BEYOND THE TICK BOX

Working with young people

As seems to be becoming a tradition and an ode to hope for the future, the conference was kicked off with the help of the young people of RCPCH and Us.  Three teenage boys including a lovely welsh lad called Scot highlighted poignantly how their fear of transitioning to adult services after a lifetime of paediatric care was far more terrifying than leaving home to go to university. They also identified the need for new, flexible and innovative ways of working including the use of outreach nurses and social media to reach young people with medical conditions.

 

Inequality and the state of child health

Following this Dr Ronny Cheung, clinical advisor to Public Health England outlined the main findings from the State of Child Health Report; identifying both the positive and negative findings. An almost halving of the number of road traffic accidents, reduced infant mortality and increasing MMR vaccination rates are all something to be proud of but the pervasive inequality in child health between different socioeconomic groups in the UK was evident in all areas. Internationally the gap between the UK and other more egalitarian countries is growing so in essence although things like infant mortality have improved; they are improving more slowly than elsewhere. 

 

What is most worrying I suppose is that the UK has fallen from 11th to 156th in the Childrens Rights Index due to lack of legalisation around Childrens' Rights. After all, a population who don’t vote tend to get rather overlooked by government especially around election time. The college have called for a four-nationwide strategy to improve children's health through policy change, with focus on more vigorous data collection, national standards for practice, a restoration of public health investment and measures to reduce poverty and inequality. The Whitehall Study of the 1970s identified that wealth equality is not the only determinant of health and that society needs to be both educationally and socially more equal as well. It was Nelson Mandela who said:

 

“There can be no keener revelation of a society’s soul than the way it treats its children”

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Integrated working- The GP-Paediatric relationship

This call to arms was followed by a talk by Dr Chloe McCauley from the London Deanery about the successful implementation of ‘Learning Together’ clinics in North and South London. With the recognition that paediatric training is frequently acute and hospital focused, with little experience of primary care, and that only 40-50% of general practitioners rotate through a paediatric training post, it is not surprising that the relationship has broken down a little. Their experience of integrated GP and Paediatric registrar clinics with inbuilt debriefing sessions from both qualified GPs and consultant paediatricians facilitated improved clinical practice, collaboration and patient outcomes between these 2 groups. It was all very positive but the realistic prospect of releasing registrars from paediatric rotas in areas where there is a real paucity of trainees was highlighted as a potential barrier for its introduction elsewhere.

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Insight into the needs of seriously ill teenagers

Emma Day, a PHD researcher then gave us a valuable insight into seriously ill teenagers perspectives of their care, particularly in relation to issues such as end of life care. Although medical professionals identified that decision making should be teenager led and recognised the ethos “no conversation about me without me”, this was infrequently practiced in reality. However, despite this the teenage patients trusted the health care professionals to do what was right for them even if it meant ignoring their wishes and identified that they did not necessarily want decisional authority or access to all the information. The majority of teenagers in the study understood the risk of death or serious illness, something that health care professionals and parents commonly try to protect them from. This identified the need for a collaborative approach to care led by health care professionals. 

 

Obesity, obesity, obesity- the true burden

Professor Russell Viner (one of BTTB’s favourite speakers!) then gave us an unhealthy dose of reality by quantifying the actual scale of the obesity epidemic in the UK. 11% of our UK child population are clinically obese and therefore eligible for primary care assessment as per NICE guidelines. Thankfully only 15% of these families consult their GP due to weight concerns. Imagine how overwhelmed our GP systems could become if they all turned up. A further 5.1% have physical or psychological comorbidity warranting secondary care assessment and 2.4% of the UK child population (age 13-18 years) actually meet the criteria for bariatric surgery! If we’re going to do things properly, we really need to give primary care the skills and support to assess these children. 

 

A bit more about inequality

Next was a nod to being European as Dr Johan Mackenbach from the Netherlands took to the stage and talked further about health inequality and how persistently stubborn it could be even in countries such as the Netherlands with highly rated welfare states. This could be due to the fact that health improvements partly depend on behavioural changes which can be both expensive and difficult to understand for the least educated. What was clear however is that an increase in health care expenditure was associated with a clear decline in mortality and this effect was greater in the less educated groups within society. Are you listening Westminster? 

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What the college has been up to?

There were the usual updates from the college vice presidents. The health policy team have obviously been busy writing the State of Child Health report as well as sorting out the medical workforce disaster. The Child Protection Committee have been rewriting the child protection companion book and looking specifically at the needs of child migrants. The Education committee continue to expand their reach through technology with the CPD and e-Learning/Compass apps, and online learning modules such as Disability Matters. Dr David Evans of training and assessment fame has been busy writing a new paediatric curriculum based on evaluating us as a finished product rather than ticking boxes along the way and figuring out how to recruit more people into paediatrics (desperately needed...) The shout out to trainees was lovely and I wasn’t aware of trainee initiatives such as ‘The Inbetweeners’ stepping up group or the existence of the PAFTA awards (read more here).

 

Paediatric Mental Health Workshop

It was then time for the morning workshops. As a community paediatrician, increasingly feeling like a CAMHS trainee; I attended the ‘Promoting Mental Health and Wellbeing for all Children’ workshop run by Dr Max Davie. He posed the unanswerable question “For which Children in Paediatric Care is attention to their mental health unimportant in their care?”

 

First we discussed the concept of resilience which contrary to British belief is not necessarily smiling, putting our heads up and getting on with it as if nothing has happened. Resilience is facing our difficulties and responding in a positive way. There are many ways in which we can improve the resilience of an individual child and effective parenting can be key. He identified the importance of;

 

• Positive shared interaction as a family​

This doesn’t usually involve screens for starters and could be anything in which families spend quality time together working towards shared goals and having time to listen to each other: Board games are a good example

• Structure

The same rules should be present for everybody including parents! E.g- no one hits and shouts in this house

• Praise

Children need to succeed in small ways on a regular basis. Let them earn that X-Box back and tell them what they can do to achieve this

• Physiological regulation

Sleep, exercise and relaxation exercises (all good stuff…)

 

In encouraging resilience, context is everything. For example, poverty had multiple ways in which to sap and undermine a child’s resilience. However, all families and children have a baseline on which to build on and what is achievable in terms of the above should very much be recognised on a family to family basis. “There is always something useful we can say but we have to listen first”

 

The topic of digital media and its effect on the mental health of our nations children was briefly skirted around. The college are reluctant to present their official stance as they believe there is still more we need to learn in this area. I understand that the American Academy of Paediatrics have released a digital media statement which introduces the concept of a ‘family media plan’. Not sure if that would work in Blighty…

 

Polly Casey from the Anna Freud centre then talked a little about whole school approaches to mental health in schools. Something needs to fill the gap as the current CAMHS situation is dire and 80% of children with mental health problems do not receive any support. Schools are ideally placed as teachers are often the first point of contact for children who are struggling and are ideally placed to provide an on-site service. There is growing evidence for such approaches to mental health with small but meaningful effects demonstrated especially in our most deprived populations. There is no indication that external personal can produce better outcomes than school staff either as long as appropriate training occurs. 

 

Lunch was interesting and much needed at this point. I’d never thought of putting sweet and sour sauce with paneer.... The fruit salad was good though! 

 

Public Health Forum

I started my afternoon in the British Association of Paediatric Public Health Forum where again the initial focus was on inequality, in particular poverty and financial inequality. We confused ourselves with definitions of poverty, debating the relevance of income thresholds but also other poverty measures such as the maternal deprivation index. Read our previous article on childhood poverty for an overview of the current situation.

 

What is evident from the latest Child Poverty Action Group and RCPCH report is that the majority of paediatric doctors are clearly seeing evidence of poverty impacting on children’s health in their day to day work (2/3rd to be exact).  Following the election there are plans for the college to campaign to raise awareness of the issue, creating networks of dedicated professionals and mitigating the consequences of poverty locally. 

 

Following this a trainee from the Paediatric Research Across the Midlands Group (PRAM) presented the findings of her project on childhood obesity. Essentially the children of the UK are fat and we don’t tend to do much about it. Unfortunately, education of staff working with children produced little change in this behaviour, possibly due to a lack of follow up services. Does anyone else feel like we’re banging our heads against a brick wall?

 

Alisha Davies from the University of Cardiff educated us on the long term impact of adverse childhood events or ACE’s. ACEs are a fashionable acronym for those chronic or repetitive life stressors such as child abuse, parental separation, and domestic violence and can lead to a state of fixed hyper alertness and a subsequent association with ill health (cardiovascular and respiratory disease and increased use of healthcare services). They are also associated with high risk drinking, teenage pregnancy, imprisonment, violence and class A drug use, quite clearly meaning that subsequent generations also experience ACEs and the cycle continues.  So how do we respond? Well, obviously we need to address the causes and raise awareness as well as try and break the intergenerational cycle by promoting resilience and emotional literacy.  Easy eh? This requires a multiagency approach and I understand public health are working with the police, charities such as Barnardos and even the housing association to recognise and mitigate the effect of ACES in Wales. Click here to read more. 

 

A bit of safeguarding…

I then skipped across to the child protection forum where Michelle Richardson (Welsh Paediatric Trainee) gave a fantastic presentation highlighting the need to provide paediatricians involved in child protection work with emotional support. Peer Review was not felt to meet this need and I understand several informal peer support groups are already working well in other parts of the UK. We also heard from the charity sectors (NSPCC, The Childrens' Society and Barnardos) regarding the valuable work that they are currently involved in. Check out seenandheard.org.uk, a free online training programme provided by The Childrens Society to educated healthcare workers about spotting child sexual abuse and exploitation. 

 

Dr Ingrid Prosser (also from Wales…) then updated us on the future of the CORE INFO systematic review project. This valuable project lost its NSPCC funding in 2015 and there were fears it may not be able to continue. Fortunately for us, the Royal College of Paediatrics have agreed to take on the mantle and this vital evidence based resource will continue to be updated regularly. Surprisingly somebody mentioned that trainee use of both this resource and the Child Protection Companion was poor. I couldn’t quite believe this as I find them so useful myself…Please take a look here if you’ve never seen them before as it really will make writing your Child Protection reports easier (and evidence based)

 

It was at this point I started to get a bit sleepy from my 5am wakeup that morning so I’m not sure I can reliably update you on the last 2 sessions. However I’m sure they were very very good….Look out for day 2 of my RCPCH 2017 coming up next.