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We read Professor Stephenson's excellent perspective on the state of the NHS with interest.1 This is a very comprehensive account of the NHS budget, NHS reform and implications for children's services. We would like to add a few points specific to the impact of the new NHS on the care of children, both current and in the future, due its effect on the training of new paediatricians.
Towards the end of the article, the important point is made that patient choice and plurality of providers may well not be the best solution for children with multiple coexisting long‐term problems. We would like to add that there is also a real danger that the system by offering more patient choice may lead to delayed flagging up of child protection issues. One of the strengths of the old NHS was that it encouraged clinical networks and tertiary specialists were generally enthusiastic about giving informal telephone advice to generalist paediatricians. Many paediatricians will be worried that the Payment by Results scheme will demotivate the formation of such networks and financial implications may get in the way of professional relationships. Finally, while it is important to ensure paediatric services are efficient and to emphasise the importance of discharging children back to primary care, it is arguable if measuring outcomes such as new to follow‐up ratios and dissuading consultant‐to‐consultant referrals are in the best interests of the child.
The NHS has always been about both service provision and medical training. The patient has been put in the centre of the equation, but what about the trainee? We believe that financially motivated changes in the way we work without understanding how this will impact on training are short‐sighted. Many changes have revolved around providing the most activity with minimum staff and ensuring that service needs are met without doctors working over the number of hours allowed by European Work Time Directives. This has meant that trainees are often stretched by service commitments, demoralised and demotivated so that they do not derive full benefit from the many learning opportunities that clinical care offers.
While educational supervision and regular appraisal of trainees do take place, we believe it is common for junior doctors and consultants to feel there is little room for tailoring each doctor's work experience to suit their training needs. For example, in most hospitals, junior doctors who are GPVTS trainees have the same service commitments as career grade paediatricians, even though their training needs are likely to be very dissimilar. Similarly, while the training needs of different specialist registrars will be different, service priorities usually mean that their needs cannot be catered for. This makes the process of supervision and setting targets for learning less meaningful and can lead to low morale and lack of enthusiasm for such activities. Many junior doctors feel anxious about how well they will be prepared by their training and what jobs await them at the end of it. This anxiety can translate to less happiness and goodwill when they are working and increase in leave due to sickness.
The government and the politicians are likely to be less aware of the training needs of doctors and will tend to concentrate on using the current trained doctors to best advantage to run the NHS. The Royal Colleges and Deaneries must take it upon themselves to remind the powers of the dual role of the NHS so that the doctors of the future are well trained and competent to serve tomorrow's Britain.
Competing interests: None.