Paediatric Workforce in the UK and the Wider Implications
The Royal College of Paediatrics and Child Health (RCPCH) (UK) has recently issued a document which reports a serious shortfall in the UK Paediatric workforce. More than half of paediatric units are understaffed. Among trainees, general paediatric and neonatal rotas are experiencing a 14% vacancy rate. Over the last 3 years there has been a 27.2% decline in the number of Foundation 1 doctors who intend to apply for paediatric training. Deficiencies in paediatric consultant and associate specialists are also being encountered. More than 1 in 4 general paediatric posts at a senior level are vacant. The pressure is compounded by 35% of consultants having to fill gaps in the junior hospital doctor rosters at short notice.
The staff shortages impact on the ability to provide clinical care and services to children. In the last 3 years, 31% of paediatric and 41% of neonatal units have been forced to temporarily close or reduce their services. These deficiencies are taking place against a background of increasing demands for paediatric care. The number of admissions for children in England over the last 3 years has increased 25%, 1.2 million to 1.5 million. Attendances at paediatric ED units has grown 7%, from 4.5 million to 4.8 million. It is estimated that an additional 752 consultants are required to meet the current and future medical needs of children. The difficulty facing UK services in where these consultants will come from. In 2017 the specialist training interviews achieved just an 83% fill rate. The number of applicants who are EU graduates has decreased 58% in the last 2 years from 91 to 41.
The shortages in paediatric manpower appear to be multifactorial. The succession planners underestimated the current and future manpower needs. The feminization of paediatrics was not adequately considered. Currently 52% of consultants and 74% of trainees are female. The demands for part-time working and maternity leave should have been addressed. At present in the UK, 33% of women and 9% of men work less than full-time. The protracted row over the imposed junior hospital doctor contract has impacted negatively. It has resulted in reduced morale among trainees.
The reduction in the number of academic consultant posts makes the specialty less attractive makes the specialty less attractive to medical graduates interested in a career as a physician scientist. The number of academics has decreased from 8.7% to 4.2% of the consultant-level workforce. This downward trend is worrying for the progress of paediatrics. A strong R&D sector is important for any large organization such as health. A survey undertaken in 2015 found that in the previous 2 years, 62.5% of consultants had not been an author of a peer review research paper, and just 20% had authored a chapter in a textbook. Specialist paediatricians had authored 5 times as many papers as general paediatricians. The uncertainty around immigration status and conditions of employment for non-UK doctors following Brexit is a new concern. The RCPCH states that the calculation of paediatric workforce numbers has been heavily influenced by the UK Government rather than being based on what children need.
The current shortfall in paediatric manpower is in part due to a miscalculation on how the specialty would evolve. Over the last 25 years there has been an emphasis on the development of specialist paediatrics. It had been thought that much of general paediatrics would transfer into primary care. This has not happened because the burden was too great. The assessment and management of the undifferentiated sick child has proven more complex than initially predicted. When their child becomes unwell, parents seek certainty. When a baby has a fever and poor feeding, the family will frequently seek additional assessment and tests to ensure that its just a viral illness rather than something more serious. This places greater pressure on primary care to refer to the hospital services. Similar scenarios apply to children with less acute conditions. The resultant pressure points are at ED, OPD, and acute assessment units. It is now appreciated that the paediatric consultant workforce should consist of two thirds general paediatricians and one third specialist paediatricians.
The situation in the Irish paediatric health service is different and there are different challenges. On the positive side there is strong level of interest in a career in paediatrics among Irish medical graduates. Each year the RCPI paediatric training programme enrolls 40 BSTs and 25-30 SpRs. The programme is oversubscribed with applicants. The consultant paediatrician workforce is low at 15 per 100,000 and needs expansion. The Irish paediatric Model of Care has calculated that local hospitals require 6 consultants, regional hospitals require 12 consultants, and subspecialties require 5-8 consultants. The model also recognizes the need to develop general paediatics and to recalibrate the interface between paediatrics and primary care.
Another model being explored at a pilot site is a consultant provided service. There is a recognition of the need to both attract and retain consultants. A recent HSE document Towards Successful Consultant Recruitment, Appointment and Retention3 has made a wide range of recommendations on the consultant appointment process. Red tape has led to long delays of up to 2 years between a successful candidate accepting a job offer and taking up the post. The Report recommends that the CAAC make a decision on post application within 8 weeks of receipt. It has been recommendations that the hospital complete the contract documentation within 2 weeks of receiving the notification of the successful candidate. There should be a single document that covers the whole selection process.
The challenges being experienced by Paediatric services in the UK could also be encountered in this country. The major goal must be a motivated, well-trained, satisfied workforce that feels valued and respected. Junior doctors look for clarity about their training and the prospect of a consultant post when it is complete. Consultants look for facilities, clinical staff, and administrative staff to deliver optimal care to their patients.
1. State of Child Health. The Paediatric Workforce. RCPCH 2017 www.rcpch.ac.uk
2. Model of Care for Paediatric Healthcare Services in Ireland. www.hse.ie
3.HSE Ireland, ‘Towards Successful Consultant Recruitment, Appointment and Retention’,Dublin 2016 available from http://www.hse.ie/eng/staff/Resources/HR_publications/consultantrecruitment_dec16.pdf