You are the Future!

Dr Cliona Ni Bhrolchain, CSAC ChairCCH Trainees Study Day

19.4.13(With thanks to Martin McColgan and Jack Cornish for collating some of the

figs in this presentation)

Where are we now?(The retirement time bomb)

<35 35-39 40-44 45-49 50-54 55-59 60-64 65+0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

SpecialistGeneralCommunity

RCPCH 2011 Census

The retirement time bomb

<35 35-39 40-44 45-49 50-54 55-59 60-64 65+0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

SpecialistGeneralCommunity

RCPCH 2011 Census

The retirement time bomb

<35 35-39 40-44 45-49 50-54 55-59 60-64 65+0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

SpecialistGeneralCommunity

50% of CCH consultants are > 50

RCPCH 2011 Census

Number of CCH consultants nearing retirement

Age in years Number of CCH Consultants

50 3151 2652 1653 2454 2455 2756 2757 2158 2159 2260 1761 1462 1763 864 865+ 13

• Approx 20 – 25 CCTs per year needed just to replace consultants

• Doesn’t include– Varying retirement ages– Expansion– Attrition e.g. overseas– SSASG post conversions

• Likely to need ~30 - 35 per year in total

Martin McColgan personal communication

How many CCTs in CCH are awarded each year?

Year No. awarded

2010 15

2011 20

2012 10 (+5) = 15

Expected (24 CCT dates unknown)

2013 22 (+1) = 23

2014 16

2015 15

• Vacancy rate for CCH posts = 4.3% (vs 7.3% in 2009)• Vacancy rates for other posts = 2.4% (general paediatrics);

1.5% (tertiary specialists)

Jack Cornish personal communication

What kind of posts are being advertised?

Tertiar

y

Genera

l

Combined

Community

N/K

0

5

10

15

20

25

30

Consultant posts advertised 1996, 2001, 2011 and 2013

1996 2001 2011 2013

And last week…

• Another 6 posts advertised!!

• = 18 posts in 7 weeks

What about paediatric audiology?

0102030405060708090

100

Cumulative retiral as a % of current workforce

Consultant

AssociateSpecialist/SCMO

Staff Grade/CMO

Specialist Registrars

BACDA census 2005

Service lead

Electrophysiological diagnostic follow up as

part of the newborn hearing scheme

Targeted follow up of babies with risk factors for late-onset hearing

impairment

Audiology services for older babies and

children up to 3 years

Medical diagnostic service for babies who are found to be hearing

impaired in the early weeks of life

Medical diagnostic service for children of

any age

No. % No. % No. % No. % No. %

Audiological scientist 66 39.1% 49 29.0% 47 27.8% 0 0.0% 0 0.0%

Consultant adult audiovestibular physician 5 3.0% 6 3.6% 8 4.7% 5 3.0% 7 4.1%

Consultant community paediatrician 0* NA 0* NA 0* NA 28 16.6% 28 16.6%

Consultant community paediatrician with an interest in audiology

11 6.5% 16 9.5% 17 10.1% 22 13.0% 21 12.4%

Consultant general paediatrician 0* 0.0% 0* 0.0% 0* 0.0% 20 11.8% 15 8.9%

Consultant paediatric audiovestibular physician 12 7.1% 17 10.1% 16 9.5% 16 9.5% 15 8.9%

ENT consultant 0* NA 0* NA 0* NA 20 11.8% 23 13.6%

SSASG audiovestibular physician 5 3.0% 4 2.4% 5 3.0% 4 2.4% 4 2.4%

SSASG community paediatrician 22 13.0% 36 21.3% 41 24.3% 34 20.1% 34 20.1%

Provided by another service 37 21.9% 25 14.8% 25 14.8% 14 8.3% 13 7.7%

Other 10 5.9% 12 7.1% 10 5.9% 4 2.4% 4 2.4%

Not provided in this area 1 0.6% 4 2.4% 0 0.0% 2 1.2% 5 3.0%

Clinical Supervisor for SSASG No %

Consultant adult audiovestibular physician 9 9.2%

Consultant community paediatrician 42 42.9%

Consultant community paediatrician with an interest in audiology 16 16.3%

ENT consultant 14 14.3%

General paediatrician 9 9.2%

Other 8 8.2%

Total 98 100.0%

Why is this important?

‘Analysis …showed that audiovestibular physicians and paediatricians in audiology were more likely than other specialists to request level 1 (aetiological) investigations’

Rangan S, Borgstein B, Lowe J. Deafness in children: a national survey of aetiologicalinvestigations. BMJ Open 2012;2:e001174 doi:10.1136/bmjopen-2012-001174

What about combined posts?

RCPCH Census 2001 - 11

2001 2003 2005 2007 2009 20110

50

100

150

200

250

300

350

400

Number of combined posts 2001 - 2011(All career grades)

2001 2003 2005 2007 2009 20110%

2%

4%

6%

8%

10%

12%

Proportion of combined posts 2001 - 2011(All career grades)

What happens to CCT holders?

• 15 (4.7%) CCTs awarded in CCH – vs 21.6% of consultant workforce– All but 1 in substantive post

• Another 8 working in CCH with a CCT in general paediatrics i.e. not fully trained in CCH

• Why?– 198 (62.7%) CCTs in general paediatrics

• vs 41.4% of consultant workforce

RCPCH 2010 CCT Holder Survey

What's changing?More training places being created to meet demand!

Expanding• East Midlands South (new

post recognised)• Mersey (competitive

interviews: unable to accommodate 2 applicants)

• South West/Peninsula (seeking to expand)

• Wales (already expanding)• Yorks & Humber South

(seeking to re-establish CCH training in Sheffield)

Reviewing posts• South London • North West• W Midlands

Top up Training needs• CCT holder survey• North West• Re-entry programmes

How many CCH trainees are there?

RCPCH Education & Training Support

Yorkshire and Humber Deanery

Wessex Deanery

Kent, Surrey and Sussex Deanery (KSS)

East of England Deanery

Scotland (all deaneries)

Northern Ireland

Peninsula Deanery

North Western Deanery

Wales Deanery

East Midlands Deanery (South)

West Midlands Deanery

East Midlands Deanery (North)

London Deanery

Severn Deanery

Mersey Deanery

Oxford Deanery

Northern Deanery

0 2 4 6 8 10 12 14 16 18 20

Number of trainees 2012 n=58

Northern Ireland

Kent, Surrey and Sussex Deanery (KSS)

Wessex Deanery

SW/Peninsula Deanery

Scotland (all deaneries)

Yorkshire and Humber Deanery

East Midlands Deanery (South)

East of England Deanery

Oxford Deanery

East Midlands Deanery (North)

Wales Deanery

North Western Deanery

West Midlands Deanery

Mersey Deanery

Severn Deanery

Northern Deanery

London Deanery

0 2 4 6 8 10 12 14 16 18

Number of trainees 2013 n=89

Who encourages CCH trainees?

RCPCH Education & Training Support

Yorkshire and Humber DeaneryKent, Surrey and Sussex Deanery (KSS)

Wessex DeaneryLondon Deanery

East of England DeaneryScotland (all deaneries)

West Midlands DeaneryNorth Western Deanery

Wales DeaneryNorthern Ireland

East Midlands Deanery (South)SW/Peninsula Deanery

East Midlands Deanery (North)Severn Deanery

Mersey DeaneryNorthern Deanery

Oxford Deanery

0.001.00

2.003.00

4.005.00

6.007.00

8.00

Percentage of total trainees training in CCH 2012

Northern IrelandYorkshire and Humber Deanery

Kent, Surrey and Sussex Deanery (KSS)Scotland (all deaneries)

Wessex DeaneryEast of England Deanery

London DeaneryOxford Deanery

East Midlands Deanery (South)SW/Peninsula Deanery

West Midlands DeaneryEast Midlands Deanery (North)

North Western DeaneryWales Deanery

Mersey DeanerySevern Deanery

Northern Deanery

0.001.00

2.003.00

4.005.00

6.007.00

8.00

Percentage of total trainees training in CCH 2013

Getting the right people

• CCH is now a popular choice in many Deaneries!

• CCH is a shortage specialty and most trainees go straight into consultant posts (or are headhunted even before CCT!)

• We need to consider training capacity to meet the demand for consultants and SSASGs who will be retiring in the foreseeable future

Should we have a Grid?

Positive• National profile• Like everyone else• Competition• National standard for

recruitment• More control of

appointment and numbers• Even out numbers

Risks• Lack of mobility might put

off trainees with family commitments (? higher proportion of CCH trainees)

• A lot of time and effort for same result (past experience!)

Training programme

Training in CCH: basics

• Three year programme (not just a series of posts)

• Structure– 2 years in CCH– 1 year more flexible. Can be in CCH, a specific

area of CCH or relevant specialty• Curriculum• Competency-based (except old-style SpR)

Allied subspecialties

• Paediatric neurodisability

• Child mental health

• Audiovestibular Medicine

CCH curriculum (specific areas)

• Child public health

• Behavioural paediatrics

• Safeguarding incl adoption & fostering

• Neurodisability incl audiology and visual impairment

http://www.rcpch.ac.uk/training-examinations-professional-development/quality-training/curriculum/curriculum

What is a relevant specialty?

• Must be a specialty/placement that enhances competencies approved prospectively e.g.– Paediatric neurology– Paediatric audiology– Palliative care– DGH neuro/epilepsy (perhaps 3/12)– Enteral/parenteral feeding (perhaps 3/12)– Longterm ventilation (perhaps 3/12)– General paediatrics?? (depends on content)

Remember

• CCT in Paediatrics (CCH)

• MUST be competent in– Gen paediatrics– Neonatal paediatrics– CCH

• Not just CCH

But…

• Trainees complain their general/neonatal service commitments interfering with CCH training

• General/neonatal should be – no more than 1/3 of 48 hours and – try to preserve daytime clinical commitments as

much as possible e.g. flexible days off, daytime urgent care to avoid rest period after nights

Supporting training

• Curriculum and assessment guidance

• Resource pack of ideas www.communitychildhealth.co.uk

• Guidance on preparing CV

• Guidance on CESR requirements

• Deanery leads for CCH (all deaneries)

• Specialty Training Advisor (STA) for individual advice on

CCT/CESRhttp://www.bacch.org.uk/training/trainees.php

Assessment

• WPBA

• Annual ARCP including trainer’s report

• START

• CCT application (assessed by STA)

http://www.rcpch.ac.uk/training-examinations-professional-development/quality-training/quality-training

CCT requirements

SpR• Three-year programme

• Show they have covered the syllabus, incl. breadth and depth

• Satisfactory progression

ST• Competence-based but

indicative three-year programme

• Show they have attained competences, incl. breadth and depth

• Satisfactory progression

Remember

• Still subspecialty trainees even w/o grid appt

• Expect 32/48 hours in the subspecialty

• Training needs should be met

• Quality of training should be paramount

• College (CSAC) role is to ensure quality

Quality

Ensuring quality

• Deanery questionnaire (should differentiate CCH)

• GMC questionnaire (should differentiate CCH)

• New consultant questionnaire

• BACCH ASM trainees meeting; other trainee mtgs

• Trainee rep on CSAC

Issues with quality assurance

• Unusual in that CCH has no grid– Grid is only an appointments process but were…

• Unable to identify trainees• Unable to monitor trainees

• The solution– Work with Heads of School– Deanery leads for CCH– RCPCH database of all CCH trainees

CCH programme satisfaction 2007 & 2008-09 PMETB

Quality of trainingBACCH survey 2012

General paediatrics

Community Child Health

Neonates In a DGH In a Specialist Hospital

0

2

4

6

8

10

12

14

16

18

20

How well have the following elements of your train-ing prepared you for your current post?

Very wellWellSatisfactorilyPoorlyVery poorly

BACCH survey 2012 H Brewer & T Woodbridge

Trainee survey 2011

• Did not differentiate CCH trainees

Another piece of the jigsaw

• Community paediatricians no more likely to be referred to NCAS than other paediatricians and not early in their careers

CCT Holder survey 2012

• 270/330 responded (81%)• 91% in same post as their Specialist

registration but…• 8/xx (%) in CCH don’t have a CCT in CCH. All

registered in general paediatrics• CCTs awarded:

– 15 CCH– 11 PND

Other routes to Specialist Register• CESR (combined programme)

– Includes overseas training

• CESR in CCT specialty: Paediatrics (CCH)– Training/qualifications/experience equivalent to CCT

• CESR in non-CCT specialty (CCH)– Must have overseas

training/qualifications/experience to follow this route (currently)

CESR

• Must demonstrate training and experience lead to competency equivalent to CCT

• Standard required– CESR paediatrics = CCT– CESR CCH = ‘knowledge & skills consistent with

practice as a consultant in the NHS’

http://www.rcpch.ac.uk/training-examinations-professional-development/certification/certificate-eligibility-specialist-regi

Suggestions given to HoS

• Establish expected workforce needs (next 5 years)

• Re-evaluate CCH training programme– Demand for places– Quality checklist– Trainee feedback

• Is your training programme fit for purpose?

If not…

• Expand training capacity– Use existing posts flexibly

• Reassess using checklist/’virtual visit form’• Get level 2 posts approved for Level 3 (needs CSAC

approval)• Consider > 1 Level 3 trainee together for support

– Create additional posts• Needs GMC approval only if centre not previously

recognised

• Remember your SSASGs…

Mersey

• 8 CCH trainees– 6 FT– 2 LTFT

• 2 PND trainees (both LTFT)– 1 Academic

• 7 more wanting to start in Aug 2012– Interviewing for the first time

Mersey programmePrinciple is that everyone gets at least • 1 year block at AHCH with child protection on call• 1 year block in periphery with general on call• 6 months neurology• Other 6 months ‘relevant specialty’ experience could

be a community placement with CAMHS attachment, but should be able to offer flexibility in case they want to do safeguarding/public health or something else too.

Post 1 Warrington Warrington Neurology Elective AHCH AHCH

Post 2 APH APH Elective Neurology AHCH AHCH

Post 3 AHCH AHCH Warrington Warrington Neurology Elective

Post 4 AHCH AHCH APH APH Elective Neurology

Post 5 Neurology Elective AHCH AHCH Warrington Warrington

Post 6 Elective Neurology AHCH AHCH APH APH

(Post 7) Neurodisability grid post

What effect has rotating through posts in dif -ferent hospitals/locations had on your training?

Very positivePositiveNeutralNegativeVery negative

What effect has rotating through posts in different hospitals/locations had on your personal life?

Very positivePositiveNeutralNegativeVery negative