521933 research-article2014
RSH0010.1177/1757913914521933In PracticeIn Practice
In Practice
In Practice Integrated paediatric training to improve child health Reports often highlight that the UK has higher mortality and morbidity rates than other European countries. Dr Chloe Macaulay, a Paediatric Registrar at North Middlesex Hospital, takes a look at the solutions to support the delivery of improved healthcare to children in the UK, including schemes such as the Learning Together project which integrates child health training and primary care.
Various reports have highlighted substandard care for children in the UK, with higher mortality and morbidity rates than its European counterparts being found.1 Despite the recognition that there are a wide number of social and environmental determinants of child health, health service quality is an important factor which deserves our attention and scrutiny. Our current health system in the United Kingdom is the legacy of many historical and bureaucratic structural changes: primary care is the remit of general practitioners (GPs), who provide a familycentred first point of care for children, what Americans call the ‘medical home’, and act traditionally as gatekeepers to secondary specialist care, either in hospital or in community settings. There are obvious problems with this system as far as children are concerned, with decreasing numbers of GPs training formally in paediatrics, a rising use of the emergency services by parents and carers, and unclear responsibilities when it comes to care of those children with chronic longstanding illnesses and disabilities.2 Moreover, the UK is falling behind its European neighbours in terms of child health outcomes, and the escalating costs in the health service have forced us to reconsider the traditional models of service provision.
The Government is committed to care closer to home, and ‘integrated care’ has been a catchphrase for some time now. The concept, of different agencies and individuals working together around the needs of children and their families, delivering care in a much more coordinated way, is something that parents desire and commissioners are striving for. To this end, we need to think about training a workforce for the future, where services for children are arranged around children not around historical structures and fixed geographical locations.3
The current training status quo
know and be able to manage as GPs. A minority complete a dedicated paediatrics placement, although this is often not particularly focused on their future needs as relatively autonomous community practitioners: GP trainees often fill in for hospital rotas, covering acute out-of-hours services, neonatal units, blood-taking services and so on. GPs will argue that the majority of their paediatric training takes place within primary care and is therefore heavily dependent on the confidence and competence of their GP trainers. While a number of locations support innovative training programmes in paediatrics, and the Royal College of General Practitioners (RCGP) supports the idea of extending GP training to four years, the money is not there yet, and there is therefore a need to think creatively within these current constraints.
Current training reflects the service status quo: paediatricians are trained almost exclusively within and for a hospitalbased system. There is a large emphasis on acute care and inpatient paediatrics, with chronic or long-term condition care Looking for solutions often receiving less focused attention. A The Department of Health’s Education recent survey of paediatric trainees in Outcomes Framework aims to ‘ensure London reported that over half felt that the workforce has the right skills inadequately trained in managing longbehaviour and training…to support the term conditions.4 With the increasing delivery of excellent healthcare…’.6 sub-specialisation of community Another document, the Children and paediatrics, there is less appreciation of Young People’s Health Outcomes Forum, the nature of localities, their practitioners’ reported that all children want to be seen strengths and weaknesses and the by people who have been trained in resources available to looking after children.7 families. This is being This is currently not the paediatric somewhat addressed in case, and we are trainees...felt undergraduate training as certainly not training our inadequately ‘the patient journey’ and child healthcare trained in patient experiences are workforce for the future. managing longgaining a more central Coordinated and efficient term conditions services for children place in curricula,5 but there delivered by professionals is still a way to go. from a number of GPs complete a three different disciplines require a mutual year training programme to cover the understanding of each other’s roles and breadth and depth of what they need to
March 2014 Vol 134 No 2 l Perspectives in Public Health 65 Downloaded from rsh.sagepub.com at UNIVERSITE LAVAL on May 10, 2015
In Practice patients before and after, with post-clinic responsibilities. While different health discussion and supervision by the GP professionals are usually siloed in their trainer and the Consultant Paediatrician. undergraduate or early postgraduate The patients are then discussed in training, ‘on the job’ experience is often practice meetings after the clinic, which multi-professional. Given that we are all cascades learning to the wider GP team working together for a common aim, and supports continuity of patient care. should we not be training together? To date, over 30 paediatric and GP One example of such an initiative is the trainees have taken part in these clinics. Learning Together project. The London They report valuable learning, not only in Schools of Paediatrics and General clinical and communication knowledge Practice have developed a model of and skills but also in a shift of shared training clinics, called Learning perspective: almost all described that Together clinics, which are currently participating in the clinics and working being scaled-up across areas of North together was a departure from much that Central and East London. they had done before, and this Central to the model impacted not only on the is a joint integrated patients they saw together but child health training cascades also on subsequent patients clinic held within learning to the they saw alone. One paediatric primary care, with GP wider GP team trainee commented ‘… learnt and paediatric higherand supports about how much parental level trainees sitting in continuity of anxiety a GP has to hold and the same room seeing patient care manage’. A GP trainee stated, patients together, and ‘I learnt how to differentiate learning from one between children who can be treated in another. An extension of the learning primary care and those who need further comes from pre- and post-patient investigation … I am much more likely to discussion, case-related reading and pick up the phone and discuss a patient follow-up of the patient journey. Patients with a paediatrician’. for the clinics are referred and selected by On the basis of this pilot work general practice staff: a typical clinic might University College London (UCL) Partners have four to six secondary care-type (UCL’s Academic Health Science Centre) referrals or long-term condition reviews has been awarded funding to roll-out the (20 to 30 minute slots) followed by two clinics with an added inter-professional acute, walk-in type appointments. element to all North Central and East Trainees are encouraged to discuss the
London areas, offering project support and a robust evaluation of the value of this learning intervention. The aim is to make the case for such inter-professional integrated training to become an integral part of postgraduate training. This model is being developed within paediatrics but is certainly generalisable to many other patient groups, and some pilot work is currently being developed within care for the elderly groups. These clinics are an example of more integrated child health training: training professionals together, to work together, and also of developing new ways of working. Joint learning is certainly not all of the solution to transforming the care we provide to children, but it has the potential to be a central part. Through initiatives such as these we have the opportunity not just to give practitioners new skills but to have a real impact on patient care. A child public health approach to service delivery at an individual patient and family-level strengthens the practitioner knowledge of these determinants in dealing with the case in front of them. However, over time, a much greater appreciation of population-level factors will enhance both GP and paediatrician awareness and effectiveness in delivering preventive measures. Watch this space for further results. Dr Chloe Macaulay Paediatric Registrar, North Middlesex Hospital
References 1. Wolfe I, Cass H, Thompson MJ, Craft A, Peile E, Wiegersma PA et al. Improving child health services in the UK: Insights from Europe and their implications for the NHS reforms. British Medical Journal 2011; 342: d1277. 2. UNICEF. Innocenti Report Card. UNICEF Office of Research, 2013. Available online at: http://www. unicef-irc.org/publications/series/16/ (Last accessed 28th January 2013). 3. Kennedy I. Getting It Right for Children and Young People. DOH, September 2010. Available online at:
https://www.gov.uk/government/uploads/system/ uploads/attachment_data/file/216282/dh_119446. pdf 4. London School of Paediatrics Trainee Survey, 2012 (Last accessed 22nd January 2014). 5. Muir F. Placing the patient at the core of teaching. Medical Teacher 2007; 29(2–3): 258–60. 6. DOH. The Education Outcomes Framework. DOH, March 2013. Available online at: https://hee.nhs. uk/work-programmes/education-outcomes/(Last accessed 22nd January 2014).
66 Perspectives in Public Health l March 2014 Vol 134 No 2 Downloaded from rsh.sagepub.com at UNIVERSITE LAVAL on May 10, 2015
7. DOH. Children and Young People’s Health Outcomes Forum. DOH, 2012. Available online at: https://www.gov.uk/government/publications/ independent-experts-set-out-recommendationsto-improve-children-and-young-people-s-healthresults (Last accessed 22nd January 2014).
RSH0010.1177/1757913914521933In PracticeIn Practice
In Practice
In Practice Integrated paediatric training to improve child health Reports often highlight that the UK has higher mortality and morbidity rates than other European countries. Dr Chloe Macaulay, a Paediatric Registrar at North Middlesex Hospital, takes a look at the solutions to support the delivery of improved healthcare to children in the UK, including schemes such as the Learning Together project which integrates child health training and primary care.
Various reports have highlighted substandard care for children in the UK, with higher mortality and morbidity rates than its European counterparts being found.1 Despite the recognition that there are a wide number of social and environmental determinants of child health, health service quality is an important factor which deserves our attention and scrutiny. Our current health system in the United Kingdom is the legacy of many historical and bureaucratic structural changes: primary care is the remit of general practitioners (GPs), who provide a familycentred first point of care for children, what Americans call the ‘medical home’, and act traditionally as gatekeepers to secondary specialist care, either in hospital or in community settings. There are obvious problems with this system as far as children are concerned, with decreasing numbers of GPs training formally in paediatrics, a rising use of the emergency services by parents and carers, and unclear responsibilities when it comes to care of those children with chronic longstanding illnesses and disabilities.2 Moreover, the UK is falling behind its European neighbours in terms of child health outcomes, and the escalating costs in the health service have forced us to reconsider the traditional models of service provision.
The Government is committed to care closer to home, and ‘integrated care’ has been a catchphrase for some time now. The concept, of different agencies and individuals working together around the needs of children and their families, delivering care in a much more coordinated way, is something that parents desire and commissioners are striving for. To this end, we need to think about training a workforce for the future, where services for children are arranged around children not around historical structures and fixed geographical locations.3
The current training status quo
know and be able to manage as GPs. A minority complete a dedicated paediatrics placement, although this is often not particularly focused on their future needs as relatively autonomous community practitioners: GP trainees often fill in for hospital rotas, covering acute out-of-hours services, neonatal units, blood-taking services and so on. GPs will argue that the majority of their paediatric training takes place within primary care and is therefore heavily dependent on the confidence and competence of their GP trainers. While a number of locations support innovative training programmes in paediatrics, and the Royal College of General Practitioners (RCGP) supports the idea of extending GP training to four years, the money is not there yet, and there is therefore a need to think creatively within these current constraints.
Current training reflects the service status quo: paediatricians are trained almost exclusively within and for a hospitalbased system. There is a large emphasis on acute care and inpatient paediatrics, with chronic or long-term condition care Looking for solutions often receiving less focused attention. A The Department of Health’s Education recent survey of paediatric trainees in Outcomes Framework aims to ‘ensure London reported that over half felt that the workforce has the right skills inadequately trained in managing longbehaviour and training…to support the term conditions.4 With the increasing delivery of excellent healthcare…’.6 sub-specialisation of community Another document, the Children and paediatrics, there is less appreciation of Young People’s Health Outcomes Forum, the nature of localities, their practitioners’ reported that all children want to be seen strengths and weaknesses and the by people who have been trained in resources available to looking after children.7 families. This is being This is currently not the paediatric somewhat addressed in case, and we are trainees...felt undergraduate training as certainly not training our inadequately ‘the patient journey’ and child healthcare trained in patient experiences are workforce for the future. managing longgaining a more central Coordinated and efficient term conditions services for children place in curricula,5 but there delivered by professionals is still a way to go. from a number of GPs complete a three different disciplines require a mutual year training programme to cover the understanding of each other’s roles and breadth and depth of what they need to
March 2014 Vol 134 No 2 l Perspectives in Public Health 65 Downloaded from rsh.sagepub.com at UNIVERSITE LAVAL on May 10, 2015
In Practice patients before and after, with post-clinic responsibilities. While different health discussion and supervision by the GP professionals are usually siloed in their trainer and the Consultant Paediatrician. undergraduate or early postgraduate The patients are then discussed in training, ‘on the job’ experience is often practice meetings after the clinic, which multi-professional. Given that we are all cascades learning to the wider GP team working together for a common aim, and supports continuity of patient care. should we not be training together? To date, over 30 paediatric and GP One example of such an initiative is the trainees have taken part in these clinics. Learning Together project. The London They report valuable learning, not only in Schools of Paediatrics and General clinical and communication knowledge Practice have developed a model of and skills but also in a shift of shared training clinics, called Learning perspective: almost all described that Together clinics, which are currently participating in the clinics and working being scaled-up across areas of North together was a departure from much that Central and East London. they had done before, and this Central to the model impacted not only on the is a joint integrated patients they saw together but child health training cascades also on subsequent patients clinic held within learning to the they saw alone. One paediatric primary care, with GP wider GP team trainee commented ‘… learnt and paediatric higherand supports about how much parental level trainees sitting in continuity of anxiety a GP has to hold and the same room seeing patient care manage’. A GP trainee stated, patients together, and ‘I learnt how to differentiate learning from one between children who can be treated in another. An extension of the learning primary care and those who need further comes from pre- and post-patient investigation … I am much more likely to discussion, case-related reading and pick up the phone and discuss a patient follow-up of the patient journey. Patients with a paediatrician’. for the clinics are referred and selected by On the basis of this pilot work general practice staff: a typical clinic might University College London (UCL) Partners have four to six secondary care-type (UCL’s Academic Health Science Centre) referrals or long-term condition reviews has been awarded funding to roll-out the (20 to 30 minute slots) followed by two clinics with an added inter-professional acute, walk-in type appointments. element to all North Central and East Trainees are encouraged to discuss the
London areas, offering project support and a robust evaluation of the value of this learning intervention. The aim is to make the case for such inter-professional integrated training to become an integral part of postgraduate training. This model is being developed within paediatrics but is certainly generalisable to many other patient groups, and some pilot work is currently being developed within care for the elderly groups. These clinics are an example of more integrated child health training: training professionals together, to work together, and also of developing new ways of working. Joint learning is certainly not all of the solution to transforming the care we provide to children, but it has the potential to be a central part. Through initiatives such as these we have the opportunity not just to give practitioners new skills but to have a real impact on patient care. A child public health approach to service delivery at an individual patient and family-level strengthens the practitioner knowledge of these determinants in dealing with the case in front of them. However, over time, a much greater appreciation of population-level factors will enhance both GP and paediatrician awareness and effectiveness in delivering preventive measures. Watch this space for further results. Dr Chloe Macaulay Paediatric Registrar, North Middlesex Hospital
References 1. Wolfe I, Cass H, Thompson MJ, Craft A, Peile E, Wiegersma PA et al. Improving child health services in the UK: Insights from Europe and their implications for the NHS reforms. British Medical Journal 2011; 342: d1277. 2. UNICEF. Innocenti Report Card. UNICEF Office of Research, 2013. Available online at: http://www. unicef-irc.org/publications/series/16/ (Last accessed 28th January 2013). 3. Kennedy I. Getting It Right for Children and Young People. DOH, September 2010. Available online at:
https://www.gov.uk/government/uploads/system/ uploads/attachment_data/file/216282/dh_119446. pdf 4. London School of Paediatrics Trainee Survey, 2012 (Last accessed 22nd January 2014). 5. Muir F. Placing the patient at the core of teaching. Medical Teacher 2007; 29(2–3): 258–60. 6. DOH. The Education Outcomes Framework. DOH, March 2013. Available online at: https://hee.nhs. uk/work-programmes/education-outcomes/(Last accessed 22nd January 2014).
66 Perspectives in Public Health l March 2014 Vol 134 No 2 Downloaded from rsh.sagepub.com at UNIVERSITE LAVAL on May 10, 2015
7. DOH. Children and Young People’s Health Outcomes Forum. DOH, 2012. Available online at: https://www.gov.uk/government/publications/ independent-experts-set-out-recommendationsto-improve-children-and-young-people-s-healthresults (Last accessed 22nd January 2014).
