Paediatrics: A wicked problem?

Dr Nicola Jay, consultant paediatrician at Sheffield Children's Hospital, has been appointed as the new Officer for Workforce Planning and Health Services. She considers an example of a 'wicked problem' in paediatrics - the health workforce crisis in the UK - and how we can move forward.

Paediatrics has changed. Fifty years ago, when I was born, my greatest risk was either dying at birth or being susceptible to a pathogenic organism that would cause me harm. The latter is now a simple problem that can be solved or prevented by a single course of action: immunisation. Likewise, the probability of me being obese as a child was minimal.

The changing burden of disease for children and young people over the past 20 years is well documented, thanks to the RCPCH State of Child Health report. The increasing prevalence of obesity, mental health and child poverty are limiting children’s ability to thrive, and paediatricians are struggling to produce solutions to ‘fix’ them.

Increased complexity of disease also affects the workload on paediatric services, and we know that the child health workforce supply is not keeping pace with demand.

[We need to] have clearly defined outcomes with exemplary consistent leadership which is inclusive, empowering but strong with no bias

When things are complex, multifactorial and involve many different people, reaching a solution is challenging because information and knowledge is incomplete, contradictory and changes over time. There are said to be ten defining characteristics of a ‘wicked problem’, with significant social and political inferences, first defined in 1973.

There is no definitive formulation of a wicked problem.

Wicked problems have no stopping rule.

Solutions to wicked problems are not true-or-false, but better or worse.

There is no immediate and no ultimate test of a solution to a wicked problem.

Every solution to a wicked problem is a "one-shot operation"; because there is no opportunity to learn by trial and error, every attempt counts significantly.

Wicked problems do not have an enumerable (or an exhaustively describable) set of potential solutions, nor is there a well-described set of permissible operations that may be incorporated into the plan.

Every wicked problem is essentially unique.

Every wicked problem can be considered to be a symptom of another problem.

The existence of a discrepancy representing a wicked problem can be explained in numerous ways. The choice of explanation determines the nature of the problem's resolution.

The social planner has no right to be wrong (i.e., planners are liable for the consequences of the actions they generate).

Ritter, Webber and Melvin (1973)1

This is where we are at in paediatrics. Things are complex, multifactorial with many different people to consider. There is disagreement about the way forward, which makes the situation even more difficult to resolve. 

The heath care workforce crisis in the UK is a good example of a wicked problem. The child health workforce does not exist in isolation and attempts to find the root cause of problems result in seeing flaws across the whole social system.

Pressures in primary care have the knock on effect of more parents bringing their children to A&E, and GPs without much paediatric experience referring high numbers of children. In community paediatrics, rising caseload of conditions such as ASD (autism spectrum disorder) and ADHD (attention deficit hyperactivity disorder) are overloading the system, alongside cuts to social services, increasing child poverty and inequality. Increasing urbanisation means remote and rural care is struggling, with long travel times between remote units. 

What is the solution to wicked problems? The only way forward is to have clearly defined outcomes with exemplary consistent leadership which is inclusive, empowering but strong with no bias. For children, this requires child health care professionals to have a seat at the table when any policy changes are being discussed that may influence child health outcomes.

We have to have perseverance, tolerance and the ability to transform

A children and young people’s transformation programme is being developed as part of the NHS Long Term Plan which will provide the assurance to the NHS commitment to give children the best start in life and continued health to thrive. 

The RCPCH is also updating the State of Child Health report that is due to be published in March 2020. This landmark document brings evidence together from a variety of indicators, enabling child health professionals to advocate for policy changes so that child health outcomes are a priority across government.

The Paediatrics 2040 project is working with paediatricians to develop a credible vision for the future of paediatrics that follows four lines of enquiry, including data and evidence, impact of innovation, new models of care and working lives - and will be inviting members to input. You can also explore other RCPCH volunteering opportunities.

Together we can tackle the wicked problems that plague the field of child health but we have to have perseverance, tolerance and the ability to transform. These qualities are crucial to improving health outcomes for children and young people.

  • 1. Rittel, Horst W. J.; Webber, Melvin M. (1973). "Dilemmas in a General Theory of Planning". Policy Sciences. 4 (2): 155–169. doi:10.1007/bf01405730.