WF 16
Ymchwiliad i gynaliadwyedd y gweithlu iechyd a gofal cymdeithasol
Inquiry into the sustainability of the health and social care workforce
Ymateb gan: Coleg Brenhinol Pediatreg ac Iechyd Plant
Response from: Royal College of Paediatrics and Child Health
Consultation response from the Royal College of Paediatrics and Child Health (RCPCH):
Inquiry into the sustainability of the health and social care workforce
1. Who we are
1.1 The Royal College of Paediatrics and Child Health (RCPCH) works to transform child health through knowledge, innovation and expertise. We have over 550 members in Wales and over 17,000 worldwide. The College is responsible for training and examining paediatricians. We also advocate on behalf of our members, represent their views and draw upon their expertise to inform policy development and the maintenance of professional standards.
1.2 For further information please contact Gethin Jones, External Affairs Manager for Wales: XXXXXXXXXXXXXXXXXX or XXXXXXXXXXXX.
2. Our priorities for child health in Wales
2.1 Infants, children and young people (ICYP) aged 0 to 18 make up around 20% of the UK population[1] and they are high users of healthcare services; accounting for around a quarter of a typical GP’s workload[2] and more than a quarter of emergency department attendances. Yet services for ICYP appear to be a low priority. ICYP must be considered equitably to adults in all aspects of healthcare. Under Article 24 of the UN Convention on the Rights of the Child (UNCRC), all ICYP have the right to be as healthy as they can be and to access health services.
2.2 While children’s health has improved greatly in the UK over the last 30 years, the UK lags behind much of Western Europe on key measures of child health and wellbeing and continues to have one of the highest mortality rates in Western Europe for under-fives[3]. UNICEF places the UK 16th out of 29 rich countries in measures of child wellbeing[4].
2.3 Since the founding of the NHS in 1948, there has been a strong shift in the burden of disease in childhood away from infectious diseases to more chronic, long term conditions. One in seven (15%) of 11 to 15 year olds now have a long term condition or disability[5]. The increased long-term survival of children with complex disabilities, in part due to better survival rates for low birth weight and improvements in care, means that appropriate care needs to be in place to support these ICYP from infancy through to adulthood.
2.4 Wales has the opportunity to deliver better models of care for infants, children and young people.
2.5 The RCPCH’s Why Children Die report highlights a need to better manage sick ICYP and recommends that measures are taken to improve recognition and management of serious illness across the healthcare service.
2.6 Last year we published Child Health Matters: A Vision for 2016 in Wales. Following a consultation with our members in Wales, this document set out a series of policy calls that we believe would have the most positive impact on the health and wellbeing of children and young people in Wales.
2.7 RCPCH’s Facing the Future (FtF): Standards for Acute General Paediatric Services makes the case for whole system change in paediatrics to more effectively meet the needs of ICYP. The model recommends fewer, larger inpatient units which provide consultant delivered care and which are better equipped to provide safe and sustainable care. These units must be supported by networked services and more care delivered closer to home through community children’s nursing teams and better paediatric provision in primary care.
2.8 RCPCH, Royal College of General Practitioners (RCGP) and Royal College of Nursing (RCN) have also worked together to develop a new set of standards in the Facing the Future suite, Facing the Future: Together for Child Health. These standards apply across the unscheduled care pathway to improve healthcare and outcomes for ICYP. They aim to ensure there is always high-quality diagnosis and care early in the pathway, providing care closer to home where appropriate (right care, right time and right place). The standards will ensure specialist child health expertise and support are available directly into primary care services where the needs of the child and their family are known and will build good connectivity between hospital and community settings; primary and secondary care; and paediatrics and general practice.
2.9 We can provide hard copies of these publications upon request.
3. Do we have an accurate picture of the current health and care workforce? Are there any data gaps?
3.1 RCPCH carries out a biennial census of the UK paediatric workforce and child health services, from which we produce figures for Wales. The report to be disseminated late in 2016 will be a comprehensive picture of the paediatric workforce and services in Wales.
3.2 It is important for the Welsh Government to recognise the importance of the Workforce Census (see references) and support RCPCH to achieve a 100% completion rate so that we have a complete picture of the paediatric workforce and avoid the need for additional projects that risk duplicating this work.
3.3 From our previous census in 2013 (see references), we reported that there were 153 wte (whole time equivalent) paediatric consultants in Wales i.e. 27.5 per 100,000 children aged 0-15. This ratio was lower than that in Scotland, London and the North of England but higher than the ratios on Northern Ireland, South of England, Midlands and East of England. However the College estimate that across the UK as a whole approximately 800-1000 wte consultants are needed to meet its standards for acute care such as 12 hour consultant presence in hospital 7 days a week (FtF) and British Association for Perinatal Medicine (BAPM) standards for neonatal care. This demand increases if there is to be greater integration between primary and secondary care for child health or an increase to 24 hour consultant presence.
3.4 From the data received to date from our 2015 census (2 hospitals outstanding) we estimate that 11% of posts on tier 1 rotas in Wales (junior trainees) and 21% of posts on tier 2 rotas (usually more senior trainees) were vacant over the 15/16 winter period. These figures are slightly higher than elsewhere in the UK. Most tier 1 rotas are made up of 10 wte or more posts in line with College standard (FtF) whereas the average wte of slots on tier 2 rotas is 8.4 doctors.
3.5 It is important to note that while we have a good picture of the number of paediatricians and gaps in paediatric units, we need a better picture of the paediatric workforce overall – in particular GPs, children’s nurses, health visitors and CAMHS. This is crucial in order to deliver the models set out in the Facing the Future suite and we would urge the Welsh Government to ensure that we have a comprehensive picture of the child health workforce.
4. Is there a clear understanding of the Welsh Government’s vision for health and care services and the workforce needed to deliver this?
4.1 Dealing with pressures in the paediatric and child health workforce will help child health services achieve the care standards set out by RCPCH and ensure safe and sustainable services for children across Wales.
4.2 We would welcome Welsh Government support for our vision. We have called on the Welsh Government to work with the Wales Deanery, RCPCH, other stakeholders and UK Government to develop a strategic workforce plan, which should include measures to address the child health and paediatric workforce.
4.3 Other medical royal colleges have also called for a workforce strategy. Royal College of Physicians Wales has called for “a national medical workforce and training strategy which ensures that staff are deployed and trained effectively, now and in the future.”[6]
4.4 For the paediatric element of the strategy and plan RCPCH recommends the workforce requirements are designed around the introduction of new service models:
4.5 More effective paediatric care in hospital settings:
• Increased number of paediatric consultants to provide consultant cover to meet the RCPCH standards. In general paediatrics (assuming the same number of units) an additional 35 consultants would be needed plus community child health and subspecialty consultants.
• Increased number of trainees to fill rota vacancies and meet RCPCH standards of ten trainees on a training rota
• Development of new rota models including the role of Advanced Nurse Practitioners on paediatric tier one rotas and resident consultants.
• Increased number of registered children’s nurses
4.6 Better management of the health of infants, children and young people in primary care and the wider community
• Delivery of more care in the community, including increased training and development of community children’s nursing teams and increased numbers of GPs trained in paediatrics.
• Greater paediatric support for the delivering of care in the community e.g. consultant hot phones, rapid access, outreach clinics
• Development of safer staffing arrangements and transport infrastructure for remote and rural units.
• Increased number of registered children’s nurses
4.7 Increased use of associate professionals
• Physician Associates. There have been very few working in paediatrics to date but RCPCH expects the numbers will increase, which will enable effective evaluation.
• Advanced Paediatric Nurse Practitioners.
• Resident consultants.
4.8 We do not therefore have a clear understanding of the Welsh Government’s plan to deliver the health and social care workforce we need.
4.9 We ask the Welsh Government to support our vision and develop the comprehensive health and social care workforce strategy that would give us a clear understanding of how the Welsh Government will deliver this.
5. How well-equipped is the workforce to meet future health and care needs?
5.1 As mentioned above, to meet future demands of College standards and to provide safe care, consultant numbers need to increase, which means the number of new Certificate of Completion of Training (CCT) holders in Wales should be appropriate to meet this demand.
5.2 Figures from the Welsh Deanery show that there are currently (Summer 2016) 148 paediatric trainees in Wales, which represents a fall from an RCPCH estimate of 156 in 2015. Clearly a decline in the number of trainees would impact the number of new CCT holders who qualify as future consultants. In 2014 only 13 doctors achieved CCT in paediatrics and its subspecialties in Wales, 5 of whom had worked less than full time as trainees.
5.3 Again, we would call for a comprehensive health and social care workforce strategy to address these issues.
6. What are the factors that influence recruitment and retention of staff across Wales? This might include for example:
· the opportunities for young people to find out about/experience the range of NHS and social care careers;
· education and training (commissioning and/or delivery);
· pay and terms of employment/contract;
· Whether there are there particular issues in some geographic areas, rural or urban areas, or areas of deprivation for example.
6.1 When paediatricians resign early or take up posts elsewhere, they are given an exit interview. RCPCH does not hold this information but we would recommend that the data is anonymised and headlines made available to the Welsh Government to inform its strategy to retain paediatric and child health staff in Wales.
6.2 36 consultant appointment committees were reported to the College in Wales in 2014 and 2015. For 10 of those (27.7%) an appointment was not made. This data may be incomplete if not all appointment committees are reported to us, but we are obviously concerned that the available data suggests over a quarter of consultant posts advertised in Wales are not filled.
6.3 We asked a panel of RCPCH members representing each region in Wales whether they could identify factors relating to geography, rural or urban areas, or areas of deprivation. The feedback we received included the following statements from RCPCH members:
6.4 On urban and rural areas:
6.5 “Often the adverts say you will be based at one hospital but you may be expected to travel all over the Health Board if necessary (or words to that effect) As travel times in rural areas are not as simple as judging it on the mileage this is a factor.”
6.6 “Whilst most hospital services in the UK are experiencing difficulties with the recruitment of junior doctors it is especially challenging for those hospitals in rural areas. Many junior doctors perceive rural DGH’s to be too small and therefore less attractive for training purposes and many prefer to settle with their families in larger urban/city areas where the density of hospitals is greater and the chances of employment at more academic/tertiary institutions greater… Doctors and their families will settle in the larger cities closer to the hospitals that provide the majority of their specialist training (ie tertiary centres) and as a result will be very reluctant to move away to more rural locations for work.”
6.7 On larger and smaller hospitals:
6.8 “Acute/on-call rotas for Consultants in smaller hospitals are more onerous than in the teaching hospitals (appreciate different intensity but the frequency of on-call is a big factor for many when considering a job).”
6.9 Other issues:
6.10 “Too often it is the clinical staff (mainly consultants) who are spending significant period of time during their working week attempting to fill rotas, contacting locums, persuading doctors to change their shifts to plug gaps etc. In my view this is very poor use of consultant time but has resulted mostly due cutbacks within the administrative workforce who should provide the practical support for recruitment.”
References
Facing the Future: Standards for Acute General Paediatric Services http://www.rcpch.ac.uk/facingthefuture
Facing the Future: Together for Child Health http://www.rcpch.ac.uk/facing-future-together-child-health
RCPCH Workforce Census 2013 http://www.rcpch.ac.uk/improving-child-health/better-nhs-children/workforce-planning/workforce-census-2015/previous-censuse
RCPCH Workforce Census 2015 http://www.rcpch.ac.uk/census
Why Children Die report http://www.rcpch.ac.uk/news-campaigns/campaigns/why-children-die/why-children-die-rcpch-campaign
[1] 2011 Census, ONS
[2] Hippisley-Cox J et al. Trends in consultation rates in general practice 1995 to 2006: analysis of QRESEARCH database 2007. Cited in Wolfe et al. Improving child health services in the UK: insights from Europe and their implications for the NHS reforms? BMJ 2011.
[3] Royal College of Paediatrics and Child Health, National Children’s Bureau and British Association for Child and Adolescent Public Health. Why Children Die: death in infants, children and young people in the UK. 2014
[4] UNICEF Report Card 11, 2013
[5] Association for Young People’s Health Key Data on Adolescence 2013
[6] RCP Wales, Focus on the future, June 2015