A Workforce crisis in paediatrics - failing to thrive?
Paediatrics is a very rewarding medical specialty, providing care for infants, children and young people and supporting their carers. Maintaining a sustainable medical workforce of paediatric junior doctors who have protected time for training is essential for patient safety, their job satisfaction and them feeling valued (1). Providing safe junior doctor rotas in paediatrics is, however, now a problem in many hospitals as there is a 19.5% vacancy rate on paediatric middle grade rotas across the UK (2). This impacts adversely on the ability of Trusts to provide safe patient care and junior doctor training. A recent Royal College of Paediatrics and Child Health (RCPCH) Modernising Medical Careers cohort study of trainees that started paediatric training in 2007 demonstrated that 3.6% of paediatric trainees leave the training scheme annually (3). This implies that over 20% of those recruited to paediatric training eventually leave. A recent survey of London paediatric trainees who have left paediatric training demonstrated that 80% of those that leave continue to practice, but in other medical specialties in the UK or overseas; 20% leave medicine altogether. Other reasons for the rota gaps are trainees take time out of training or extend the time of training for family reasons, research opportunities or to work overseas. In addition to this, there has been a worrying reduction in the numbers of doctors applying to paediatric training. Compared to the previous three years, applications for paediatric speciality training at ST1 level are substantially lower in 2016, with 12.2 % fewer applicants (Table 1). This reduction in applications combined with trainees leaving or taking time out of training raises significant concerns about the sustainability of the future workforce with implications for paediatric, obstetric and emergency departments. Inadequate numbers of paediatric trainees will have effects on the numbers of paediatric consultants of the future.
Some junior doctors have decided to work overseas and not applied for subspecialty training this year. It is not known how many will return to UK paediatric training. Another potential reason for the reduction in applications and trainees leaving is poor junior doctor morale due to rota issues and the high workload particularly in middle grade posts. Trainees recognise that paediatrics is becoming a 24/7 consultant delivered service; they may be resident on call overnight as a consultant and be frequently called on to provide emergency care. The effect of the planned contract in England is unknown, but due to the effect on morale, this may be associated with further reductions in applications and increased resignations.
To try and address some of the above important problems, the RCPCH has changed the paediatric recruitment strategy at ST1 in an attempt to identify those most suited to paediatric training. Previously, questions with a requirement for some paediatric knowledge were used, this, however potentially disadvantaged applicants who had not had the opportunity to work in paediatrics. Knowledge and skill-based competencies are acquired within the eight-year paediatric training programme, hence now questions at interview are asked to select for the essential generic competencies (Table 2). The aim of this change is to recruit more resilience into the specialty and hopefully reduce the number of junior doctors leaving training. Innovative workforce solutions are also required to reduce gaps in rotas. Some organisations have produced successful rotas which include Advanced Nurse Practitioners and Physicians Associates. Such healthcare staff, however, can require lengthy training to be at a “middle grade decision making level” and thus likely to be only part of the solution. Another possibility is to increase recruitment of overseas trainees through the RCPCH Medical Training Initiative (MTI), which offers sponsored, accredited training for overseas doctors for two years. This would be more effective if paediatric non training middle grade posts were relisted as shortage occupation posts with the border agency, as they were until 2012 (4). Nevertheless, more radical workforce planning solutions will likely be required to ensure there is a competent and valued workforce able to deal with the challenges ahead and continue to provide the best possible care to infants, children, young people and support their families and carers.
We are grateful to Martin McColgan (RCPCH Work Force Information Manager) for supplying data informing this letter.
1) Department of Health, 2015. Delivering high quality, effective, compassionate care: Developing the right people with the right skills and the right values. A mandate from the Government to Health Education England: April 2015 to March 2016. Accessed online February 2015: https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
2) RCPCH 2015, Rota vacancies and Compliance survey December 2014 to April 2015 http://www.rcpch.ac.uk/system/files/protected/page/Rota vacancies and compliance survey 14-15 report FINAL.pdf
3) RCPCH MMC Cohort Study (Part 4). (http://www.rcpch.ac.uk/system/files/protected/page/Key%20Findings%20(final).pdf)
4) Partial review of the Shortage Occupation Lists for the UK and for Scotland. Migration Advisory Committee 2015. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
Table 1: The number of applicants to paediatric speciality training at ST1 level, 2013-2016.
Year, Number of Applicants to ST1
Table 2 – Generic competencies to be assessed at interview
Enjoys working with children
Enthusiasm and commitment to specialty
Considerate, compassionate and caring
Emotional intelligence and empathy
Well-structured effective communication
Knowing limits and when to escalate
Good prioritisation and time management skills
Active followership skills with potential of Leadership skills
Able to think on their feet and to use all resources available to them
Competing interests: No competing interests