Implications of the Calman report on child health and paediatrics

Full text

Archives
of
Disease
in
Childhood
1996;
74:
260-263
CURRENT
TOPIC
Implications
of
the
Calman
report
on
child
health
and
paediatrics
David
W
A
Milligan,
David
M
B
Hall
Background
Medical
education has
come
under
increasing
scrutiny
over
the
last
10
years.
A
reliance
on
the
traditional
disciplines
of
hospital
based
medicine,
the
apprenticeship
nature
of
post-
graduate
learning,
and
the
bias
toward
acade-
mic
qualification
for
specialists
too
often
resulted
in
doctors
without
the
essential
core
knowledge
for
their
area
of
practice
and
with-
out
the
mental
tools
to
translate
it
into
direct
benefit
to
the
patient.
The
undergraduate
cur-
riculum
has
already
been
extensively
revised.
The
training
bodies
of
the
royal
colleges
were
planning
wide
ranging
changes
in
their
post-
graduate
training
programmes
when,
in
1992,
the
European
Commission
(EC)
initiated
infraction
proceedings
against
the
UK
on
the
grounds
that
the
system
of
awarding
specialist
medical
certification
and
the
arrangements
in
place
for
mutual
recognition
of
specialist
qualifications
between
the
UK
and
European
partners
did
not
comply
with
European
law.
A
working
group
was
set
up
under
the
chairman-
ship
of
the
chief
medical
officer,
Dr
Kenneth
Calman,
with a
brief
to
harmonise
UK
and
European
practice.
The
working
group
reported
in
April
1993.1
Their
principal
rec-
ommendations
were:
*
That
the
colleges/faculties
and
postgraduate
deans
should
implement
their
new
training
programmes
by
the
end
of
1995
and
make
arrangements
to
monitor
the
changes
to
ensure
that
standards
were
being
maintained.
*
That
readiness
for
independent
practice
and
eligibility
for
consultant
appointment
should
be
formalised
by
the
award
of
an
exit
certifi-
cate,
the
UK
certificate
of
completion
of
specialist
training
(CCST),
and
that
this
should
have
reciprocity
with
similar
qualifi-
cations
throughout
the
EC.
*
That
the
current
senior
registrar
and
regis-
trar
grades
should
be
combined
into
an
inte-
grated
training
grade
and
that
average
training
time
should
come
more
into
line
with
that
in
Europe.
What
are
the
implications
for
paediatricians?
Specialist
training
will
be
more
focused
and
therefore
shorter.
A
new
specialist
training
grade
(the
specialist
registrar)
will
replace
the
existing
registrar
and
senior
registrar
grades.
The
entry
requirements
to
the
grade
will
be
specified
(as
they
are
now)
by
a
specialist
advisory
committee
(SAC)
in
paediatrics,
which
is
currently
a
subcommittee
of
the
Joint
Committee
on
Higher
Medical
Training.
A
minimum
of
two
years
of
general
professional
training
at
senior
house
officer
level
is
expected
at
the
end
of
which
MRCP(Paed)
must
be
obtained
in
order
to
become
a
specialist
registrar.
The
minimum
training
period
in
the
specialist
registrar
grade
will
be
four
years
for
general
paediatrics
and
five
years
for
those
who
wish
to
develop
a
specialty
interest.
Progress
will
be
reviewed
annually.
There
will
be
formal
exit
certification,
the
UK
CCST.
At
the
time
of
writing
the
NHS
Executive
takes
the
view
that
there
should
be
only
one
CCST
for
paediatrics
whatever
specialty
training
has
been
under-
taken.
The
CCST
will
be
awarded
by
the
new
Special
Training
Authority.
The
British
Paediatric
Association
(BPA)
has
only
observer
status
on
this
group
until
it
becomes
a
college.
The
award
of
a
CCST
will
entitle
doctors
to
apply
to
the
General
Medical
Council
for
inclusion
on
the
specialist
register.
During
the
transition
phase
doctors
who
have
been
accredited
by
the
SAC
and
those
who
are
or
have
been
consultants
(but
not
locums)
will
have
an
automatic
right
for
inclusion.
Other
doctors
who
will
be
eligible
for
inclusion
are
holders
of
an
European
economic
area
specialist
certificate,
non-European
economic
area
specialists
who
are
assessed
to
have
appro-
priate
training,
and
those
with
unorthodox
or
highly
academic
career
posts
so
long
as
their
training
is
assessed
by
the
Special
Training
Authority
as
being
equivalent
to
CCST
standards.
Inclusion
on
the
specialist
register
confers
the
right
to
independent
specialist
practice
and
will
become
an
essential
prerequi-
site
for
consultant
appointment
from
the
beginning
of
1997.
The
new
training
programmes
will
place
more
emphasis
on
structured
teaching
and
supervised
learning
and
less
on
unsupervised
experiential
apprenticeship.
Defining
training
programmes
and
maintaining
standards
will
be
the
responsibility
of
the
SAC,
working
in
collaboration
with
the
BPA.
The
responsibility
for
ensuring
that
training
takes
place
lies
with
the
postgraduate
deans
who
will
continue
to
hold
50%
of
the
trainees'
salaries
(100%
in
Scotland).
There
will
be
regular
appraisal
and
Royal
Victoria
Infirmary,
Newcastle
upon
Tyne
D
W
A
Milligan
Sheffield
Children's
Hospital
D
M
B
Hall
Correspondence
to:
Dr
D
W
A
Milligan,
Ward
35,
Leazes
Wing,
Royal
Victoria
Infirmary,
Newcastle
upon
Tyne
NE
1
4LP.
260
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Implications
of
the
Calman
report
on
child
health
and
paediatrics
assessment,
supervised
by
the
deans
and
the
SAC
and
mediated
through
regional
advisors,
BPA
tutors,
and
local
consultant
mentors.
An
annual
review
between
the
specialist
registrar
and
the
dean
provides
information
for
the
record
of
in-training
assessment.
What
are
the
main
effects?
A
reduction
in
higher
specialist
training
time
means
that
more
trainees
will
be
ready
for
con-
sultant
posts
earlier.
In
order
to
accommodate
this
change
there
must
therefore
either
be
an
increase
in
consultant
numbers
or
a
reduction
in
the
number
of
trainees.
Inherent
in
the
Calman
proposals
is
the
notion
that
more
patients
should
receive
their
care
directly
from
consultants.
In
the
short
term,
therefore,
con-
sultant
numbers
will
need
to
rise.
The
shorter
training
programmes,
coupled
with
shorter
working
hours
during
training,2
will
result
in
new
consultants
who
are
younger
and
less
experienced
at
appointment.
Exposure
to
individual
clinical
problems
after
appointment
will
be
diluted
by
the
larger
con-
sultant
pool.
The
shorter
period
of
generic
training
will
require
earlier
decisions
on
a
career
pathway
and
there
will
be
less
flexibility
for
changes
at
a
later
stage.
The
parallel
with
the
rest
of
Europe
is
not
a
comfortable
one;
most
paediatricians
in
the
EC
practise
office
based
primary
care.
The
hope
is
that
the
more
structured
training
will
provide
a
more
inte-
grated
knowledge
base
and
the
mindset
for
evi-
dence
based
decision
making.
Consultants
will
work
much
more
as
teams,
continuing
educa-
tion
will
become
the
norm,
and
junior
consul-
tants
will
continue
to
learn
from,
and
be
supported
by,
their
more
senior
colleagues.
It
has
been
suggested
that
only
some
consultants
will
be
identified
as
trainers
and
that
they
will
have
a
contract
which
will
have
protected
ses-
sions
for
education
which
may
be
separately
funded.
One
of
the
consequences
of
producing
more
integrated
training
programmes
is
that
much
of
the
training
will
take
place
within
the
same
deanery.
While
this
will
cause
less
disruption
in
family
life
and
will
be
beneficial
in
terms
of
ease
of
organisation,
it
will
decrease
what
many
see
to
be
one
of
the
strengths
of
the
current
British
training
system,
the
ability
for
trainees
to
move
to
different
training
centres
so
that
they
are
exposed
to
a
broad
range
of
opinion
and
experience.
It
will
still
be
possible
to
move
between
deaneries
but
careful
advance
plan-
ning
in
consultation
with
the
deans
will
be
essential,
particularly
if
the
intended
move
is
between
England
and
Wales
and
Scotland
or
Northern
Ireland
which
have
their
own
separate
numbering
systems
and
training
pro-
grammes.
Who
makes
the
decisions
on
numbers?
There
are
two
key
bodies:
the
Specialist
Workforce
Advisory
Group
(SWAG)
and
the
Advisory
Group
on
Medical
Education,
Training
and
Staffing.
SWAG
deals
with
the
mechanics
of
calculating
the
appropriate
number
of
trainees
for
each
specialty
and
takes
over
these
functions
from
the
Joint
Planning
Advisory
Committee
which
has
now
been
dis-
banded.
The
intention
is
that
the
adjustment
of
individual
specialty
numbers
should
be
more
flexible,
more
responsive
to
medium
term
changes,
and
based
on
more
accurate
data
than
has
been
hitherto
available.
The
key
source
of
data
on
trainees
will
be
the
postgrad-
uate
deans
who
are
obliged
to
hold
a
common
core
dataset
on
each
trainee
and
to
make
a
planning
and
census
return
to
NHS
Executive
once
a
year.
Deans
have
recently
completed
a
trawl
of
all
potential
specialist
registrars
within
their
deaneries
and
have
made
the
first
return
of
data.
The
NHS
Executive
are
confident
that
this
has
given
them
an
accurate
picture
of
existing
career
registrars
and
senior
registrars
but
acknowledge
that
there
is
still
a
problem
with
the
reliable
identification
of
doctors
in
research
or
who
are
currently
overseas
-
the
'twilight
zone'.
The
dataset
and
its
handling
is
the
responsibility
of
the
Unified
Training
Grade
Steering
Group.
The
BPA
has
been
involved
in
planning
discussions
together
with
other
colleges
and
will
have
access
to
the
rele-
vant
parts
of
the
current
deans'
dataset
at
the
end
of
1995.
SWAG
will
consult
trusts
about
medium
term
(3-5
year)
plans
for
consultant
expansion
in
different
specialties.
Local
Medical
Workforce
Advisory
Groups
will
provide
comment,
including
the
implications
for
the
new
deal,
on
the
plans
of
trusts
in
their
'patch'
to
the
regional
director.
The
BPA
is
installing
a
new
data
system
which
will
have
fields
that
correspond
to
the
deans'
dataset
so
that
information
transfer
should
be
reliable
and
simple.
In
the
long
term
the
deans'
database
should
provide
an
accurate
picture
of
numbers
and
distribution
of
doctors
in
the
specialist
registrar
grade.
During
the
transition
the
BPA
proposes
to
monitor
numbers
in
parallel
in
addition
to
collecting
fresh
baseline
data
on
all
doctors
working
in
paediatrics
and
child
health
by
means
of
a
census
based
on
30
September
1995.
In
the
long
term
the
BPA
database
should
not
only
be
able
to
provide
paediatric
trainees
with
a
fore-
cast
of
consultant
opportunities
but
also
act
as
a
useful
recruitment
tool
as
it
is
likely
that
most
new
graduates
will
be
advised
to
train
for
the
available
market.
What
are
the
numbers
for
paediatrics?
In
June
1995
the
BPA
submitted
details
of
all
existing
career,
visiting,
and
research
registrars
and
senior
registrars
to
SWAG
together
with
an
analysis
of
the
predicted
consultant
work-
force
needed
by
the
year
2000
and
an
estima-
tion
of
the
number
of
extra
specialist
registrars
required
to
fill
that
number
of
consultant
posts.
Existing
numbers
were
based
on
a
1994
update
of
the
1992
census.
Projected
consul-
tant
numbers
were
based
on
advice
from
specialty
groups,3
from
British
Association
for
Community
Child
Health
(BACCH),
and
from
previous
work
on
the
optimum
configura-
tion
of
paediatric
units.4
They
took
into
account
known
retirements
during
that
time
261
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Milligan,
Hafl
and
the
extra
input
required
from
trainers
after
Calman
implementation.
Specialist
registrar
numbers
were
calculated
using
an
average
five
year
training
time
with
allowances
for
research,
part
time
working,
and
wastage.
SWAG
(addressing
the
transition
phase
only)
used
an
algorithm
which
assumes
that
the
historical
rate
of
consultant
expansion
is
the
most
important
determinant
of
future
con-
sultant
numbers.
Additional
allowances
are
made
for
the
proportion
of
service
input
lost
from
a
reduction
in
the
existing
pool
of
trainees
(the
'Calman
factor'),
the
predicted
retirement
rate
and
loss
to
the
specialty,
and
an
assump-
tion
that
average
time
between
CCST
and
consultant
appointment
(the
'gap')
will
be
six
months.
The
number
of
additional
trainees
provisionally
allocated
on
this
basis
was
786,
scaled
down
by
two
thirds
to
262
for
1996/7.
Are
these
numbers
realistic?
How
do
we
find
a
large
number
of
new
specialist
registrar
recruits
and
who
will
fund
their
training?
Neither
question
has
yet
been
satisfactorily
answered.
Some
changes
will
be
revenue
neutral
but
we
would
still
need
to
find
the
people
to
fill
the
posts.
It
will
be
possible
to
replace
visiting
registrar
posts
with
career
posts
once
the
current
incumbents
have
completed
their
permit
free
training.
We
estimate
that
there
are
around
100
visiting
posts
which
could
eventually
be
transferred
in
this
way
if
it
was
thought
to
be
appropriate.
A
further
intention
is
to
translate
as
many
senior
senior
house
officer
posts
as
possible
into
specialist
registrar
posts,
though
this
may
create
problems
with
rotas
and
junior
doctors'
hours.
There
are
about
300
such
posts
in
paediatrics
but,
under
the
present
rules,
postholders
will
need
to
have
passed
the
MRCP
before
they
are
eligible
for
an
specialist
registrar
appointment.
We
hope
to
obtain
the
MRCP
status
of
all
current
senior
senior
house
officers
in
the
forthcoming
census.
It
may
be
possible
to
use
some
funds
identified
for
the
new
deal
in
deaneries
where
the
major
issues
of
junior
doctors'
hours
have
been
satis-
factorily
addressed.
At
the
time
of
writing
there
is
no
undertaking
that
the
government
will
fund
the
remaining
posts.
Even
if
the
50%
of
salaries
held
by
the
deans
were
funded
the
balance
would
have
to
be
found
by
individual
trusts.
When
is
it
all
going
to
happen?
The
commissioning
date
of
the
specialist
regis-
trar
grade
nationally
is
1
April
1996
although
two
specialities,
surgery
and
radiology,
started
on
1
December
1995.
Paediatrics
and
child
health
enters
the
fray
on
1
October
1996
by
which
time
we
will
need
to
fulfil
the
criteria
laid
down
in
the
Guide
to
Specialist
Registrar
Training.5
These
include
transition
arrange-
ments;
curricula,
training
programmes
and
training
records
('logbooks'),
approved
by
the
SAC,
for
each
specialty;
planned
rotations;
and
a
mechanism
for
assessment.
The
transition
phase
will
end
when
all
potential
specialist
reg-
istrars
have
been
identified
and
notified,
when
a
mechanism
for
handling
researchers
who
return
after
the
end
of
transition
(up
to
three
years
later)
is
in
place,
and
when
deans
are
in
a
position
to
begin
recruiting
to
the
grade
on
a
competitive
basis.
What
happens
to
existing
registrars
and
senior
registrars?
Approved
trainees
will
be
allocated
a
national
training
number
which
is
their
passport
to
a
training
programme.
Some
senior
registrars
(we
estimate
around
50)
will
be
eligible
for
a
CCST
as
soon
as
the
legislation
is
through.
The
remainder
will
automatically
be
allocated
a
national
training
number
if
they
wish
to
enter
the
specialist
registrar
grade
but
they
have
the
option
of
remaining
on
a
senior
registrar
contract.
Existing
registrars
who
fulfil
the
minimum
entry
requirements
to
the
specialist
registrar
grade
will
be
assessed
(under
the
aegis
of
the
dean)
for
transfer
to
the
specialist
regis-
trar
grade.
For
most
people
there
will
be
no
difficulty
but
some,
particularly
those
who
have
entered
a
research
programme
without
formal
interview
for
a
registrar
training
post
and
those
whose
career
progression
is
in
doubt,
will
need
a
more
thorough
formal
review.
Flexible
trainees
will
be
treated
in
the
same
way.
The
quotas
and
points
system
have
been
abolished.
Visiting
registrars
have
the
right
to
remain
in
their
posts
until
the
expiry
of
their
permit
free
training.
Each
programme
will
consist
of
a
series
of
approved
posts
identified
by
a
national
post
number.
Posts
themselves
will
be
assessed
for
suitability
for
specialist
registrar
training
on
the
basis
of
their
proposed
training
content.
The
mechanism
is
likely
to
be
through
local
struc-
tures
in
the
interests
of
efficiency;
the
SAC
will
set
standards
and
guidelines,
but
will
only
become
directly
involved
in
cases
of
dispute
or
real
difficulty.
It
will
be
possible
to
move
out
of
specialist
registrar
training
to
undertake
research,
or
for
other
reasons,
such
as
a
period
overseas,
while
retaining
the
national
training
number
but
specialist
registrars
should
always
take
advice
from
their
dean
and
regional
adviser
well
in
advance
of
committing
them-
selves
to
such
a
move.
Appointments
and
contracts
There
is
new
guidance
on
the
constitution
and
function
of
the
advisory
appointments
com-
mittees
but
any
changes
to
the
existing
statu-
tory
instrument
have
to
be
ratified
by
parliament.
The
suggested
changes
include
mandatory
representation
of
the
dean,
struc-
tured
references,
and
a
range
of
improvements
that
reflect
good
employment
practice
in
general.
The
appointment
contract
will
usually
be
for
5-5
years.
There
may
be
a
gap
after
the
award
of
the
CCST
while
the
doctor
seeks
a
consultant
post.
To
cover
this
period
the
con-
tract
can
be
extended
for
a
limited
period
by
the
dean.
The
length
of
the
extension
will
be
limited
by
availability
of
finance
in
the
deanery
concerned.
It
is
not
intended
that
this
conces-
sion
should
be
regarded
as
a
means
of
extend-
ing
specialty
training;
doctors
who
wish
to
262
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Implications
of
the
Calman
report
on
child
health
and
paediatrics
263
acquire
additional
skills
or
expertise
should
normally
seek
to
extend
their
specialist
regis-
trar
training
before
they
receive
their
CCST.
The
tasks
ahead
The
two
most
urgent
tasks
are
for
specialty
groups
to
publish
detailed
guidance
on
the
minimum
content
of
training
programmes
and
for
individual
(groups
of)
trainers
to
define
local
core
and
subspecialty
training
pro-
grammes
and
submit
them
for
approval
to
the
regional
adviser
and
dean
who
will
need
to
fit
them
in
to
workable
training
rotations.
Discussions
with
trusts
about
funding
of
at
least
50%
of
any
proposed
new
specialist
regis-
trar
posts
should
take
place
without
delay.
The
most
important
long
term
issue
to
be
addressed
is
that
of
recruitment:
how
to
make
paediatrics
more
attractive
as
a
career
and
to
try
and
seize
the
advantage
now
of
the
recent
10%
increase
in
medical
school
intake.
Glossary
Advisory
Group
on
Medical
Education,
Training
and
Staffing
(AGMETS)
-
Chaired
by
the
chief
medical
officer;
reports
directly
to
the
secretary
of
state.
Responsible
for
England
and
Wales
only.
Equivalent
body
for
Scotland
is
the
Advisory
Committee
on
Medical
Establishments,
and
for
Northern
Ireland
the
Hospital
Services
Sub-Committee
of
the
Central
Advisory
Medical
Committee.
Calman
factor
-
The
decrease
in
service
provision
by
specialist
trainees
resulting
from
shortening
the
training
programme
-
for
example,
if
training
time
falls
from
seven
to
five
years
service
delivery
will
fall
by
2/7ths
(and
will
need
to
be
replaced
by
consultant
input).
Certificate
of
completion
of
specialist
training
(CCST)
-
Awarded
by
the
Special
Training
Authority.
Passport
to
independent
specialist
practice
and
eligibility
for
consultant
appoint-
ment.
Continuing
medical
education
-
Came
on
stream
for
paediatrics
on
1
January
1996.
Commissioning
date
-
When
the
specialist
registrar
grade
comes
into
being;
1
October
1996
for
paediatrics
and
child
health.
Deanery
-
The
area
of
a
dean's
jurisdiction.
Corresponds
closely
with
old
regions
in
most
instances.
Deans'
database
-
The
source
of
information
on
all
trainees.
More
accurately
a
dataset
as
all
deans
do
not
have
the
same
software.
European
economic
area
-
European
Economic
Community
countries
together
with
some
European
Free
Trace
Association
coun-
tries
and
Liechtenstein.
Gap
-
The
time
between
award
of
CCST
and
consultant
appointment.
Average
default
assumed
to
be
six
months
for
transitional
phase
calculations.
J7CHMT
-
Joint
Committee
(of
the
Royal
College
of
Physicians)
on
Higher
Medical
Training.
Joint
Planning
Advisory
Committee
-
Used
to
plan
registrar
and
senior
registrar
numbers;
now
disbanded.
Local
Medical
Workforce
Advisory
Group
-
Composed
of
members
appointed
by
regional
director
to
comment
on
trust
plans
for
work-
force
planning.
May
eventually
take
over
role
of
task
forces.
Still
in
discussion
phase.
National
programme
or
post
number
-
Refers
to
a
funded
post
approved
for
specialist
regis-
trar
training
by
dean/regional
adviser
with
or
without
the
Specialist
Advisory
Committee
(SAC).
Issued
by
the
dean.
Similar
structure
to
national
training
number.
National
training
number
-
Passport
to a
specialist
registrar
training
programme.
Retained
by
holder
throughout
training
(even
during
time
out)
and,
usually,
until
appoint-
ment
as
a
consultant.
Issued
by
postgraduate
dean
-
for
example
NTH/002/374N
refers
to
visiting
specialist
registrar
374
in
paediatrics
(002)
in
the
northern
(NTH)
deanery.
Paediatric
SAC
-
One
of
several
specialist
advisory
committees
of
the
JCHMT
which
currently
represents
all
of
paediatrics.
Record
of
in-training
assessment
-
A
standard-
ised
system
which
deans
will
use
to
record
the
annual
review
of
progress
of
individual
specialist
registrars.
May
be
used
to
support
recommendation
of
CCST
award.
Specialist
registrar
-
(was
called
higher
specialist
trainee).
Specialist
training
authority
-
Assesses
training
and
awards
CCST.
Composed
of
college
presi-
dents
and
representatives
from
the
General
Medical
Council,
deans,
and
lay
public.
Specialist
Workforce
Advisory
Group
-
Subcommittee
of
AGMETS.
Chaired
by
Dr
Graham
Winyard
(Medical
Director,
NHS
Management
Executive).
Transition
phase
-
The
time
agreed
nationally
between
NHS
Management
Executive
and
individual
specialty
between
the
specialty
commissioning
date
and
full
implementation
of
the
new
arrangements.
Twilight
zone
-
Registrars
(or
equivalent)
who
are
currently
in
full
time
research
(usually
on
soft
money)
and
are
not
known
to
the
system.
Not
thought
to
be
a
big
problem
in
paediatrics.
Unified
Training
Grade
Steering
Group
-
Oversees
planning
of
information
transfer.
1
Department
of
Health.
Hospital
doctors:
training
for
the
future.
The
report
of
the
Working
Group
on
Specialist
Medical
Training.
London:
Department
of
Health,
1993.
2
NHS
Management
Executive.
J7unior
doctors'
hours
-
the
new
deal.
London:
NHS
Management
Executive,
1991.
3
British
Paediatric
Association.
Tertiary
services
for
children
and
young
people.
London:
BPA,
1995.
4
British
Paediatric
Association.
Hospital
paediatric
medical
staffing.
London:
BPA,
1993.
5
NHS
Executive.
Guide
to
specialist
registrar
training.
London:
NHS
Executive,
1995.
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doi: 10.1136/adc.74.3.260
1996 74: 260-263Arch Dis Child
D W Milligan and D M Hall
health and paediatrics.
Implications of the Calman report on child
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