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Background: As clinical leadership becomes an expectation in medical professionals of the future, careful consideration needs to be given to the planning, design, structure and evaluation of leadership development programmes. Aim: To take a structured approach to the designing and planning of a work-based leadership development programme for paediatric doctors in training. Methods: A total of 30 trainees within the London Specialty School of Paediatrics were given the opportunity to develop their leadership skills by working in small groups alongside the training programme directors in a number of areas of the work of the School. The design of the leadership programme was built around learning from three key sources, namely literature review, focus groups involving the participants, and small-groupworkshops, all ofwhich contributed to the thinking behind the ethos of the programme. Learning outcomes were derived from the Medical Leadership Competency Framework. A comprehensive evaluation of the programme, using a combination of peer assessment and self-assessment tools, was planned and piloted prior to the start of the programme. Results: The literature review found very few leadership development programmes that had been fully evaluated. Where planning had been described, the benefit of aligning programmes to existing leadership curricula was highlighted. The majority of programmes took learners out of their working environment to learn. Although the focus groups provided useful information about the leadership perspectives of trainees, above all it was the process of participation that engendered confidence and a feeling of ownership in the planning and structure of the programme. This concept of trainee participation was taken further with the small-group workshops which used peer learning to produce practical ideas for the benefit of the group. Conclusions: Leadership development programmes, as with all educational interventions, need to be properly planned and evaluated. Programmes need to be aligned to leadership curricula, and should incorporate the views of participants. There are also benefits to considering an approach to learning that is embedded in the clinical workplace. [ABSTRACT FROM AUTHOR]

The architectural design of hospitals worldwide is centred around individual departments, which require the movement of patients between wards. However, patients do not always take the simplest route from admission to discharge, but can experience convoluted movement patterns, particularly when bed availability is low. Few studies have explored the impact of these rarer, atypical trajectories. Using a mixed-method explanatory sequential study design, we firstly used three continuous years of electronic health record data prior to the Covid-19 pandemic, from 55,152 patients admitted to a London hospital network to define the ward specialities by patient type using the Herfindahl-Hirschman index. We explored the impact of 'regular transfers' between pairs of wards with shared specialities, 'atypical transfers' between pairs of wards with no shared specialities and 'site transfers' between pairs of wards in different hospital site locations, on length of stay, 30-day readmission and mortality. Secondly, to understand the possible reasons behind atypical transfers we conducted three focus groups and three in-depth interviews with site nurse practitioners and bed managers within the same hospital network. We found that at least one atypical transfer was experienced by 12.9% of patients. Each atypical transfer is associated with a larger increase in length of stay, 2.84 days (95% CI 2.56-3.12), compared to regular transfers, 1.92 days (95% CI 1.82-2.03). No association was found between odds of mortality, or 30-day readmission and atypical transfers after adjusting for confounders. Atypical transfers appear to be driven by complex patient conditions, a lack of hospital capacity, the need to reach specific services and facilities, and more exceptionally, rare events such as major incidents. Our work provides an important first step in identifying unusual patient movement and its impacts on key patient outcomes using a system-wide, data-driven approach. The broader impact of moving patients between hospital wards, and possible downstream effects should be considered in hospital policy and service planning., (© 2023. Springer Nature Limited.)

Competing Interests: Competing interests: None declared.

Advances in paediatric care mean that more children with complex medical problems (heart disease, neurodevelopmental problems and so on) are surviving their early years. This has important implications for the design and delivery of healthcare given their extensive multidisciplinary requirements and susceptibility to poor outcomes when not optimally managed. Importantly, their medical needs must also be understood and addressed within the context of the child and family's life circumstances. There is growing recognition that many other factors contribute to a child's complex health needs (CHNs), for example, family problems, fragmentation of health and care provision, psychological difficulties or social issues.To facilitate proactive care for these patients, we must develop accurate ways to identify them. Whole Systems Integrated Care-an online platform that integrates routinely collected data from primary and secondary care-offers an example of how to do this. An algorithm applied to this data identifies children with CHNs from the entire patient population. When tested in a large inner-city GP practice, this analysis shows good concordance with clinical opinion and identifies complex children in the population to a much higher proportion than expected. Ongoing refinement of these data-driven processes will allow accurate quantification and identification of need in local populations, thus aiding the development of tailored services., Competing Interests: Competing interests: REK is an associate editor for BMJ Leader., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Quality improvement (QI) is an essential component of modern clinical practice. Front-line professionals offer valuable perspectives on areas for improvement and are motivated to deliver change. In the UK, all junior doctors are expected to participate in QI in order to advance to the next stage of their training. However, UK undergraduates receive no standardized training in QI methods. This is perpetuated within medical schools by a lack of teaching capacity and competing priorities, and may lead to tokenistic engagement with future QI projects., Methods: We describe a near-peer teaching programme designed to introduce students to QI methods. This pilot study was conceived and delivered in full by junior doctors and used existing resources to ensure high quality teaching content. 111 fifth-year medical students from the University of Cambridge were taught in interactive, participative workshops that encourage them to develop their own QI change ideas and projects. Core topics included the model for improvement, driver diagrams, stakeholder engagement, measurement for improvement and analysing and presenting data. Students completed surveys before and immediately after this intervention to assess their understanding of and confidence in utilizing QI methods. Questionnaires were also completed by junior doctor tutors., Results: Analysis of questionnaires completed before and immediately after the intervention revealed statistically significant improvements in students' self-reported understanding of QI (p < 0.05) and confidence in applying techniques to their own work (p < 0.05). Students expressed a preference for QI teaching delivered by junior doctors, citing a relaxed learning environment and greater relevance to their stage of training. Tutors reported increased confidence in using QI techniques and a greater willingness to engage with QI in future., Conclusions: In this single-centre study, near-peer teaching produced significant improvements in students' self-reported understanding of QI and confidence in applying QI methods. Near-peer teaching may constitute a sustainable means of teaching essential QI skills at undergraduate level. Future work must evaluate objective measures of student engagement with and competence in conducting QI.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and and declare the following interests: NM is co-founder of Next Generation GP.

Competing Interests: Competing interests: None declared.

Carboxypeptidase E is a peptide processing enzyme, involved in cleaving numerous peptide precursors, including neuropeptides and hormones involved in appetite control and glucose metabolism. Exome sequencing of a morbidly obese female from a consanguineous family revealed homozygosity for a truncating mutation of the CPE gene (c.76&#95;98del; p.E26RfsX68). Analysis detected no CPE expression in whole blood-derived RNA from the proband, consistent with nonsense-mediated decay. The morbid obesity, intellectual disability, abnormal glucose homeostasis and hypogonadotrophic hypogonadism seen in this individual recapitulates phenotypes in the previously described fat/fat and Cpe knockout mouse models, evidencing the importance of this peptide/hormone-processing enzyme in regulating body weight, metabolism, and brain and reproductive function in humans.

Quality improvement (QI) is described as being about changing the way in which patient care is delivered. It is more than just a theoretical framework against which innovations can be introduced; it is about a rigorous patient-centric approach to the design and delivery of care. In this paper we will explore some of the practicalities of delivering quality improvement in paediatrics and child health, and explain why it is an approach that we all must take.

Quality improvement is a focus on changing the way in which patient care is delivered. Central to this is developing a more rounded, patient-focused approach to the design and delivery of care. Here, in the first of a series, we introduce the concepts of quality improvement, explain why quality improvement should matter to paediatricians and give some pointers as to where and how paediatricians can learn and do more.

Background: Safe assessment of severe underweight in children is important but experience suggests a frequent lack of understanding. Here we sought evidence from a wide spectrum of trainees., Methods: Cross-sectional telephone survey of an on-call middle-grade paediatric doctor in hospitals providing acute inpatient general paediatric care in England and Wales., Results: Response rate was 100%. Only 50% identified BMI as the appropriate measure for underweight in children. Most did not identify any clinical cardiovascular complications of severe underweight. Only 13% identified corrected QT time (QTc) as an important ECG finding. Knowledge of the refeeding syndrome was poor with 20% unable to define it at all, 21% able to identify some clinical features and 57% aware of potential phosphate abnormalities., Conclusions: Knowledge base among middle-grades doctors in England and Wales on this topic is worryingly poor, particularly in relation to several life-threatening features. Existing and new training approaches should recognise this.

It is increasingly recognised that leadership skills are a key requirement in being successful in surgery, regardless of speciality and at all levels of experience and seniority. Where the emphasis was previously on technical ability, knowledge and diagnostic acumen, we now know that non-technical skills such as communication and leadership contribute significantly to patient safety, experience and outcomes, and should be valued. The operating theatre is a unique micro-environment which is often busier, noisier, more stressful and more physically demanding than the clinic or ward setting. As a result surgeons and their trainers, who are striving to develop leadership skills require an in-depth awareness of the challenges in this environment and the opportunities that arise from them to develop leadership effectively. This article outlines why leadership learning is so beneficial in the operating theatre, both for the team and the patient as well as what elements of daily routine activity such as the WHO checklist use, list-planning and audit can be exploited to transform the average busy operating theatre into a rich, learning environment for future leaders in surgery., (Copyright © 2012. Published by Elsevier Ltd.)

Unlabelled: A Check and Correct checklist has previously been developed to increase feedback on prescribing quality and enhance physicians' focus on patients' drug charts during ward rounds. Our objective was to assess the impact of introducing such a prescribing checklist on the quality and safety of inpatient prescribing in two paediatric wards in a London teaching hospital. Between 15 March 2011 and 15 May 2011 (pre-intervention) and between 23 May 2011 and 23 July 2011 (post-intervention), we recorded rates of both technical prescription writing errors and clinical prescribing errors twice a week. During the pre-intervention period, the overall technical error rate was 10.8 % (95 % confidence interval 10.3 %-11.2 %); the clinical error rate was 4.7 % (3.4 %-6.6 %). The most common errors were absence of prescriber's contact details and dose omissions. After the implementation of Check and Correct, error rates were 7.3 % (6.9 %-7.8 %) and 5.5 % (3.9 %-7.9 %), respectively. Segmented regression analysis revealed a significant decrease of -5.0 % in the technical error rate (-7.1 to -2.9 %; -37.7 % relative decrease; R (2) = 0.604) following the intervention, independent of changes in overall medical records' documentation quality. Regarding clinical errors, no significant impact of the intervention could be detected., Conclusion: Implementing a Check and Correct checklist led to an improvement in the quality of prescription writing. Although a change in culture may be needed to maximise its potential, we would recommend its more widespread use and evaluation.

Fundamental reform to the way we train and develop our future workforce is planned. In order to successfully achieve change the engagement of those delivering care is necessary. In this study the authors used a novel participatory design to seek the opinions of medical students, foundation doctors, specialty trainees and consultants on some key statements regarding proposed improvements to postgraduate medical education. While there was overall agreement on many of the recommendations of the Temple report, some aspects were potentially divisive, with significant differences between the views of consultants and those more junior to them. This work emphasises the importance of engaging all members of the healthcare workforce, both present and future, in the reasons for, and outcomes of, healthcare reform.

Background: Children and young people are used as cases and standardised patients in clinical exams and teaching courses. Consultation with them suggests that education and training are areas they feel they should actively participate in., Aims: To examine the perceptions, motives and concerns of children and young people participating in exam-focused clinical teaching, and to compare these views with those of their parents, trainees and tutors., Methods: Consultation and a pilot study were used to design an anonymised questionnaire with 5-point Likert scales and free text answers. This was sent to 112 children and young people, their parents, and tutors and trainees attending a clinical teaching course. Results were analysed using the Mann-Whitney U test., Results: 71% of the questionnaires sent to children and young people and their parents were completed. For children and young people the major reasons for taking part were the enjoyment of helping people to learn (92% agreement) and wanting to "give something back" (85% agreement). Parents put significantly more emphasis on giving something back than anything else. Tutors and trainees felt the chance for children and young people to earn pocket money was their most important motivation. The major problem highlighted was that it is tiring being repeatedly examined. All children and young people and their parents said that they would participate in future clinical teaching., Conclusions: This study demonstrates that in the context of well-planned, structured clinical teaching, most children and young people are primarily motivated to participate to help educate doctors.