraine; and NIRTURE – insulin for very low birth weight infants. However, there are many therapies for children which do not involve the use of medicines. We now have a window of opportunity to highlight these too. The Government’s programme has now reached a new stage. A further national network is being established to allow current and new treatments to be tested and developed for all the other areas of medicine outside the five ‘topic specific’ networks. The plan is to involve working doctors in testing treatments as part of their normal working lives. There will be funding available for sessional payment to clinicians to get involved and support to allow those who want to start or join projects. The networks are a central part of the NHS, completely embedded in the health service structure and based in small and large hospitals. We as paediatricians have the opportunity to use this to improve the care we give children and babies but we have to take the initiative. We are at the stage where local research networks (called ‘Comprehensive Clinical Research Networks’) are currently deciding which areas they want to be involved in. There will be about 25 Comprehensive Clinical Research Networks to cover the NHS in England and there will be approximately 15 Specialty Network Groups, currently envisaged for disease-specific fields such as gastro-enterology, nephrology etc. If we leave these to our colleagues in adult specialties, the likelihood is that research for children will be relatively neglected. We all need to ensure that research for children is on their agenda and that non-medicines paediatric research is recognised as a separate “Speciality Network Group”. Currently, Comprehensive Clinical Research Networks directors have been sent a list, which originated with the UK Clinical Research Collaboration, of a dozen areas (which will each become a Speciality Network Group) and asked in which of these areas they consider their Comprehensive Clinical Research Networks to be strong. This list currently does not feature non-medicines paediatric research but we are lobbying for this to be the case. A decision is unlikely before 2008. Consultant Paediatricians should take the initiative and contact the local lead of their Comprehensive Clinical Research Network and explain to them that children
need improved treatments, especially for non-medicines therapies which are outside the remit of the Medicines for Children Research Network. One tangible way in which the RCPCH Research Division can support non-medicines paediatric research is to assist RCPCH members to attend future working groups and I have earmarked funds for this.
4. Safer practice in neonatal care Led on behalf of the RCPCH by Neena Modie & Linda Haines
There were 645,881 births in England and Wales in 2005. In 2005 the perinatal mortality rate was 7.9 per 1000 and the neonatal mortality rate was 3.4 per 1000. The National Patient Safety Agency found that patient safety incidents in neonatology accounted for more than 12 % of incidents reported for children and young people in the National Reporting and Learning System. In 2006 the most frequently reported neonatal incidents were medication errors (24%), treatment or procedure errors (17%), equipment problems (10%), infrastructure issues (10%, including staffing) and transfer of care issues (8%). The NPSA is funding a College project in patient safety issues for neonatal care with the aim of developing a package of interventions (“care bundle”). A “care bundle” is “a group of evidence based interventions related to a care process that, when executed together, result in better outcomes than when implemented individually”. The three topics to be explored are medication errors, infection and safety during transfer. The project was given funding until the end of March 2009. Professor Terence Stephenson VICE-PRESIDENT FOR SCIENCE & RESEARCH
Conclusion I hope these four examples from a very long list give you a flavour of the research which the College is supporting on behalf of you and your patients and their families. Some of the other projects which the College has been involved with recently are listed below. 1. Surveillance of type 2 (non type 1) diabetes. 2. Development of a Bayesian Analysis methodology for child protection issues – with the Royal Statistical Society. 3. Qualitative survey of child protection complaints against paediatricians and how they were managed. 4. Research into parents information needs when abuse is suspected. 5. Development of “Medicines for Children” information leaflets. 6. Development of an evidence based guideline for the screening and management of Retinopathy of Prematurity. 7. Development of a National Neonatal Audit. 8. Systematic review on the management of hypernatraemia. 9. Development of a programme to prevent high risk infants from development of obesity – EMPOWER. 10. GRUFFALO project (renamed HENRY) to help parents avoid the onset of obesity in infancy. 11. Administration of a grant to the Welsh Systematic Review Group for a review of non-accidental head injury. 12. Surveillance of adverse drug reactions in Scotland. 13. Involvement with CEMACH (Confidential Enquiry into Maternal and Child Health) projects on childhood morbidity and mortality.
News SASG News Hello, I’m writing to you on the train travelling home from the RCPCH SASG information day. What a brilliant day! I hope we will be able to put all the presentations onto the SASG section of the RCPCH website and would urge you to have a look at them. In the morning we had presentations from Mary McGraw, Vice President for Training and Assessment, Hilary Cass, Registrar, and Andrew Cottrell, Chair of the Article 14 committee. We were pleased to hear that the Tooke enquiry had suggested that the SAS grade will become an increasingly important part of the workforce. The College recognises that SASG doctors offer continuity and stability and are keen to support us to get opportunities for professional development to get the most out of our grade. We were encouraged to look at the e-portfolio that has been developed for trainees, and it was
suggested we could use it to collect evidence of our experience and training. We were given an overview of the current training structures and it was pointed out that for some SASG doctors, re-entering the training grade is a possibility. For others who are trying to enter the specialist register via the Article 14 route, taking FTSTA posts to fill in gaps in experience is another possibility. Dr Greg Dilliway explained that there has been no progress on the proposed SASG contact. BMA members should be receiving a questionnaire to feed back their thoughts on the contract so this information is ready if things progress. The afternoon had a more clinical focus with Dr Sebastian Kraemer helping us to consider how we could work more effectively with our colleagues in child psychiatry. He helped us to see that we approach patients in different ways and that by working together
The effects of cancer treatment on reproductive functions: Guidance on management Report of a working party of the Royal College of Physicians, Royal College of Radiologists and the Royal College of Obstetricians and Gynaecologists New guidance produced by three Royal Colleges provides the latest information on the effects of cancer treatment on fertility. Remarkable advances have taken place in the treatment of cancer in recent years, with a marked increase in cure rates. This new guidance, written by a multidisciplinary expert group, sets out clearly the effects of those treatments on reproductive functions, and ways of preserving fertility. Approximately 11,000 patients in the 15-40 age group are diagnosed with cancer each year, and for many of these younger cancer patients fertility is or will become extremely important. The report aims to improve standards of management of fertility, calling for nationwide provision and funding and for a scientific approach to future developments. Focused primarily on treatment of adults, aged 16 upwards, this guidance is essential reading for all clinicians and health professionals involved in cancer care. The working party stresses the need for full discussion with patients before their treatment about its possible effects on fertility, and provides clear patient information for men and women. Send orders to: Publications Department, Royal College of Physicians, 11 St Andrews Place, Regent’s Park, London NW1 4LE. Order online at: www.rcplondon.ac.uk/pubs
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we can be more effective. Dr Annabelle Bundle, a member of the SASG committee, reminded us of the health inequalities faced by looked after children and updated us on who can give parental consent. Finally Professor Terrance Stephenson, Vice President for Science and Research, impressed on us how guidelines can be useful in our practice. I would like to thank all the speakers for the excellent presentations they gave and for the support they give to the SASG paediatricians. I would also like to thank John Pettitt, the SASG committee administrator, for ensuring the day ran smoothly. I would strongly urge you to look out for the presentations on the website. Dr Nataile Lyth CHAIR OF THE RCPCH SASG COMMITTEE
Workforce Census 2007 The RCPCH Workforce Census for 2007 is now well under way and information has been received from almost half of paediatric services in the UK in the first month of the survey. With workforce and related reconfiguration issues becoming increasingly important on the health services agenda, it is important that the College has the most up to date information available. We would be grateful therefore if Clinical Directors and Leads could ensure that completed census booklets are returned to the workforce team as soon as possible. This year, in addition to the regular census form completed by Clinical Directors, we have emailed a separate single-sided form to all those consultants where we have an accurate email address. All individual data collected from the Census is treated as confidential. If you have not received either form, blank copies can be found on: www.rcpch.ac.uk/workforce, and by contacting Martin McColgan 020 7323 7906 email@example.com or Shazia Mahmood 020 7323 7931 Shazia.firstname.lastname@example.org
Published by the Royal College of Paediatrics and Child Health, 50 Hallam Street, London W1W 6DE Tel: 020 7307 5600, Fax: 020 7307 5601 Website: www.rcpch.ac.uk Email: email@example.com The College is a registered charity: no. 1057744 © 2007 Royal College of Paediatrics and Child Health. The views expressed in this newsletter do not necessarily reflect the official positions of the RCPCH.
Exams: “Fit for Purpose”
We were delighted to receive approval of our examinations portfolio from PMETB. This singular achievement (others have fallen by the wayside) was steered by Mary McGraw, Vice President for Training and Assessment, and my predecessor as Officer for Examinations, Tom Lissauer. It is a fitting conclusion to Tom’s term of office, which has brought so many changes - most notably the great success of the new format MRCPCH and DCH clinical examinations. The new clinical exam and large increase in candidate numbers has necessitated the appointment of additional examiners. We are pleased to have appointed over 200 new examiners to MRCPCH and DCH in the last three years. Examiner training has advanced considerably. This has included a recent twoday training course in Cambridge which included video based standardisation of assessment. A system of analysing examiner performance has now arrived. A five-point
analysis looks at each examiner, compares them with others, and includes the return of the legendary Hawk-Dove index. Some examiners have now received feedback on their performance! Appeals against the results of the MRCPCH clinical examination have grown, reflecting the pressure on our trainees. There is now a fee of £200, returnable if appeal is successful. To date we have had 112 appeals over 8 sittings. An Appeals Panel reviews evidence from the appeal, the centre and on one occasion the child’s mother. Successful appeals are unusual (6%), and all candidates are given feedback. Good documentation by examiners will further reduce the chances of successful appeals. We are concerned, on recent analysis, to note the lower levels of pass rates amongst candidates who graduated or have trained overseas in comparison to the UK graduates. We are determined to address the causes,
Advocacy Committee News Recent issues considered by the Advocacy Committee include: 1. Corporal punishment in the home Recently there has been a review of the Children Act Section 58 by the Department of Children, Schools and Families. Section 58 applied to corporal punishment of children at home and sanctioned this as long as no bruise or visible injury was caused. The RCPCH has long opposed the acceptance of corporal punishment by parents and is a member of the Children are Unbeatable Alliance which seeks to ban all violence against children in the home, as has happened in many other European countries. The DCSF review is now complete and unfortunately has maintained the previous stance on the grounds that the majority of
parents are opposed to a ban, and ‘there are no reported significant practical problems with its operation’. This is despite the fact reported in the consultation that there is widespread lack of understanding of what the law is, and the responses both from children and from child care organisations were firmly against the acceptance of smacking within law. The RCPCH together with most other child care organisations is disappointed in this outcome and will continue to work for the same protection for children as adults receive. 2. Bone age X-rays to determine the age of young asylum seekers There continue to be concerns over health care of asylum seekers (AS) and the RCPCH is examining evidence in a number of areas. One
which may lie in content orientation, language, question format, training or access to examination preparation. Recent clinical examination results suggest this gap is closing and we are planning to try and further reduce the difference in pass rates by enhanced examination preparation which will initially be trialled in some overseas centres. A major future development is underway. The new Assessment Committee is engaged in a pilot study to evaluate differences between work-based assessment and a formal, oral assessment in ST7. We aim to evaluate the workplace Case based Discussion (CbD) and a new, structured, multi-station oral assessment. The initial pilot is planned in 2008 and we are greatly assisted by the Trainees’ committee feedback and the trainees who are on the working parties. We would welcome your involvement in examinations. We greatly value input by trainees, members and Fellows. New exam questions are needed and new examiners willing to host the exams are most welcome. Please contact Graeme Muir at the College or your Principal Regional Examiner. Participating in exams is definitely one of the best and enjoyable ways of of obtaining CPD.
Dr Simon Newell OFFICER FOR EXAMINATIONS
in which guidance has been sought by Government is in the determination of age, since a number of young unaccompanied AS are uncertain of their age yet their eligibility for children and young people’s services relies on their being known to be under 18yrs. The Home Office is considering using bone or dental X-ray as a means of determining age. Whilst the RCPCH supports the need to ensure that children are appropriately managed in children’s rather than adult services, it is of the view that there is no single reliable method to determine age and that instead, a holistic evaluation should be carried out, including a narrative account and collation of information from all sources available. This opinion has been strongly expressed to Home Office ministers. Dr Tony Waterston CHAIR, ADVOCACY COMMITTEE
Trainees’ column MMC The MMC programme board have been established for three months. There are ongoing discussions regarding the recruitment to medical and surgical training. Following open and wide consultation including web based consultation with a multitude of stakeholders including trainees, a number of decisions were made. The decision has been taken to run the application process on a specialty specific basis at a local level, based upon nationally agreed standards and principles. There will be no national IT system in place this year although there is a considerable amount of work going into developing an IT system for 2009. The application process will commence in January 2008. Candidates will be able to demonstrate achievements as well as competence during this application process. There are a number of ongoing discussions that will affect all medical specialties including the size of Units of Application and transferable competencies.
The Independent Inquiry into MMC The former Secretary of State for Health, Patricia Hewitt, invited Professor Sir John Tooke to lead an Independent Inquiry into Modernising Medical Careers (MMC) in the wake of the problems surrounding MTAS, the process used for selecting trainee doctors for specialist training. The interim report was published on 8th October 2007 highlighting the problematic issues of MMC and providing recommendations which are open to consultation. The trainees committee have responded to this consultation. The underlying theme is one of flexibility within MMC which diminished significantly following its inception. It is very clear from the consultation that we are heading towards a ‘mixed economy’ in which different specialties will adopt their own application process and potentially training pathways. The report is available on mmcinquiry.org.uk.
International Medical Graduates and BAPIO The British Association of Physicians of Indian Origin (BAPIO) won their appeal on 9th November 2007 on the basis that advice given by the Department of Health to NHS employers regarding doctors on the Highly Skilled Migrants Programme (HSMP) was not lawful. The Lord Justices were unanimous in agreeing that the DH guidance was wrong. On the basis of this, International Medical Graduates are eligible to apply for Specialty Training posts in line with UK and EEA graduates.
Abolition of limited registration On 19th October 2007, the GMC abolished limited registration. Doctors holding limited registration on 19 October 2007 were automatically granted full registration (unless they were restricted to working in a Foundation Year 1 or house officer post in which case they received provisional registration), on condition that when they take up a new post they only work in an approved practice setting until they have fulfilled the criteria for that requirement to be lifted. Doctors applying from overseas to work in paediatrics must fulfil several criteria set out by the GMC; They must hold an acceptable primary medical qualification, they must have the requisite knowledge and skills for registration, their fitness to practise is not impaired and have the necessary knowledge of English. Doctors that carried limited registration should have received notification of these changes from the GMC. If you have not please check the GMC website or contact the GMC directly.
clinical posts. The new ‘Walport’ clinical fellowships and lectureships provide an excellent pathway for the pursuit of an Academic career, but at an early stage facilitate applications for obtaining research grants and working towards a postgraduate research degree. Up to 250 fellowships are available in 2008 and will provide funding for doctors and dentists entering specialty training and for those already in specialty training who hold a National Training Number. Successful applicants will have 25 per cent of their time protected so they can develop their academic skills.
ST7/8 Assessments The Trainees Committee is currently involved in discussion with senior members of the RCPCH regarding the potential implementation of an assessment process in the final years of training. This is still very much in the discussion phase and no decisions have been take as to the format of this process. However, the Trainees Committee did conduct a national online survey to canvass the opinions of trainees around the country. I would like to thank those that completed this survey and the EWTD survey that has just taken place.
Regional Representation on the Trainees Committee Several times during the year, the Trainees Committee advertises posts for lead and deputy regional representatives. We have just welcomed onto the committee new reps from the North West and west Midlands. I would encourage all trainees from ST1-8 to consider applying for a place on the Trainees Committee. Traditionally representatives were SpR. However, the only prerequisite is membership of the College which is now an MMC requirement of Specialty Training. Therefore, trainees from ST1-8 are welcome.
Academic Medicine The first stage of recruitment for Academic Clinical Fellowships has occurred before the recruitment phase for clinical posts on 15th November. It is vital that willing and competent trainees apply for academic
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Meetings Media update We've been talking to journalists about many things over the past few months, including growth charts, respecting the rights of children and young people and child asylum seekers. When the Department of Health issued a response in August to the joint report submitted by the Scientific Advisory Committee on Nutrition (SACN) and the RCPCH on child growth standards, we spoke to the media on the subject. Peter Aggett, chair of the Nutrition Committee was quoted in a few of the nationals and took part in a discussion on Radio 4 Women’s Hour, with the National Childbirth Trust. Also in August, Russell Viner talked on behalf of the College to the Daily Telegraph about hypertension in children and adolescents, and Terence Stephenson also spoke to the Daily Telegraph about feverish illness in children. News coverage in September kicked off
RCPCH news with the RCPCH Policy Officer, Geoff Lawson, talking to the Scotsman about the benefits of breastfeeding. In late September, the GMC launched new guidance asking doctors to respect the rights of under 18s. Patricia Hamilton was quoted on the BBC News website saying that “this is an important step forward in ensuring the medical profession recognises that children are not just little adults and that their specific needs should be met accordingly.” The College issued a press statement in early October about Channel 4's Bringing Up Baby programme – in essence voicing concern about some of the child-rearing practices portrayed in the programme and in particular sleeping arrangements. We strongly advised viewers in our press statement if they were considering any of the methods shown in the programme to read the Department of Health’s guidance on reducing the risk of cot death. The statement was covered in the Times and Observer and discussions and opinion in the
media continue surrounding this programme. Also in October, the Royal College of Obstetricians and Gynaecologists launched a joint report entitled Safer Childbirth, which the College was heavily involved in and we are mentioned in much of the coverage. Moving into November, the Guardian interviewed Sir Al Aynsley-Green, the children's commissioner for England, about establishing the age of asylum seeking children and whether xrays should be used to do this. Hilary Cass was also quoted in the Guardian article explaining that there is no good research evidence for the use of x-rays for age assessment. To keep up-to-date with any statements that the College makes, or the latest news in paediatrics and child health, go to www.rcpch.ac.uk Claire Brunert HEAD OF MEDIA
RCPCH meetings UK meetings and courses
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25-29 February Other Forms of Diabetes: From Genetics to Obesity Venue: Warwick Medical School, Coventry Contact: Mary Nejedly Tel: 024 7657 4634 Email: firstname.lastname@example.org Website: www.warwick.ac.uk/go/childhealth
14-18 January Health Protection, Promotion and Prevention Venue: Warwick Medical School, Coventry Contact: Annette Finn Tel: 024 7652 2035 Email: email@example.com Website: www.warwick.ac.uk/go/childhealth 29 January BritSPAG Training Day – joint RCOG/British Society of Paediatric and Adolescent Gynaecology meeting Venue: College of Obstetricians and Gynaecologists, London Contact: Conference Office Tel: 020 7772 6245 Email: firstname.lastname@example.org Website: www.rcog.org.uk/meetings 27 February Running Sexual Assault Services for Children: St. Mary’s Centre 6th Annual Conference 2008 Venue: Town Hall, Manchester Contact: Claire Gledhill Tel: 0161 276 6515
28 February Cardiology in Neonates and Infants Venue: National Heart and Lung Institute, London Contact: Karina Dixon Tel: 020 7351 8172 Email: email@example.com Website: www1.imperial.ac.uk/medicine/ about/divisions/nhli/events/ 10-14 March Child Law and Child Protection Venue: Warwick Medical School, Coventry Contact: Annette Finn Tel: 024 7652 2035 Email: firstname.lastname@example.org Website: www.warwick.ac.uk/go/childhealth 14-17 April RCPCH 12th Spring Meeting Venue: University of York, York
Contact: Aaron Barham Tel: 020 7307 5633 Email: email@example.com Website: www.rcpch.ac.uk/Education/Events/ RCPCH-Annual-Spring-Meeting 14-18 April Developmental Paediatrics and Special Needs Venue: Warwick Medical School, Coventry Contact: Annette Finn Tel: 024 7652 2035 Email: firstname.lastname@example.org May 2008 Court Skills in Child Protection (England and Wales) Venue: RCPCH, London Contact: Aaron Barham Tel: 020 7307 5633 Email: email@example.com Website: www.rcpch.ac.uk/Education/ Education-Courses-and-Programmes/ Court-Skills-in-Child-Protection 12-16 May Diploma in Paediatric Nutrition 5-day College Diploma Course Venue: Chilworth Manor Hotel, Southampton Contact: Education Projects Administrator Tel: 020 7307 5644 Website: www.rcpch.ac.uk/Education/ Education-Courses-and-Programmes/ Diploma-in-Paediatric-Nutrition
12 SASG News The effects of cancer treatment on reproductive functions: Guidance on management Workforce Census 2007 5 Application for CESR...