Developing a community child health service for the 21st century

Annexe 7

Scottish Association of Community Child Health Survey of Paediatric Consultants Working in Community Child Health in Scotland 2010 (Dr Helen Gibson)

Summary

In May 2010, SACCH conducted a survey of Consultant Paediatricians in Scotland, who worked at least one session per week in a traditional Community Child Health ( CCH) specialty.

48 responses were received and 44 met the criteria for analysis. 10 out of 14 Health Board areas were represented. There was a great deal of diversity in response and after initial analysis, it proved more useful to compare those Consultants working more than 75% of the time in CCH specialties (Group 1, n=16) with those working less than 50% of the time in CCH (Group 2, n=11).

Results :

Consultants in Group 1 were more likely to be female (75% cf. 54.5%), less likely to work full-time (62.5% cf. 90.9%) and more likely to work in community settings, such as Child Development Centres ( CDCs) (68.75% cf. 9.1%). 82% of those in Group 2 worked in District General Hospitals ( DGHs).

Group 1 were less likely to work a 'out of hours' rota (50% cf. 72.7%). They predominantly covered specialist Child Protection rotas (75%). 100% of Group 2, who worked out of hours, covered general paediatrics and 50% of this group also did neonatology.

In both groups the main area of work is neuro-development/ neuro-disability. 93.8% of Group 1 worked in this area compared to 55.6% in Group 2. Traditionally, the Community Paediatrician has worked in several inter-related areas. 43.8% of Group 1 worked in four or more CCH specialties (cf. 12.5% in Group 2), whilst 36.4% of Group 2 work in a single specialty (cf. 12.5% in Group 1).

For Group 1, the main pressures on CCH practice were CCH workload (87.5%) and difficulty in recruiting CCH doctors (75%). For Group 2, the main pressures were acute/general Paediatric workload (60%) and difficulty in recruiting CCH doctors (50%).

More of Group 2 were within 5 years of appointment (45.5% cf. 25.1%) but more had been appointed in Group 1 than 2 in the past 2 years (18.8% cf. 0%). Percentages for those working longer than 10 years were similar (36.4% cf. 37.5%) but were lower for those working in DGHs (25%).

100% of Group 1 had intended to work in CCH specialties as a consultant, compared to 14.3% of those in Group 2. 90.9% of Group 1 had received more than 6 months training in CCH prior to appointment compared to 42.9% of Group 2. 20.5% of the survey had previously worked as Non-Consultant Career Grade Paediatricians before appointment to Consultant posts.

When asked if they had adequate time and support to increase CCH skills in post, 62.5% of Group 2 said yes compared to 43.8% of Group 1. Only 37.5% of previous Non-Consultant Grade doctors answered yes. For all groups, the main barriers to further training were overwhelmingly time (91.3%) and workload (82.6%).

In terms of training and support, clinical guidelines were universally used and the majority of Consultants used conferences and seminars and local educational meetings. Group 1 had high usage of Special Interest groups (87.5%) and peer review (81.3%) compared to 37.5% each for Group 2. Group 2, however, cited peer mentoring/buddy system at 62.5% compared to 12.5% of Group 1.

60.5% of responses were from three Health Board areas (Greater Glasgow and Clyde, Lothian and Grampian). SACCH had previously identified 40 consultants thought to be working predominantly as "Community Paediatricians" and 87.5% were based in the three Health Board areas. Analysing survey responses from these Health Boards, 90.1% worked over 50% of the time in CCH specialties compared to 21.4% in other Health Boards. 82.2% had intended to work in CCH specialties compared to 33.3% and 82.2% had over 6 months training in CCH compared to 37.5% in other Health Boards.

Discussion

From the survey results, there appear to be two predominant models of CCH provision for Consultants in Scotland. The majority of responding Consultants working in the traditional CCH role are based around three teaching hospitals. These consultants are more likely to be based in community settings, work for most of the time in CCH and cover a number of CCH specialties. They intended to work in CCH and have more training. Outside of the teaching hospital Health Boards, Consultants working in CCH are most likely to be based in District General Hospitals, have integrated posts with general paediatrics and to cover fewer or a single CCH specialty. Many did not intend to work in CCH specialties and they have less training. The implications for this is that outside the three centres, Consultant practice in CCH is moving out of the community and becoming a hospital-based outpatient specialty. Even with the greater awareness of multidisciplinary and multiagency working, this tends to encourage shorter appointments and a more problem-orientated approach.

The core issue of the definition of CCH was present throughout the survey. Is CCH an integrated, holistic approach to working in a number of inter-related specialties in community settings or is it currently a loose amalgamation of specialties, which are increasingly fragmenting into independent special interests? Despite the criteria for the survey, which was to do at least one session in a CCH specialty, 27.3% of Group 2 said they had no sessions in CCH. They may have entered the survey in error, but comments suggested that these Consultants did not consider, for example, their child protection work as CCH or they considered the CCH specialties as part of General Paediatrics.

The increasingly integrated approach to General and Community Paediatrics was overwhelmingly welcomed with two provisos. Both those working in integrated posts and those in wholly community posts were concerned that acute workload impacted negatively on CCH practice. There were also concerns about maintaining adequate skills to work in diverse areas of Paediatrics. Some of those working predominantly in CCH were concerned that acute colleagues perceived it as less important.

The prevalence of the traditional CCH working model in teaching hospital Health Boards may reflect the nature of tertiary Paediatrics. In DGHs, Consultant care is based around the individual child, whilst in teaching hospitals, Consultants work predominantly in individual specialties. A child with Complex needs is likely to have several specialists and so there is a need for someone (traditionally the Community Paediatrician) to take a holistic view. In this survey, however, those taking the traditional Community Paediatric role cite increasing workload pressures with longer waiting lists and an increasingly complexity. This, in particular, also applies to Specialty and Associate Specialty Grade ( SASG) doctors, who work a similar model and are crucial to the delivery of CCH services in most areas. There needs to be careful consideration of whether the current model is sustainable, what the core CCH services are and how they are provided in future.

There have been suggestions that as Consultants become more senior, they move from acute to CCH work. In this survey, only one Consultant had taken on CCH duties after appointment. This was for service development and was seen as a positive move. This does not suggest that currently this model is happening to any great extent and pressures on acute services put this into some doubt.

All Paediatric trainees now undertake core training of 6 months in CCH, but this is under pressure from acute paediatric rotas. For the same reason, it is becoming harder to obtain significant training in CCH outside of Grid posts, suggesting that those qualifying are less experienced than their predecessors. At the moment, those with most expertise are being retained around teaching hospitals, although the needs of children are the same throughout the country.

With the difficulty in recruitment of Consultants and SASG doctors into CCH posts, the role of the specialist nurse is becoming increasingly important. It is increasingly recognised that the holistic and flexible approach of nursing services may be more appropriate in some circumstances; however, there remains an important wider leadership and advocacy role for doctors beyond the role of diagnostician. This is particularly important in specialties such as the Looked After and Accommodated Children's service, where there are increasing problems in recruiting doctors, but a multiagency, multidisciplinary approach is vital.