Working lives: Context

Here we summarise the results of our survey of members and explore the recent changes to paediatric training.

Most of you reading this will either be paediatricians or closely linked to the profession and will therefore have some idea of the current context of being a paediatrician in 2020.

In February 2020, we ran a survey across our UK membership, and over 300 paediatricians took the time to share their views with us, reflecting on the past and joining us on a journey to the future.

This summary is a reflection on your thoughts from the members’ survey, in addition to insight taken from our work on Shape of Training[1] and reports produced by the RCPCH workforce team[2].

Survey of RCPCH members

Here are some of the thoughts from our members shared in the survey conducted in February 2020. We have focused in particular on the following question:

“In the last ten years, what one change, initiative, idea or process has impacted the most on your working life?”

We have used grounded theory[3] to analyse the qualitative responses that we received. As well as our summary below, the full set of responses to the question are presented as a flowchart further down this page.

Key themes

  • The most pressing concern and the largest perceived risk to delivering effective paediatric service is staffing levels. This includes rota gaps, difficulties in recruitment and retention within the specialty, and work force gaps due to Brexit and the departure of valued overseas colleagues.
  • Service concerns were also shared, especially lack of continuity of service and reduced individual ownership of patients. It was felt this could lead to a lack of longer-term understanding and impact on health outcomes.
  • In terms of training, some felt the change in training to a competency-based system has led to less core knowledge, and lack of confidence in trainees. The sub/super specialisation causes loss of general skills and gaps in delivered care.
  • The number of children with complex medical needs has increased very significantly, and their care has placed a large demand on paediatric care. Equally there are concerns about the increased number of parents, who are worried but have well children, needing secondary care, as primary care is not enough. Public expectation of health and ability to manage risk has changed.
  • Years of austerity and conservative policies have led to increasing inequalities. Societal changes have followed, with an increase in violence and drug and alcohol addiction. This has affected children, both directly and indirectly. Social media has brought pressures, with some children and young people feeling bullied and isolated. Child safeguarding has needed to increase as a direct consequence of poverty.
  • Social media coverage of the management of complex patients has led to conflict and disagreement between parents and health care staff. Defensive medicine leads to unnecessary and harmful interventions as well as increasing costs. Doctors being accused of manslaughter and brought to court has led to low morale. An awareness of the lack of diversity and inclusion across our specialty, within the RCPCH, and also within clinical leadership and research, is a concern.
  • Funding for the NHS, commissioning and the risk of privatisation are a concern for current paediatricians. IT systems and how they affect practice are often not thought through and, despite being there to help, can create dangerous and unsafe situations.

Figure 1: In the last ten years, what one change, initiative, idea or process has impacted the most on your working life?

These views of RCPCH members were given through an online survey undertaken shortly before the COVID-19 pandemic. Some of these issues will be felt more intensely and changed dramatically during the pandemic: for example, the issues with rotas both became more significant and at the same time were ‘resolved’ through direct involvement of trainees and enormous flexibility and ability to change.

But most of the concerns our members expressed in the survey are pertinent for the present and future.

Workforce census

RCPCH conducts a biannual workforce census,[4] which gives the College a detailed picture of paediatric and child health services and staffing across the UK. These are used to produce spotlight reports on the workforce in each UK nation in addition to reports focused on particular workforce cohorts, including staff grade, associate specialist and specialty (SAS) doctors and the vulnerable children workforce. The data help with workforce planning and make recommendations around rota gaps and winter pressures, in addition to other necessary changes in the paediatric workforce, including greater recruitment and retention.

The child health workforce across the UK is suffering from the same planning problems, underfunding and staffing issues as the rest of the health workforce.[5] There is growing evidence that workforce problems are affecting the delivery of high quality, safe paediatric services in each of the UK countries.

The latest report, published in 2019 and based on 2017 census data, made a number of clear recommendations.

  • Planning the child health workforce: a strategy for the child health work force should be produced based on modelling until at least 2030.
  • Recruiting, training and retaining more paediatricians: there should be an increase in number of Paediatric and general practice trainees, including from overseas through the medical training initiative (MTI). SAS doctors should be supported in their career development
  • Incentivising the paediatric workforce: The Department of Health should offer pay incentives to trainees and returning paediatrician, where recruitment is difficult.
  • Attracting more overseas-trained doctors and health professionals: new migration systems need to take into account the value and contribution of overseas doctors to the NHS
  • Planning for and expanding the non-medical workforce: there needs to be a career strategy for advanced clinical practitioners, including advanced nurse practitioners and work should continue on the model of physician associates, as applicable to the NHS.

Paediatric training

Paediatric training before 1993 consisted of numerous appointments as senior house officer (SHO), registrar and senior registrar, of unsupervised service provision. There was no formal assessment, apart from the College examinations and feedback was considered ‘unstructured, unreliable and invalid’.

In 1993 Sir Kenneth Calman, the then Chief Medical Officer for England, produced reforms, called ‘Hospital Doctors – Training for the Future’.[6] The Calman reforms consisted of a shorter, more structured training pathway. Independent clinical competency could and had to be achieved within a fixed time period, rather than previous, when the end of training occurred when a consultant post was obtained. The National Training Number (NTN) and the yearly appraisal were introduced.

The next major change to postgraduate medical training took place in 2005, when Modernising Medical Careers (MMC) was introduced, with a focus of introducing a two-year foundation training programme and plans to review the content and lengths of training programmes, including the SAS doctor careers.[7] There were concerns with MMC’s inflexibility for recruitment, with fixed training numbers. Together with an increased awareness of the need of the patient population, further changes to postgraduate medical education were considered.

Shape of Training

Since 2018, paediatric specialty training has been laid out in the Progress curriculum, which describes the relevant generic and specialty specific competencies, divided currently into three levels of training

The RCPCH has produced a strategic implementation plan of its vision of the Shape of Training report, produced by Professor Greenaway in 2013, which provided a detailed view on the need to reform postgraduate medical training.[8]

The newly proposed changes will include greater flexibility, allowing doctors to progress faster through the training programme, to spend time out of the training programme and to obtain cross-boundary learning with primary care, child mental health services. It offers entry and exit points during training and has a strong emphasis on the ability to obtain training out of programme or have a period of pausing training. It also supports a flexible academic training pathway.

The Progress curriculum[9] was devised with the flexibility and adaptability of the need for change in mind and is able to move to a two level, shorter training programme. Shape of Training outlines the need for medical careers to be sustainable, with opportunities for doctors to change roles and specialties throughout their career. It promotes flexibility and very much fits with a vision for training in 2040.

To help implement the Progress+ curriculum as part of the Shape of Training initiative, the RCPCH published ‘Paediatrician of the Future: Delivering really good training’ in 2020.[10] This report embodies the RCPCH philosophy of keeping children and young people at the centre of everything, whilst managing training in the best possible way, with all workforce issues in mind (rota gaps, workload issues) and looking at the future.

Eleven training principles emerged, with defined standards, indicative examples of good practice and practical case studies to support each principle:

  1. Every patient encounter is a learning opportunity
  2. Complex case management provides rich learning opportunities
  3. Clinical reasoning skills are explicitly taught within training
  4. Patients and families are heard
  5. A biopsychosocial approach is applied at all times
  6. Leadership skills are developed and nurtured
  7. Training time and learning opportunities are prioritised within the workplace
  8. Educational supervision is high quality and provides consistency
  9. Morale and job satisfaction is improved
  10. Assessment is used as a learning tool
  11. Progression and length of training are personalised and flexible.

This report advises on developing a really good training programme, using patients and parents as educators, promoting learning in settings other than hospitals, having an increased focus on mental health, health promotion, and working with primary care. Good training programmes in the future should include use of simulation teaching, teaching about human factors, and sharing learning with other professionals and disciplines.

Looking ahead

When we surveyed our members in February 2020 about their reflections on the past, we also did a small thought experiment, where we asked participants to join in a journey to imagine the future.

Of particular relation to the context of this work are the responses to the following question:

“In 2040, what is the top thing you want to be different about the working lives of paediatricians?”

The responses that we received have been themed, and we will be looking at some of these themes in more detail.

Figure 2: In 2040, what is the top thing you want to be different about the working lives of paediatricians?

In summary...

Paediatricians are concerned about their working lives. Every day, they feel the impact of the lack of staffing. They reflect on how the change of paediatric working conditions impacts their clinical practice. Morale can be low and they are aware of changes in society having an impact on their way of working, with concerns of wider social issues, including inequality and poverty impacting on child health.

The College has been at the forefront of making policy makers and governments aware of staffing issues and workforce strategies for a number of years. More recently, we have produced a plan for changes to training, fitting the current need of patients and allowing greater flexibility.

These challenges are not going to go away overnight. Although we want to be aspirational in our vision for the next 20 years, we need to be practical. We have a long way to go in order to achieve what our members want to see.

References

VisualV1 - PlusCreated with Sketch. VisualV1 - Plus CopyCreated with Sketch.
(1)

RCPCH – Shape of Training. https://www.rcpch.ac.uk/shape-of-training 

(2)

RCPCH – Workforce and service design. https://www.rcpch.ac.uk/work-we-do/workforce-service-design

(3)

Chun Tie Y, Birks M, Francis K. Grounded theory research: A design framework for novice researchers. SAGE Open Med. 2019;7:2050312118822927. Published 2019 Jan 2. doi:10.1177/2050312118822927.

(5)

The Health Foundation, The King’s Fund, and Nuffield Trust, The health care workforce in England. 2018: https://www.nuffieldtrust.org.uk/files/2018-11/health-foundation-king-s-fund-and-nuffield-trust-the-health-care-workforce-in-england.pdf

(6)

Sir Kenneth Calman CMO 1993; Hospital Doctors – Training for the future.

(7)

UK Government. Modernising Medical Careers. Download PDF

(8)

David Greenaway. Securing the future of excellent patient care. October 2013. Download PDF

VisualV1 - ArrowCreated with Sketch. VisualV1 - ArrowCreated with Sketch.