Accreditation of centres
The CSAC will be responsible for creating and maintatining a
list of centres, units, training directors, tutors and teachers
should be compiled and updated on an annual basis. Each centre
is defined by the available modules or areas of teaching activity,
tutors and teachers available and the size of the clinical practice
as defined by the needs of the trainee.
Accreditation will initially be given by CSAC in conjunction
with RCPCH. The inspection and approval process will follow the
EU Guidelines currently in preparation.
Criteria for assessment of centres
Bids have been received from 15 potential Paediatric Endocrine
training centres or consortia of centres each comprising a "Training
Unit".
The Endocrine CSAC of the Royal College of Paediatrics and Child
Health or its deputies will visit Units (& Centres) requesting
accreditation and approve them on the criteria as outlined below.
The visit will usually be made with the joint agreement of the
Training Unit Chief, the Regional Advisor in Paediatrics and the
Chair of the CSAC.
The personnel making the visit will usually be a member of the
CSAC, a co-opted paediatric endocrine consultant colleague (both
from outside the region to be visited) and the Regional Advisor.
Information will be gathered in advance of the visit and at the
time (see attached forms of record of visit).
Details have been sought on:
A. Personnel
- Identification of ‘Chief of service’ within the
coordinating unit to be in over all charge of training programme
and to act as supervisor to trainee.
Full details of individuals C.V.
- Identification of ‘Tutors’ to be in charge of specific
sections of the training programme and to provide training and
clinical experience.
Full details of individuals C.V.
- Identification of ‘Teachers’ to be involved in specific
sub-sections of the training programme providing training in
specific clinical and non-clinical areas.
Full details of individuals C.V.
- Numbers of SpRs.
- Number of Senior House Officers.
- Number of Clinical Nurse Specialists.
B. Institution / s
- Detail of site and interrelationship between centres comprising
training unit
- Laboratory facilities.
- Imaging facilities.
- Library and on-line education facilities.
C. Clinical.
- Local training syllabus.
- Detail of endocrine experience available.
- Detail of diabetes experience available.
- Access to appropriate adult endocrine experience.
- Access to appropriate adult diabetes experience.
Information will normally be gathered over the course of a one
or two day visit from the Chief of Service, a selection of Tutors
and Teachers, specialist nurses and any trainee/s in post.
Visual inspection will take place of Trainee’s office and
library facilities, of laboratory facilities and clinical facilities
(inpatient, outpatient & day-case).
Manpower
This document sets out the current manpower situation in the
United Kingdom in the subspecialty of Paediatric Endocrinology
and Diabetes. The document considers the position with respect
to the position of general paediatrics with an interest and the
specific issues regarding the needs for tertiary care. Possible
changes in the provision of Paediatric Health Care are considered
but the assessment is based on the current provisions.
It is assumed that the award of a Certificate of Completion of
Specialist Training (CCST) will occur in conjunction with non-statutory
certification by The Royal College of Paediatrics and Child Health
(RCPCH) in:-
a). General Paediatrics with a Special Interest. b). Paediatric
Endocrinology and Diabetes as a Subspecialist
These awards will be made by the RCPCH in conjunction with and
on the recommendation by the College Speciality Advisory Committee
(CSAC) in Endocrinology and Diabetes.
CONSULTANT PROVISIONS IN ENDOCRINOLOGY AND DIABETES
1. Division of Expertise
The current situation in the United Kingdom is that Paediatric
Endocrinology and Diabetes services are provided between District
General Hospitals and Tertiary Centres with a degree of overlap
between the two depending on the level of expertise. With the
introduction of the Calman training system then essentially two
levels of service are expected to be provided and the Training
Programme is directed towards this need.
The Secondary course in Paediatric Endocrinology and Diabetes
training would provide training to allow competent practice to
be undertaken as a Paediatrician with a Special Interest. It is
likely that such an individual would be expected to provide care
for:-
- - the district diabetic population
- - children with primary hypothyroidism
- - individuals with delayed puberty
- - growth hormone deficient children (possibly)
- - short and tall stature children
More complex endocrine problems could be cared for locally but
only in the context of a joint Consultative Clinic held with a
Paediatric Endocrinologist. This concept of a joint working partnership
is central to this proposal. This could take the form of outreach
clinics held jointly and/or the Paediatrician with an Interest
working with the Specialist in Paediatric Endocrinology at their
Endocrine Centre.
The Tertiary course in Paediatric Endocrinology and Diabetes
training would provide training to allow competent practice to
be undertaken as a Specialist in Paediatric Endocrinology and
Diabetes whose practice would be expected to deal with complex
endocrinology:-
- - disorders of the adrenal gland
- - ambiguous genitalia
- - disorders of the anterior and posterior pituitary gland
excluding isolated growth hormone deficiency
- - hyperthyroidism
- - complications of diabetes
- - early puberty
- - hypoglycaemia
- - disorders of calcium metabolism
- - liaison with adult and paediatric colleagues re complex
cases eg. post oncology
It is clear that individuals within each of the two groups may
wish to develop personal skills in certain areas. Different levels
of clinical responsibility are expected from the two groups although
it is clear that this is based on the experience gained as trainees.
It is envisaged that by employing a modular approach to the Endocrinology
and Diabetes training that a persons accreditation might be modified
with time if they underwent subsequent modular training in certain
components of the advanced course eg. disorders of the adrenal
gland.
2. Estimation of Workload
District General Hospital
The ideal situation would be for District General Hospitals to
work together as consortia in the delivery of Paediatric Health
Care. This would enable a critical number of Consultant Paediatricians
to be gathered together to provide General Paediatric care as
well as each individual to be able to practice their own special
Interest.
Diabetic care should be provided by one individual and the critical
mass of patients should be sufficient to fulfil the criteria for
the employment of a Clinical Nurse Specialist in Diabetes. There
should be at least 100 diabetic children on the Register. This
could effectively achieved by the merging of services between
2 or possibly 3 District Hospitals. Consideration would need to
be given to the geographical location (town/city versus rural
practice). This size of population would imply a Paediatric population
of approximately 100,000. This would yield in Endocrine terms
20-30 cases of congenital hypothyroidism and 10-20 cases of GH
deficiency. Given the other Endocrine patients that would also
be referred for an opinion then it would seem reasonable that
this load could be coped with 1 or 2 Diabetic/Endocrine Clinics
per week.
Tertiary Centre
It would seem reasonable at present to continue with the conventionally
accepted ratio between a population and a paediatric endocrinologist
of one endocrinologist per 1 million of the population. This assumes
that this individual will also provide the local District Service
in Endocrinology and Diabetes. The workload for a NHS appointment
should be full-time with minimal or no commitment to acute Paediatrics.
Where the appointment is to an Academic position and Research
is a key component then the maximum NHS commitment should be 0.6
WTE. In such a situation then the ratio should be one endocrinologist
per 600,000 population. Again care must be exercised in determining
manpower in the absence of a consideration of geographical constraints.
3. Data Source and Assumptions in Calculations
The data provided on Consultant numbers are estimates and can
be viewed in two ways:
- the optimum service to be provided
- what needs to be done to maintain the status quo.
The estimates do not take into account changes in medical practice
that might ensue in endocrinology eg. endocrine basis to essential
hypertension, childhood origins of Type 2 diabetes mellitus and
obesity, nor do they take account of the introduction of Nurse-led
Practice.
District General Hospital
If the current pattern of district work continues then it will
be extremely difficult for BSPED and RCPCH to maintain adequate
standards of care for Endocrine and Diabetic patients and patients
will not have access to an equitable pattern of care as each District
will not necessarily have a Paediatrician with an Interest in
Endocrinology and Diabetes.
1. Status quo
Maintainance of the status quo in the UK would require District
services to be provided in 240 acute hospitals. If each District
were to have a dedicated Paediatric Diabetologist who would also
do the Secondary Paediatric Endocrinology then we would need 240
individuals. Assuming a 20 year working life then we would need
to feed into the system approximately 12 Trained individuals per
annum. It is likely that such an individual would practice most
of the time in General Paediatrics. We should also include in
the calculation a 20% flexible working factor for part time training,
20% factor for extra teaching and service post Calman, a 5% factor
for CME and a 10% fall out rate. This would suggest that we need
approximately 18 Trainees per annum.
2. Reconfigured District Service
If District Services were to be merged as suggested above then
it would be expected that the Secondary Care services provided
would use up a greater amount of time of the Generalist with an
Interest. Moving to merging 3 out of 5 District Hospitals would
allow this individual to develop an extremelt effective Service.
In this situation the number of Trainees entering per year would
be 10-11 per year but 12 might be a better option bearing in mind
geography might work against us in some areas.
The sums are self explanatory if we went to 2 out of 5 Districts
when we would only need in theory 7-8 but in practice the work
load per individual would then be too high.
The advantage in terms of the 3 out of 5 proposal is that the
Service would be truly Consultant delivered but it would have
profound implications for the provision of services in General
Paediatrics.
Until we have a clearer idea of developments in this area then
we should opt for the status quo model.
Tertiary Centre
For the purposes of constructing figures in this area the status
quo has been assumed. This would seem reasonable at present in
that NHS/University finance is tight and if the District scenario
does come to fruition less non-complex cases would be expected
to be referred.
In the construction of Figure 1 only persons practising 0.6 WTE
or more in Paediatric Endocrinology are considered. In addition
it is assumed that the majority of individuals will retire at
63 years of age. Real intentions will need to be established within
BSPED.
Figure 1. Manpower Requirements in the UK from Year 2000-2024
The data clearly show two large peaks of requirements around
the years 2005-2010 and 2015-2020. Unfortunately with these bumps
it is going to be difficult to adequately plan for replacement
particularly in view of the current inflexibility of the Calman
training duration. In part the current assumptions may iron out
this problem but a careful ongoing appraisal of training numbers
is going to be required. The current numbers that should be trained
per annum in this scenario allowing for the additional factors
detailed above should be approximately 2-2.5 per annum.
Some Tertiary Departments have only one consultant or Senior
Academic in the Tertiary Speciality. This is not included in the
calculations above which simply maintains the status quo. We shouls
aim for a gradual expansion so perhaps 3 per annum would be a
reasonable number.
However, we do need to think carefully about the need for fewer
larger departments even if they are virtual departments. This
will become increasingly critical to generate the right mass for
clinical experience, working conditions and research. It is evident
that if we only need 3 trainees poruced per annum then we should
only have at most 3-5 training centres. For subjects such as Intersex
disorders then there may only be a need for 2-3 centres in the
whole of the UK.
Training in Tertiary endocrinology and diabetes may need to take
place in National Posts an area that needs to be discussed within
RCPCH as this will impinge on the role of the regional advisers.
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