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We are committed to supporting paediatric trainees and those who deliver paediatric training in the UK. The COVID-19 pandemic will cause unprecedented disruption to training and assessment in paediatrics. We know that training for all paediatric trainees will be affected, although some trainees will feel this disruption more acutely, as they would have been approaching more critical points in their training than other trainees, prior to the pandemic.
We know that trainees will understandably be anxious and have many questions. Many of the answers to these questions will ultimately involve other agencies, including the four-nation Statutory Education Bodies (HEE, HEIW, NES, NIMDTA) and the General Medical Council. The RCPCH has a defined and predominantly advisory remit.
Nevertheless, as your College, we feel acutely the need to share our thoughts and plans with you, as early as possible, although you will undoubtably realise that many of the plans will be in outline form only and will encompass more than one potential solution.
Annual Review of Competence Progression (ARCP)
Trainee progression is assessed at ARCP, based upon educational supervisor reports and ePortfolio evidence, and may also require certain mandatory assessments, such as exams, etc.
This process has been disrupted at many points because of the COVID-19 pandemic.
On 19 March 2020, the Academy of Medical Royal Colleges (AoMRC) published a contingency policy for ARCPs (PDF).
The RCPCH will be supporting Schools in identifying which trainees are approaching critical progression points, so that their ARCPs can be prioritised.
The contingency policy directs ARCP panels to take into account the impact of the COVID-19 pandemic, including more flexible approaches to evidence requirements and any time-off due to illness or meeting isolation requirements. There is an acceptance in the policy that some outstanding capabilities can be gained later in training and should not necessarily interrupt trainee progression.
The RCPCH Education & Training Division will work with Heads of Schools, trainee representatives and, where applicable, CSACs, to produce guidance on how the flexibility should be interpreted by Paediatric ARCP panels - to ensure fairness and consistency throughout UK paediatric training.
We will be aiming to focus on a reduced number of key pieces of evidence, using data to inform which of these are the most valid and reliable.
This guidance will be specific to each training level; some of the level specific issues will be described in later sections.
Disruption to paediatric rotations
A reminder: Paediatric trainees are required to demonstrate the key capabilities, as described in the relevant sections of the Progress curriculum. With the exception of sub-specialty (“GRID”) rotations, trainees are not currently required to undertake specific placements. No trainee is required to undertake any placement for a minimum period. Training is capability-based, not time-based, providing trainees spend a minimum of four years in the paediatric training programme.
Some schools have designed rotational programmes with a time element, often arising from the historical time-based curriculum, coupled with balancing training and service needs – for example, level 2 (ST4-5) programmes comprising 12 months general paediatrics, 6 months neonatology and 6 months community child health.
The RCPCH will remind all Schools that there is no requirement at ARCP for any level 1 or level 2 trainee to satisfy any minimum time-based rotational elements within each level of training. Any such practice must cease immediately.
The COVID-19 pandemic has disrupted planning rotations. Indeed, some trainees may be required to work in adult settings. This will require agreement from the Postgraduate Dean and will be subject to satisfactory guidance, support and clinical supervision – see the statement from the General Medical Council (GMC), issued on 11 March 2020.
Many of the key capabilities within the paediatric curriculum can be evidenced from working in non-paediatric (and non-clinical) settings.
The RCPCH Education & Training Division has produced some guidance for trainees and their supervisors on how to use non-paediatric experience to satisfy some of the Progress curriculum requirements, in a time-efficient manner.
Disruption to working patterns (OOP, LTFT and academic training)
Some trainees will have volunteered, or been asked, to work at a higher-than-anticipated percentage in the clinical workplace. For example, OOPR (out of programme research) - where the 50% research time has been temporarily been withdrawn and the trainee will now be 100% clinical; LTFT (less than full time training) trainees - who increase from 60% to 100% clinical.
For those in academic training, our VP for Science and Research, Professor Nick Bishop, is having continued discussions about the effects on those trainees who are being asked to cover clinical duties. We'll post more information here.
Ordinarily, such changes would potentially impact CCT (Certificate of Completion of Training) dates. These are not ordinary times. There are likely to be individual factors that make issuing specific guidance to cover every situation impossible.
In general, however:
The RCPCH will not support rigid, time-based approaches to calculating training time, providing the minimum training times are fulfilled.
We expect that negotiation, flexibility and common sense should be exercised on an individual basis.
Level 3 trainees (ST6-8)
The two specific challenges for level 3 trainees are certification (CCT) and RCPCH START (Specialty Trainee Assessment of Readiness for Tenure), which are interlinked challenges for some trainees.
As this is an electronic process, it is unlikely to be disrupted. The process is, however, dependent upon the award of an outcome 6 at ARCP, which should be facilitated by producing guidance for ARCP panel and the CSAC on the flexibility allowed for judgement on outcome.
Some trainees will have experienced disruption to their sub-specialty programmes; in some cases, this might prevent them from acquiring the required level 3 capabilities, depending upon the syllabus. It would be rare for this to have occurred in the final year of training, but CSACs and sub-specialty trainees will be asked to flag any cases to the RCPCH Education & Training Division and their School as soon as possible, so that senior advice can be sought on a case-by-case basis.
Some level 3 trainees will have planned to undertake the START assessment in April 2020 prior to their anticipated CCT date in the autumn (see more about START below). As this assessment is cancelled, these trainees are unable to complete a mandatory assessment requirement before their due CCT date. This will also include trainees whose CCT date was originally in late 2020 / early 2021, and who wanted to bring this forward to summer/autumn 2020 and were therefore relying on undertaking START in April.
The RCPCH will explore options with the GMC, including whether it is possible to issue an official letter for employing NHS authorities to use when appointing, potentially as a locum consultant, pending full certification.
RCPCH START assessment
In addition to the certification challenge, the feasibility of running a centralised, multi-scenario, face-to-face assessment later in the year is unknown. There will be a backlog of trainees wishing to undertake START, following the cancellation of the April assessment. The RCPCH will need to increase provision for trainees needing this assessment; what form the provision will take depends upon the timescale of the COVID-19 pandemic restrictions and the degree of flexibility afforded to us by the GMC, who regulate our assessments.
The RCPCH is committed to exploring all options (with the GMC, Schools and trainees) to provide an assessment that fulfils the purpose of START, that is accessible and high quality, preparing trainees for their future role as consultant paediatricians.
Options may include (none are mutually exclusive):
- Prioritise places in subsequent START assessments, according to identified trainee urgency
- Extra places in subsequent START assessments, run as currently
- Reduce number of scenarios to cover key, generic elements and ask CSAC / Schools to ensure trainees are assessed for clinical capability at the workplace
- Deliver a reduced number of scenarios and using local assessors in each deanery
- Exploring alternatives to face-to-face assessment, use of remote working, etc.
Level 2 trainees (ST4-5)
The challenges facing trainees anticipating progression from level 2 will be met by issuing guidance on ARCP judgements, reducing to key pieces of evidence and allowing more flexibility, as described above. We are also reminding all ARCP panels about the requirement for trainees to acquire capabilities, rather than serve time in specific rotations.
All trainees who accepted places on sub-specialty training programmes (“GRID”) should have those rotations honoured (providing medical staff rotations are allowed in the UK by August / September 2020).
As these trainees have already had an additional assessment at interview in late 2019, it is proposed that the default position will be to allow progression to level 3, unless there are significant, overriding concerns that would justify an unfavourable ARCP outcome.
Level 1 trainees (ST1-3)
In addition to the general issues about ARCPs and curriculum requirements, covered above, the specific challenges for level 1 trainee progression are likely to be related to the MRCPCH examination. Currently, there are two exam-dependent progression points: (a) trainees progressing to ST3 need two out of the three theory components of MRCPCH, and (b) trainees progressing to ST4 (level 2) need the MRCPCH clinical exam.
The challenges posed by examination restrictions and cancellation are likely to be the most difficult to solve. This will require discussion with the GMC and likely solutions will depend upon: (a) number of trainees affected, (b) patient safety considerations, and (c) potential for mitigating risks to patient safety by other means.
MRCPCH theory components
The ability of the RCPCH to deliver computer-based testing may be compromised by restrictions placed on bringing groups of clinicians together in the computer testing venues, ensuring there are enough staff to run the test; the venues and staff are provided by a third-party supplier.
Trainees may also encounter difficulty in being released by employers to sit an exam. Trainees have already had study leave and training opportunities cancelled; some will be redeployed. These are factors that are likely to compromise their ability to prepare adequately.
With the implementation of outcomes-based capability curricula across medical training, there is less emphasis on the assessment of knowledge as an outcome. This might present an opportunity for the GMC to allow some flexibility in theory exam-based progression points because capability-based clinical outcomes will be assessed later in the pathway.
MRCPCH Clinical exam
The ability of the RCPCH to deliver clinically based examinations has been severely compromised by the reduction in the use of clinical areas for any non-COVID-19 related activity, protecting children and young people patient volunteers and the reduction in clinical examiner availability. These challenges are likely to persist for longer than the challenges to the theory components, as it will take time for the NHS to recover non-COVID-19 capacity.
The RCPCH Examinations team will explore a number of options to reduce the impact of theory and clinical exam cancellations on trainee progression. You can keep updated on our COVID-19 - impact on examinations: FAQs.