rcpch newsletter 07 winter

newsRCPCHWINTER 2007

Royal College of Paediatrics and Child Health

Taking a closer look:

Research special 8

4New groups for Academic Paediatrics and Young People’s Health

5Article 14 update

6Comparing Modelling the Futureand Our NHS Our Future

7Spring Meeting 2008:PREVIEW

13Exams: “Fit for Purpose”

14News for Trainees

Leading the way in children’s health

Examples of research involving the RCPCH, relevant to everyday practice

“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 intomy gynae SHO job, and well beforeinduction for junior doctors had beeninvented! There had been a riot on alocal estate, and within minutes almostevery doctor in the hospital hadconverged on A&E, without the slightestclue what to do. The surgical registrarseized the initiative and began emptyingthe general surgery ward onto the ENTward to make space for incomingcasualties. If only he had known thatthe ENT ward was the designated majorincident receiving area! The SeniorNurse – the one person who did knowwhat to do – was completely bemused;as fast as she cleared ENT, the bedsrefilled with a mysterious stream ofdisplaced and irritable post-op patients.Fortunately there were few realcasualties to treat. Within an hour acocktail party atmosphere hadsupervened in A&E, as 40 doctors andnurses stood chatting over coffee and sandwiches, watching an unseemlyfight between the surgical and A&Econsultants over who should be wearingthe Major Incident Officer tabard.

Traditionally, doctors have neverbeen terribly good at systems andprocesses. To make matters worse,junior doctors move rapidly, and needconstant induction into local policies. So it is at the College. Officers comeand go, but the staff remain, and musthold the continuity and organisationalknowledge.

Someone recently asked me whetherthe staff have the same passion as thedoctors – who after all are the ones with the ‘sharp end’ experience. Ibelieve they do – but it is a differentkind of passion, driven by a focusedengagement in their particular area ofexpertise – be that publications, training,finance, research or a host of otherfunctions. We have a great staff team – some with interesting degrees, otherswith direct health service experience,

and still others who are parents orservice users. They bring a different and sometimes more objective view,which we meld with our ownexperience, and that of our lay groupand newly formed Youth AdvisoryPanel. All these perspectives coalesce to help us deliver the strategy set byCouncil.

One danger for complexorganisations is that departments canslip into silo working. So what happenswhen we are dealing with cross-cuttingthemes like obesity or child protection – or when there are advances in themanagement of diabetes or sickle celldisease? We need to ensure that theseare built into our curriculum, exams and CPD programmes, that guidelinesreflect latest evidence, and that weadapt policy and standards accordingly.The officers do their best to make theseconnections, but they are not in theCollege every day, so communicationcan be difficult. As you know, we will shortly have a new Collegebuilding. This will bring our staff ontoone site, provide a modern open-planenvironment, and help them to worktogether more effectively to facilitatethese important links.

This will be my last Registrar’scolumn since I will shortly be demittingoffice to take up post as the first Headof the London School of Paediatrics,which is a joint Deanery-Collegeappointment. It has been a particularprivilege to work as Registrar to anextraordinary and very special CollegePresident, as well as with a fantasticteam of officers and colleagues acrossmany committees. I will look forward to continuing to work with many ofthem in my new capacity. I end with a very fond note of thanks to the staff - confident that the transition will beseamless and they will have mysuccessor whipped into shape in no time at all.

Hilary CassRCPCH REGISTRAR

Editorials

From the Registrar4New voice for AcademicPaediatrics

Young People’s Health – a new Special InterestGroup for the RCPCH

5Application for CESR under Article 14

UNCRC training day

Palestine programme

6Comparing Modelling the Future and Our NHS, Our Future

7Spring Meeting 2008:Preview

8 & 9Research Special: Helpingpaediatricians to practiceevidence based paediatrics

12SASG News

The effects of cancertreatment on reproductivefunctions: Guidance on management

Workforce Census 2007

13Exams: “Fit for Purpose”

Advocacy Committee News

14Trainees’ column

15Media update

Meetings

In the newsWinter 2007

I have bought and sold a few properties inLondon over the years, and have found thatthere are infallible rules. Firstly, you begin to despair; secondly, as soon as you findsomewhere and commit yourself to it, theproperty market stalls and/or mortgage ratesrise precipitately. The survey then comes backsaying how remarkable it is that the propertyhad not fallen down years ago and the buyeryou thought you had for your own place,having finally decided they can overcome yourtaste in decoration, discovers that the house issitting immediately above the Northern Line.All these things and more happened in ourrecent building transaction but were resolved.The toll on my blood pressure and gastricepithelium has been considerable, but we areall relieved not to be pouring money away inrent – and not under threat of being on thestreets when various leases end.

Finally, we exchanged contracts – and canstart the equally stressful but also excitingprocess of moving. We will not be in untilMarch 31st but in the meantime will beworking to make the members’ areas and thestaff areas as attractive and as functional aspossible. This is a great opportunity to bringall the staff onto one site and to make surethat departments can easily cooperate withone another. We are confident that this willmake the College more efficient and effective.Members will benefit from this but also fromthe enhanced areas specifically for them – theeducation suite, the informal meeting-coffee-conversation area and the quiet area forworking or reading. The meeting rooms willbe functional and our architect will ensurethat the Council chamber reflects theimportance of the work we will do in it.

I do know that many are concerned thatwe are spending money on a building inLondon – but I hope that everyone will visit itat least once. We are especially thinking ofthose of you further away and we will havelots of video-conferencing facilities. I hopeyou have noticed the 4 flagpoles that adornthe facade. These will demonstrate that we flythe flag literally as well as metaphorically forpaediatricians in Wales, Ireland and Scotlandas well as England.

Meanwhile, work goes on. I was invited tospeak at the European Society of AmbulatoryPaediatrics to defend the British system ofprimary care for children before nearly 300delegates, all primary care paediatricians, manybelieving our system to be near criminal.

I knew that I was on a sticky wicket. It isquite clear that UK primary care services arenot always working well for children andfamilies. The increasing number of parentsbringing their children to EmergencyDepartments (EDs) testifies to this. Thenumber of admissions for less than a day isrising and the greatest proportions of theseare referrals from GPs. Most of theadmissions are children less than 1 year old.It is not hard to speculate that changes inprimary care are at the root of this. Only40% of GPs have any formal training inpaediatrics, and changes in out of hoursservices mean that parents come to ED ratherthan to their GP. But it is not fair to lay allthis at the GPs’ door. Other factors play apart – parents know that if they go to the EDthey will be seen within 4 hours and maywell see a paediatrician. We traditionally putour least experienced doctors at the frontline, which means that referrals there easilytranslate into admissions. Evidence fromhospitals where more senior doctors seethese children show that fewer are admittedfor very short stays. Changing morbiditymeans that children present with conditionssuch as behaviour disorders that parents andGPs alike find challenging. Many recentimmigrants know no other way of accessingdoctors than via EDs. NHS Direct oftendirects parents to the ED.

We have had to put more staff on acuterotas so fewer are available to provide long-term conditions or services closer to home.

There is some evidence that this istranslating into poorer outcomes for children.Our outcomes for solid tumours, control ofdiabetes and infant mortality rates are allworse that those of our Europeancounterparts. Immunisation rates in Londonare shamefully low.

So what is the answer?The immediate options seem to be either todevelop GPs who specialise in paediatrics, orpaediatricians who specialise in primary care.There are disadvantages to both options. TheGeneral Practitioners and their College feelthey should remain family practitioners andthat they should remain generalists. Tookerecommends that their training should beextended to 5 years and we plan to persuadethem to include mandatory training inpaediatrics. There has been variable supportfor GPwSIs – with reservations from

specialists and generalists about their trainingand re-accreditation.

Would a primary care paediatrician needto be trained for 8 years – i.e. as long as our specialists in general paediatrics? If not– would they have a different pay scale orwould there be “status” problems? Wouldthey be prepared only to see the moreroutine aspects of paediatrics? Moreimportantly would this meet the needs ofchildren and families? Would there be an out of hours service? How would they keep up to date if they were working in anoffice based system? We would not like tosee them isolated from colleagues ormultidisciplinary teams.

We would need very high numbers ofpaediatricians to provide a primary careservice. Perhaps, however, we should targetdeprived areas to try to tackle the inequitiesthat are so prevalent in the UK.

Perhaps we should look at what skills areneeded by the first contact professional – andwhat support services are needed. We needto talk to parents about what they want. We can identify the conditions that need tobe seen urgently. Lord Darzi left children outof his first review but we, amongst others,objected and in the next stage– Our NHS, our Future – each SHA has a children’sclinical care pathway group whose task is to identify good practice, the needs and the barriers to change. This is a goldenopportunity to examine the primary –secondary care interface.

Hopefully we can learn from goodpractice – where erstwhile secondary andprimary care professionals network inlocations closer to the patient’s home andwhere generalists and specialists are doingaway with what is perhaps an outmodedconcept altogether.

Finally, we say goodbye to Hilary Cass soon.She has been an energetic and excellentRegistrar and brought new ideas to the Collegefrom which we have all benefited. She willremain a good ambassador for us in her newpost as Head of the London School ofPaediatrics, and we thank her and wish her well.

Patricia HamiltonRCPCH PRESIDENT

RCPCH newsEditorials

From the President

The Academic Paediatrics Association (of Great Britain andIreland) was founded earlier this year in response to theperceived threats to academic paediatrics and particularly torecruitment and retention of academic paediatricians (seeWinyard et al., Arch. Dis. Child. 2006: 91; 1027-9). Its purposeis to promote academic paediatrics and specifically to facilitateand 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 toeducational, professional and regulatory bodies.

• Acting as a nominating body for Clinical Excellence andDistinction Awards.

Membership is open to all levels of clinical and non-clinicalstaff, and those with NHS appointments, who are activelyinvolved in research related to paediatrics and child health. Inspite of its short history, the Association already has more than130 members, drawn from all grades and most paediatricsubspecialties. The current president, Professor Richard Olver([email protected]), and secretary, Professor Nick Bishop([email protected]), provide academic representationon the Academic Board and Council of the RCPCH.

A very successful inaugural meeting, attended by 75 researchersat 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 trainingpresentations. The guest lecture was given by Dr Mark Walport,Director of the Wellcome Trust, entitled “Funding the bestresearch”, which, in spite of its somewhat dry title, managed tobe provocative, informative and entertaining.

By the time you read this, the Association will have held itssecond meeting, this time at the St Mary’s campus of ImperialCollege, which looks like being every bit as good as the first.The programme includes talks on “Clinical Research Networksand 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 numberof top quality research presentations. Professor StephenHolgate, lead on the MRC’s translational research initiative, isgiving the guest lecture “Medical Translational Research”. Thenext meeting will be in April/May 2008 and details will becirculated with papers for the College’s Spring Meeting.

For membership details, please contact Mrs Mary Hargan([email protected]) and for further details about theAssociation please go towww.academicpaediatrics.association.googlepages.com/

Richard OlverPRESIDENT, ACADEMIC PAEDIATRICS ASSOCIATION

New voice forAcademic Paediatrics

Young people, aged 11 to 19 years, haven’t always been wellserved within paediatric practice. There is now increasingawareness of the particular needs of this group forconfidentiality, appropriate communication and consultationskills and attention to transition to adult services.

With the support of the DH and Dr Pat Hamilton, a team ofinterested paediatricians have established a group with the aimof raising the profile of young people’s health within the RCPCHand encouraging the development of high quality healthservices for young people in the UK.

Work has already commenced in a number of specific areasincluding: • 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 15thApril 2008, starting at 6.15pm. The location is to be confirmedbut full details will be available in the Spring Meetingprogramme. We would be delighted for anyone with an interestin young people’s health to attend.

If you are interested in joining the group or would like to findout more about the YPHSIG, please contact us:[email protected] or [email protected]

Dr Gill Turner and Dr Naomi JonesON BEHALF OF THE YPHSIG STEERING GROUP

Young People’s Health – anew Special Interest Groupfor the RCPCH

News

News RCPCH news

Since September 2005, doctors unable toobtain a Certificate of Completion of Training(CCT) have been able to apply instead for aCertificate of Eligibility for SpecialistRegistration. This allows experience gainedoutside approved training programmes to betaken into account. The majority ofapplications are under Article 14(4) whichrequires evidence that qualifications, trainingand experience together are equivalent to aCCT programme. A small number of doctorswho have had training outside the UK in anon-CCT specialty may apply under Article14(5) for which the requirement is a “level of knowledge and skill consistent withpractice as a consultant in the NationalHealth Service”.

Applications are made to PMETB, whichpasses them to the appropriate Royal Collegefor evaluation. Within the RCPCH, eachapplication is independently assessed by atleast 2 assessors. An evaluation report forPMETB is then prepared by College staff andultimately considered and amended by theArticle 14 Chairman or a separate seniorassessor (in discussion with the initialassessors where necessary). The finaldecision is made by PMETB based on theCollege recommendation.

Up to July 2007 the RCPCH hadreceived 110 applications. 102 were underArticle 14(4) alone, of which 26 wererecommended for approval, 34 for rejection,and 42 were awaiting assessment. Someapplications were from specialists outsidethe EEA but the majority were from SASGdoctors in the UK.

Requirements for Article 14(4) includedemonstration of CCT-equivalent competencein general, neonatal and communitypaediatrics. Acute skills must have beenmaintained up to the time of application.Avoiding submission of applications whichdo not meet these standards will saveapplicants money, save time for PMETB andthe College, and allow potentially successfulapplications to be processed more rapidly.Common reasons for rejection are: lack ofsufficient general or neonatal experience incommunity doctors, lack of sufficientcommunity and child protection experiencein general paediatricians, and general lack ofsubmission of sufficient appropriate evidence.When considering evidence to be supplied,applicants are advised to bear in mindwhether their submission shows that theyhave gained the knowledge and skills to thebreadth and depth required of a UK trainee

applying for a CCT in full.Structured reports from referees are

essential supportive evidence but insufficientin themselves. Additional concrete evidencemust be supplied. Examples of useful itemsare appraisal documentation, anonymisedwritten communications including childprotection reports, reflective entries, and evidence of leading clinical governanceactivities. 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, hasregrettably been much longer than originallyenvisaged and the resultant frustration forapplicants is fully understood. Reasons haveincluded the large number of applicationsand unavoidable changes of staff within theCollege. We are constantly striving tostreamline the process.

For further details go to the CESR page onthe College website (www.rcpch.ac.uk/cesr)and follow links from there.

Dr Andrew CottrellCHAIRMAN OF RCPCH ARTICLE 14 COMMITTEE

Application for CESR under Article 14

‘This training day will be of great valueto all College members in all branches ofpaediatrics, and to trainees’.Dr. Tony Waterston, CHAIR, ADVOCACY COMMITTEE

The day will provide an introduction tochildren's rights including the impact ofdiscrimination on children’s health andhealthcare, the structure and content of theUNCRC, and how it can be used to combatrights violations and solve value conflicts inthe best interests of children.

The day will explore how the UNCRC isrelevant to the work of paediatricians, theCollege and its Committees. There will be apractical focus on the role of the UNCRC ineveryday paediatrics.

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 protectthe lives of children, but also to create an

environment in which children’sdevelopment can flourish.

• The right to be listened to and takenseriously.

Children are entitled as of right to beconsulted about decisions that affectthem, 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.

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 withthis newsletter, or contact the Policy andStandards Administrator on 020 7307 8017.

UNCRC training day: Wednesday 20 February 2008 Palestine programmeThe 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.

Both Our NHS, Our Future 1 (ONOF) andModelling the Future 2 (MtF) are currently outfor consultation, so it seemed timely tocompare 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 similaritiesand differences in terms of remit, drivers,keywords, ideology, and solutions. Given thesimilarities in both the drivers and the‘destination’ the differences are more aboutthe ideology of how they are achieved.

Our NHS, Our Future proposescontinued implementation of the NHS Plan.Central to this plan is patient choice andcontestability between services, supported byperformance measures. Improvement isdriven by a market-driven approachassuming a range of provision to enablechoice to the consumer. Modelling the Futureproposes pathways of care, delivered byteams working collaboratively in a managednetwork, improvement being learning itselfdriven by ‘measures that motivate’ clinicians.

Our NHS, Our Future makes reference to clinically driven reform, importing models ofexcellence from overseas, but the absence ofneed for significant reform of NHS managementstructures. Modelling the Future recognises thatservices need to improve using a variety ofmethods from small-scale innovation to multi-organisational reconfiguration. In particular itrecommends that commissioning, delivery,inspection and regulation need to align witheach other to reinforce patient pathways as the building blocks for the design of services. This type of approach would inevitably meanchanges in management structures to achievethe outcomes envisioned in both documents.

Both Modelling and Our Futureemphasise the need to improve primary care.The Darzi approach is to build new healthcentres in areas of poor provision andextend GP working hours. Modellingproposes staff development and an erosionof the primary-secondary care divide withteams which may be community or hospital

based working across this boundary alldelivering safe care as close to home aspossible within that network.

There are many examples withinchildren’s services that are good practice andcould be replicated for adult services – andhopefully 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 LentonVICE PRESIDENT, HEALTH SERVICES

News

Comparing Modelling the Futureand Our NHS, Our Future

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

Keywords


• Family friendly• Pathway based• Continuously improving• Sustainable• Equitable

• Fair• Personalised• Effective• Safe• Locally accountable

• EWTD drivers • Comparisons with other countries

• 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

Drivers


• Family focused• Collaboration driven• Feedback of measures that motivate• Focus on learning

• Condition focused• Competition driven• Targets and performance measures• Focus on innovation

• Promotion of patient involvement and empowerment• Designing services around patient pathways • Developing systems for continuous improvement

Ideology


• 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.

• Localise where possible, centralise where necessary• Prevention and early intervention

Solutions

Table 1: Comparison of the two documents

References1 Department of Health (2007) Our NHS Our Future. www.nhs.uk/ournhs2 RCPCH (2007) Modelling the Future. www.rcpch.ac.uk/modellingthefuture

News RCPCH news

Get the dates in your diary!14-17 April 2008 – these are the dates of the meetingthat offers something for everyone in paediatrics.

The specialty groups provide both CPD and research updates by mixing lectures with scientificpapers. 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 inhaledsteroids?’, ‘How the GMC can support paediatricians in their practice’ and ‘The historicalcontext of child abuse’. Professor Gregory Holmes will give the 2008 Windermere Lecture onthe ‘Developmental consequences of early seizures’

In personal practice sessions you can discuss the management of conditions ranging fromhypertension to constipation via epilepsy, headache, cerebral palsy, UTI, cystic fibrosis, neonatalseizures and sleep disturbance. There are guideline sessions and symposia.

Whatever your interests you should come and meet old friends, make new ones andparticipate 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 VerityCHAIR, ACADEMIC BOARD

Spring Meeting 2008

Annual General Meeting 2008In accordance with Bye Law 8 (ii) the College wishes to serve notice to the membership thatthe next Annual General Meeting of the College will be held on Wednesday 16 April 2008 at6.15pm 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 lessthan 10 weeks before the date of the meeting (Wednesday 6 February 2008), accompanied bythe signature of 15 Ordinary Members or Fellows.

In the Autumn Newsletter I wrote about the new College research strategy. I have had some very helpful feedback frommembers and as the strategy continuallyevolves, I am still happy to hear your views – you can contact me [email protected]

I have been asked to provide somespecific examples of our research work in thisWinter newsletter. I want to showcase indetail four topical projects so that you can seethe range of work which the research divisionis involved with on your behalf. Many ofthese projects are collaborative efforts withother Colleges or stakeholders – here I amflagging the RCPCH contribution. These fourare chosen from a total of approximately 20ongoing projects to reflect the fields ofcommunity child health, the district generalacute sector and tertiary care, and provideexamples of primary research, trials, guidanceand audit. One is nearing completion, two are just starting up and one emphasisesparticularly how the RCPCH can supportother organisations and initiatives whichpromote research for children. A recentNewsletter gave information on the ‘Medicinesfor Children Information Leaflets’ project – an example of advocacy and parent andchild involvement.

1. Guidance on diagnosing Child Sexual AbuseLed on behalf of the RCPCH by Neil McIntosh & Rita Ranmal

The Child SexualAbuse project toreview the evidencebase behind thephysical signs of childsex abuse is in its finalstages. The draft 180page handbook on thephysical signs of child

sexual abuse was sent out to stakeholders,paediatricians and forensic physicians in July2007. By the close of the consultation periodwe had received over 1000 individualcomments from over 50 individuals andorganisations. Since the consultation period

closed the working groups and the researchteam have been working at full capacity to address the comments. There is a verytight timeline between now and the datewhen the book has to go to the printers to be ready for the proposed launch inSpring 2008.

2. Scoping a national audit ofurgent and emergency careLed on behalf of the RCPCH by Ian Maconochie & Louise Youle

The College has beenawarded the contract toscope a National ClinicalAudit of EmergencyCare for Children. Some examples ofthe questions theRCPCH has beenasked include:

• Recommend topics which are mostimportant and most feasible for a NationalClinical Audit.

• Recommend topics to be most likely tolead to improvements in patient care.

• Determine whether a particular type ofchild is to be audited.

• Determine whether a particular disease orcondition is to be audited.

Standards for generic emergency clinicalcare for children are scarce but the ‘red-book’ specifies some clinical standardswhich could be measured:• All children, attending emergency

departments must be visually assessedwithin the first few minutes of arrival to identify an unresponsive or critically ill child.

• All children should have a brief clinicalassessment within 15 minutes of arrival.

• All attendances of children must benotified to their primary care team.

• All parents should be offered anappointment with a consultant 3-4 monthsafter a child dies.

We also need to decide whether to audit:• All Children seen in A&E departments.

• All children admitted to hospital followingA&E attendance.

• Just walk-in patients (i.e. excludingambulance patients).

• Every child or a subset (i.e. only thosewith specific conditions).

If so, which conditions? Meningitis? Seriousinjury? Other?

This scoping exercise is ongoing.Ultimately, we would hope to be awarded the substantive contract to perform thisnational audit.

3. Medicines for ChildrenResearch Network Led by RCPCH members Ros Smyth & David Edwards

Most paediatricians recognise that treatmentsavailable for children in the NHS often lackthe evidence to inform their safe andeffective use. The government hasestablished a large national programme withsubstantial funding to address this. Theyhave established a national network, theMedicines for Children Research Network, toassist the testing of drugs for children. TheRCPCH is delighted that children feature asone of the five ‘topic-specific’ networks (theothers are diabetes, stroke, dementia, cancer)and is very supportive of this initiative, co-ordinated by the centre in Liverpool. Newresearch ideas for medicines research aregenerated ‘bottom-up’ from Clinical StudyGroups covering the breadth of child health(eg. neuroscience, respiratory etc.).Examples of the 40 studies already adoptedinclude the MENDS study of melatonin inchildren with neurdevelopmental disordersand impaired sleep; the TWICS study of oral

Research

Helping paediatricians to practiceevidence based paediatricsFour examples of research involving the RCPCH, relevant to everyday practice

Research RCPCH news

steroids for pre-school wheeze; the P3MCstudy of propranolol or pizotifen to preventmigraine; and NIRTURE – insulin for verylow birth weight infants.

However, there are many therapies forchildren which do not involve the use ofmedicines. We now have a window ofopportunity to highlight these too.

The Government’s programme has nowreached a new stage. A further nationalnetwork is being established to allow currentand new treatments to be tested anddeveloped for all the other areas of medicineoutside the five ‘topic specific’ networks. Theplan is to involve working doctors in testingtreatments as part of their normal workinglives. There will be funding available forsessional payment to clinicians to getinvolved and support to allow those whowant to start or join projects. The networksare a central part of the NHS, completelyembedded in the health service structure andbased in small and large hospitals.

We as paediatricians have theopportunity to use this to improve the care we give children and babies but wehave to take the initiative. We are at thestage where local research networks (called ‘Comprehensive Clinical ResearchNetworks’) are currently deciding whichareas they want to be involved in. Therewill be about 25 Comprehensive ClinicalResearch Networks to cover the NHS inEngland and there will be approximately 15 Specialty Network Groups, currentlyenvisaged for disease-specific fields such as gastro-enterology, nephrology etc. If weleave these to our colleagues in adultspecialties, the likelihood is that research for children will be relatively neglected. We all need to ensure that research forchildren is on their agenda and that non-medicines paediatric research isrecognised as a separate “Speciality NetworkGroup”. Currently, Comprehensive ClinicalResearch Networks directors have been sent a list, which originated with the UKClinical Research Collaboration, of a dozenareas (which will each become a SpecialityNetwork Group) and asked in which of these areas they consider theirComprehensive Clinical Research Networksto be strong. This list currently does notfeature non-medicines paediatric researchbut 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 oftheir Comprehensive Clinical ResearchNetwork and explain to them that children

need improved treatments, especially fornon-medicines therapies which are outsidethe remit of the Medicines for ChildrenResearch Network. One tangible way in which the RCPCH Research Division can support non-medicines paediatricresearch is to assist RCPCH members toattend future working groups and I haveearmarked 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 andWales in 2005. In 2005 the perinatal mortalityrate was 7.9 per 1000 and the neonatalmortality rate was 3.4 per 1000.

The National Patient Safety Agency foundthat patient safety incidents in neonatologyaccounted for more than 12 % of incidentsreported for children and young people in theNational Reporting and Learning System. In 2006the most frequently reported neonatal incidentswere medication errors (24%), treatment orprocedure errors (17%), equipment problems(10%), infrastructure issues (10%, includingstaffing) and transfer of care issues (8%).

The NPSA is funding a College project inpatient safety issues for neonatal care with theaim of developing a package of interventions(“care bundle”). A “care bundle” is “a group ofevidence based interventions related to a careprocess that, when executed together, result inbetter outcomes than when implementedindividually”. The three topics to be exploredare medication errors, infection and safetyduring transfer. The project was given fundinguntil the end of March 2009.

Professor Terence StephensonVICE-PRESIDENT FOR SCIENCE & RESEARCH

1. Surveillance of type 2 (non type 1) diabetes.

2. Development of a Bayesian Analysis methodology for child protection issues – with theRoyal 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 ofRetinopathy 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) projectson childhood morbidity and mortality.

ConclusionI hope these four examples from a very long list give you a flavour of the research whichthe College is supporting on behalf of you and your patients and their families. Some of theother projects which the College has been involved with recently are listed below.

News

Hello, I’m writing to you on the train travellinghome from the RCPCH SASG information day.What a brilliant day! I hope we will be able toput all the presentations onto the SASG sectionof the RCPCH website and would urge you tohave a look at them.

In the morning we had presentations fromMary McGraw, Vice President for Training andAssessment, Hilary Cass, Registrar, andAndrew Cottrell, Chair of the Article 14committee. We were pleased to hear that theTooke enquiry had suggested that the SASgrade will become an increasingly importantpart of the workforce. The College recognisesthat SASG doctors offer continuity and stabilityand are keen to support us to getopportunities for professional development toget the most out of our grade. We wereencouraged to look at the e-portfolio that hasbeen developed for trainees, and it was

suggested we could use it to collect evidenceof our experience and training. We were givenan overview of the current training structuresand it was pointed out that for some SASGdoctors, re-entering the training grade is apossibility. For others who are trying to enterthe specialist register via the Article 14 route,taking FTSTA posts to fill in gaps inexperience is another possibility. Dr GregDilliway explained that there has been noprogress on the proposed SASG contact. BMAmembers should be receiving a questionnaireto feed back their thoughts on the contract sothis information is ready if things progress.

The afternoon had a more clinical focuswith Dr Sebastian Kraemer helping us toconsider how we could work more effectivelywith our colleagues in child psychiatry. Hehelped us to see that we approach patients indifferent ways and that by working together

we can be more effective. Dr AnnabelleBundle, a member of the SASG committee,reminded us of the health inequalities facedby looked after children and updated us onwho can give parental consent. FinallyProfessor Terrance Stephenson, Vice Presidentfor Science and Research, impressed on ushow 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 SASGpaediatricians. 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 LythCHAIR OF THE RCPCH SASG COMMITTEE

The RCPCH Workforce Census for 2007 is nowwell under way and information has beenreceived from almost half of paediatric servicesin the UK in the first month of the survey. Withworkforce and related reconfiguration issuesbecoming increasingly important on the healthservices agenda, it is important that the Collegehas the most up to date information available. Wewould be grateful therefore if Clinical Directorsand Leads could ensure that completed censusbooklets are returned to the workforce team assoon as possible. This year, in addition to theregular census form completed by Clinical Directors,we have emailed a separate single-sided form toall those consultants where we have an accurateemail address. All individual data collected fromthe Census is treated as confidential.

If you have not received either form, blankcopies can be found on:www.rcpch.ac.uk/workforce, and by contactingMartin McColgan 020 7323 [email protected] Shazia Mahmood 020 7323 [email protected]

Managing editor: Graham Sleight

Editor: Joanne Ball

Email: [email protected]

Editorial services: Chamberlain Dunn Associates

Advertisements: British Medical Journal

Published by the Royal College of Paediatrics andChild Health, 50 Hallam Street, London W1W 6DE Tel: 020 7307 5600, Fax: 020 7307 5601 Website: www.rcpch.ac.uk Email: [email protected] College is a registered charity: no. 1057744

© 2007 Royal College of Paediatrics and Child Health. The views expressed inthis newsletter do not necessarily reflect the official positions of the RCPCH.

RCPCH newsCopy deadline for next issue:

1 February 2008

SASG News

Workforce Census 2007

Report of a working party of the Royal College of Physicians, Royal College of Radiologistsand the Royal College of Obstetricians and Gynaecologists

New guidance produced by three Royal Colleges provides the latest information on the effects ofcancer treatment on fertility.

Remarkable advances have taken place in the treatment of cancer in recent years, with amarked increase in cure rates. This new guidance, written by a multidisciplinary expert group, setsout 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 formany of these younger cancer patients fertility is or will become extremely important. The reportaims to improve standards of management of fertility, calling for nationwide provision and fundingand for a scientific approach to future developments.

Focused primarily on treatment of adults, aged 16 upwards, this guidance is essential readingfor all clinicians and health professionals involved in cancer care. The working party stresses theneed for full discussion with patients before their treatment about its possible effects on fertility, andprovides 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

The effects of cancer treatment on reproductive functions: Guidance on management

News RCPCH news

We were delighted to receive approval of ourexaminations portfolio from PMETB. Thissingular achievement (others have fallen bythe wayside) was steered by Mary McGraw,Vice President for Training and Assessment,and my predecessor as Officer forExaminations, Tom Lissauer. It is a fittingconclusion to Tom’s term of office, which hasbrought so many changes - most notably thegreat success of the new format MRCPCH andDCH clinical examinations.

The new clinical exam and large increasein candidate numbers has necessitated theappointment of additional examiners. We arepleased to have appointed over 200 newexaminers to MRCPCH and DCH in the lastthree years. Examiner training has advancedconsiderably. This has included a recent two-day training course in Cambridge whichincluded video based standardisation ofassessment. A system of analysing examinerperformance has now arrived. A five-point

analysis looks at each examiner, comparesthem with others, and includes the return ofthe legendary Hawk-Dove index. Someexaminers have now received feedback ontheir performance!

Appeals against the results of theMRCPCH clinical examination have grown,reflecting the pressure on our trainees. Thereis now a fee of £200, returnable if appeal issuccessful. To date we have had 112 appealsover 8 sittings. An Appeals Panel reviewsevidence from the appeal, the centre and onone occasion the child’s mother. Successfulappeals are unusual (6%), and all candidatesare given feedback. Good documentation byexaminers will further reduce the chances ofsuccessful appeals.

We are concerned, on recent analysis, tonote the lower levels of pass rates amongstcandidates who graduated or have trainedoverseas in comparison to the UK graduates.We are determined to address the causes,

which may lie in content orientation,language, question format, training or accessto examination preparation. Recent clinicalexamination results suggest this gap is closingand we are planning to try and further reducethe difference in pass rates by enhancedexamination preparation which will initiallybe trialled in some overseas centres.

A major future development is underway.The new Assessment Committee is engagedin a pilot study to evaluate differencesbetween work-based assessment and aformal, oral assessment in ST7. We aim toevaluate the workplace Case based Discussion(CbD) and a new, structured, multi-stationoral assessment. The initial pilot is plannedin 2008 and we are greatly assisted by theTrainees’ committee feedback and the traineeswho are on the working parties.

We would welcome your involvement inexaminations. We greatly value input bytrainees, members and Fellows. New examquestions are needed and new examinerswilling to host the exams are most welcome.Please contact Graeme Muir at the College oryour Principal Regional Examiner.Participating in exams is definitely one of thebest and enjoyable ways of of obtaining CPD.

Dr Simon NewellOFFICER FOR EXAMINATIONS

Exams: “Fit for Purpose”

Recent issues considered by the AdvocacyCommittee include:

1. Corporal punishment in the homeRecently there has been a review of theChildren Act Section 58 by the Department ofChildren, Schools and Families. Section 58applied to corporal punishment of children athome and sanctioned this as long as nobruise or visible injury was caused. TheRCPCH has long opposed the acceptance ofcorporal punishment by parents and is amember of the Children are UnbeatableAlliance which seeks to ban all violenceagainst children in the home, as hashappened in many other European countries.

The DCSF review is now complete andunfortunately has maintained the previousstance on the grounds that the majority of

parents are opposed to a ban, and ‘there areno reported significant practical problemswith its operation’. This is despite the factreported in the consultation that there iswidespread lack of understanding of what the law is, and the responses both fromchildren and from child care organisationswere firmly against the acceptance ofsmacking within law.

The RCPCH together with most otherchild care organisations is disappointed in thisoutcome and will continue to work for thesame protection for children as adults receive.

2. Bone age X-rays to determine the age ofyoung asylum seekersThere continue to be concerns over healthcare of asylum seekers (AS) and the RCPCH isexamining evidence in a number of areas. One

in which guidance has been sought byGovernment is in the determination of age,since a number of young unaccompanied ASare uncertain of their age yet their eligibility forchildren and young people’s services relies ontheir being known to be under 18yrs.

The Home Office is considering using boneor dental X-ray as a means of determining age.Whilst the RCPCH supports the need to ensurethat children are appropriately managed inchildren’s rather than adult services, it is of theview that there is no single reliable method todetermine age and that instead, a holisticevaluation should be carried out, including anarrative account and collation of informationfrom all sources available.

This opinion has been strongly expressedto Home Office ministers.

Dr Tony WaterstonCHAIR, ADVOCACY COMMITTEE

Advocacy Committee News

Trainees

MMCThe MMC programme board have beenestablished for three months. There areongoing discussions regarding therecruitment to medical and surgical training.Following open and wide consultationincluding web based consultation with amultitude of stakeholders including trainees,a number of decisions were made. Thedecision has been taken to run theapplication process on a specialty specificbasis at a local level, based upon nationallyagreed standards and principles. There willbe no national IT system in place this yearalthough there is a considerable amount ofwork going into developing an IT system for2009. The application process will commencein January 2008. Candidates will be able todemonstrate achievements as well ascompetence during this application process.

There are a number of ongoingdiscussions that will affect all medicalspecialties including the size of Units ofApplication and transferable competencies.

The IndependentInquiry into MMCThe former Secretary of State for Health,Patricia Hewitt, invited Professor Sir JohnTooke to lead an Independent Inquiry intoModernising Medical Careers (MMC) in thewake of the problems surrounding MTAS,the process used for selecting trainee doctorsfor specialist training. The interim report waspublished on 8th October 2007 highlightingthe problematic issues of MMC andproviding recommendations which are opento consultation. The trainees committee haveresponded to this consultation. Theunderlying theme is one of flexibility withinMMC which diminished significantlyfollowing its inception. It is very clear fromthe consultation that we are heading towardsa ‘mixed economy’ in which differentspecialties will adopt their own applicationprocess and potentially training pathways.The report is available onmmcinquiry.org.uk.

International MedicalGraduates and BAPIOThe British Association of Physicians of IndianOrigin (BAPIO) won their appeal on 9thNovember 2007 on the basis that advice givenby the Department of Health to NHS employersregarding doctors on the Highly SkilledMigrants Programme (HSMP) was not lawful.The Lord Justices were unanimous in agreeingthat the DH guidance was wrong. On the basisof this, International Medical Graduates areeligible to apply for Specialty Training posts inline with UK and EEA graduates.

Abolition of limitedregistrationOn 19th October 2007, the GMC abolishedlimited registration. Doctors holding limitedregistration on 19 October 2007 wereautomatically granted full registration (unlessthey were restricted to working in aFoundation Year 1 or house officer post inwhich case they received provisionalregistration), on condition that when theytake up a new post they only work in anapproved practice setting until they havefulfilled the criteria for that requirement tobe lifted. Doctors applying from overseas towork in paediatrics must fulfil several criteriaset out by the GMC; They must hold anacceptable primary medical qualification,they must have the requisite knowledge andskills for registration, their fitness to practiseis not impaired and have the necessaryknowledge of English. Doctors that carriedlimited registration should have receivednotification of these changes from the GMC.If you have not please check the GMCwebsite or contact the GMC directly.

Academic MedicineThe first stage of recruitment for AcademicClinical Fellowships has occurred before therecruitment phase for clinical posts on 15thNovember. It is vital that willing andcompetent trainees apply for academic

clinical posts. The new ‘Walport’ clinicalfellowships and lectureships provide an excellent pathway for the pursuit of an Academic career, but at an early stagefacilitate applications for obtaining research grants and working towards apostgraduate research degree. Up to 250fellowships are available in 2008 and willprovide funding for doctors and dentistsentering specialty training and for thosealready in specialty training who hold aNational Training Number. Successfulapplicants will have 25 per cent of theirtime protected so they can develop theiracademic skills.

ST7/8 AssessmentsThe Trainees Committee is currently involvedin discussion with senior members of theRCPCH regarding the potentialimplementation of an assessment process inthe final years of training. This is still verymuch in the discussion phase and nodecisions have been take as to the format ofthis process. However, the TraineesCommittee did conduct a national onlinesurvey to canvass the opinions of traineesaround the country. I would like to thankthose that completed this survey and theEWTD survey that has just taken place.

Regional Representation on the TraineesCommitteeSeveral times during the year, the Trainees Committee advertises posts forlead and deputy regional representatives.We have just welcomed onto the committee new reps from the North Westand west Midlands. I would encourage all trainees from ST1-8 to consider applying for a place on the TraineesCommittee. Traditionally representativeswere SpR. However, the only prerequisite is membership of the Collegewhich is now an MMC requirement ofSpecialty Training. Therefore, trainees from ST1-8 are welcome.

Trainees’column

Paul Dimitri [email protected]

Meetings RCPCH news

UK meetings and courses

200814-18 January Health Protection, Promotion and PreventionVenue: Warwick Medical School, CoventryContact: Annette FinnTel: 024 7652 2035Email: [email protected]: www.warwick.ac.uk/go/childhealth

29 January BritSPAG Training Day – joint RCOG/BritishSociety of Paediatric and AdolescentGynaecology meetingVenue: College of Obstetricians andGynaecologists, LondonContact: Conference OfficeTel: 020 7772 6245 Email: [email protected]: www.rcog.org.uk/meetings

27 February Running Sexual Assault Services forChildren: St. Mary’s Centre 6th AnnualConference 2008Venue: Town Hall, ManchesterContact: Claire GledhillTel: 0161 276 6515

Email: [email protected]: www.stmaryscentre.org

25-29 February Other Forms of Diabetes: From Genetics to ObesityVenue: Warwick Medical School, CoventryContact: Mary NejedlyTel: 024 7657 4634Email: [email protected]: www.warwick.ac.uk/go/childhealth

28 February Cardiology in Neonates and InfantsVenue: National Heart and Lung Institute, LondonContact: Karina DixonTel: 020 7351 8172Email: [email protected]: www1.imperial.ac.uk/medicine/about/divisions/nhli/events/

10-14 March Child Law and Child ProtectionVenue: Warwick Medical School, CoventryContact: Annette FinnTel: 024 7652 2035Email: [email protected]: www.warwick.ac.uk/go/childhealth

14-17 April RCPCH 12th Spring MeetingVenue: University of York, York

Contact: Aaron BarhamTel: 020 7307 5633Email: [email protected]: www.rcpch.ac.uk/Education/Events/RCPCH-Annual-Spring-Meeting

14-18 April Developmental Paediatrics and Special NeedsVenue: Warwick Medical School, CoventryContact: Annette FinnTel: 024 7652 2035Email: [email protected]

May 2008 Court Skills in Child Protection (England and Wales)Venue: RCPCH, LondonContact: Aaron BarhamTel: 020 7307 5633Email: [email protected]: www.rcpch.ac.uk/Education/Education-Courses-and-Programmes/ Court-Skills-in-Child-Protection

12-16 May Diploma in Paediatric Nutrition5-day College Diploma CourseVenue: Chilworth Manor Hotel, SouthamptonContact: Education Projects AdministratorTel: 020 7307 5644Website: www.rcpch.ac.uk/Education/Education-Courses-and-Programmes/Diploma-in-Paediatric-Nutrition

RCPCH meetings

Media updateWe've been talking to journalists about manythings over the past few months, includinggrowth charts, respecting the rights of childrenand young people and child asylum seekers.

When the Department of Health issued aresponse in August to the joint report submittedby the Scientific Advisory Committee on Nutrition(SACN) and the RCPCH on child growthstandards, we spoke to the media on the subject.Peter Aggett, chair of the Nutrition Committeewas quoted in a few of the nationals and tookpart in a discussion on Radio 4 Women’s Hour,with the National Childbirth Trust.

Also in August, Russell Viner talked onbehalf of the College to the Daily Telegraphabout hypertension in children and adolescents,and Terence Stephenson also spoke to the DailyTelegraph about feverish illness in children.

News coverage in September kicked off

with the RCPCH Policy Officer, Geoff Lawson,talking to the Scotsman about the benefits ofbreastfeeding. In late September, the GMClaunched new guidance asking doctors torespect the rights of under 18s. PatriciaHamilton was quoted on the BBC News websitesaying that “this is an important step forward inensuring the medical profession recognises thatchildren are not just little adults and that theirspecific needs should be met accordingly.”

The College issued a press statement inearly October about Channel 4's Bringing UpBaby programme – in essence voicing concernabout some of the child-rearing practicesportrayed in the programme and in particularsleeping arrangements. We strongly advisedviewers in our press statement if they wereconsidering any of the methods shown in theprogramme to read the Department of Health’sguidance on reducing the risk of cot death.The statement was covered in the Times andObserver and discussions and opinion in the

media continue surrounding this programme.Also in October, the Royal College ofObstetricians and Gynaecologists launched ajoint report entitled Safer Childbirth, which theCollege was heavily involved in and we arementioned in much of the coverage.

Moving into November, the Guardianinterviewed Sir Al Aynsley-Green, the children'scommissioner for England, about establishing theage of asylum seeking children and whether x-rays should be used to do this. Hilary Cass wasalso quoted in the Guardian article explainingthat there is no good research evidence for theuse of x-rays for age assessment.

To keep up-to-date with any statementsthat the College makes, or the latest news inpaediatrics and child health, go towww.rcpch.ac.uk

Claire BrunertHEAD OF MEDIA

rcpch newsletter 07 winter

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