Health CommitteeWritten evidence from the Royal College of Paediatrics and Child Health (ETWP 57)

Introduction

1. The Royal College of Paediatrics and Child Health is responsible for training and examining paediatricians in the UK. The College has over 12,000 members in the UK and abroad and sets standards for professional and postgraduate medical education. The College’s key roles include:

A professional advocacy role for paediatricians across the UK, and for paediatricians in international countries.

Standard setting.

Workforce intelligence and strategic advice.

Strategic service planning.

2. The RCPCH is a member of the Academy of Royal Colleges and has been party to the Academy’s submission to your inquiry.1 We are fully supportive of the vision and principles put forward in that document, and would particularly wish to add our weight to the following points:

The service should be, in the main, consultant delivered and not dependent on trainees.

The service should enable trainers to have time to train, supervise and assess trainees effectively.

Postgraduate Deaneries and the independence of the Postgraduate Deans needs to be retained in order to maintain their vital quality assurance role.

There is lack of clarity around the governance and structure of Local Education and Training Boards (LETBS) and there are potential conflicts between service demand and training and education which may arise in an employer led body (paras 11 and 19).

There is support in principle for the establishment of Health Education England, and the need for its authority over LETBs to be established (para 17).

There is a need for involvement of clinicians with expertise in education and training at employer and LETB level (para 20).

The proposed National and Training Quality Outcomes Framework needs to have effective metrics which can be applied in a consistent way across other parts of the UK (para 23).

Medical workforce planning needs to be coordinated across the UK (para 30).

3. Future workforce requirements—RCPCH principles

3.1 The College’s publication Facing the Future (April 2011) gives a vision and strategy for service delivery, predominantly in acute general and neonatal paediatrics which entails continued consultant expansion to develop consultant delivered care models before a reduction in training numbers can be put in place.

3.2 Paediatrics is a specialty with service delivery in acute, community and subspecialty settings There are 17 paediatric subspecialties which make training and workforce planning particularly complex.

3.3 Community paediatric service provision has shifted to acute, social enterprise or bespoke community providers. It is not clear how providers (via LETBs) with few doctors will ensure that adequate training opportunities are in place to develop the specialists needed. Community paediatrics and child mental health services must be an integral part of the future paediatric workforce. Mental health morbidity/co-morbidity makes up 40% of general outpatients activity and the RCPCH needs to reflect this in a future workforce skilled in Paediatric Mental Health issues. In the UK there are very few adolescent health specialists and we are falling behind the USA and other European countries in this regard.

3.4 There are significant concerns about the falling numbers in the academic workforce, compared to other specialties. There is a need for succession planning and encouragement to trainees to take an academic career path.

3.5 Many paediatric services use a needs based approach to ensure the most appropriate pathway of care and to meet required standards. These pathways of care are commissioned. Neonatal managed clinical networks are a prime example of effective and safe services. Future structures delivering healthcare, education and workforce planning therefore should include the operational arrangements for clinical networks.

3.6 In planning the future workforce the NHS Outcomes Framework and its five domains need to be taken into account as they are all applicable to babies, children and young people.

Themes

4. Health Education England

4.1 The College supports the establishment of HEE and its role to hold the LETBs to account. There must be robust governance, quality assurance and reporting arrangements not only for LETBS to HEE but with strong links to Royal Colleges, CCGs, the NHS Commissioning Board and to Public Health England.

4.2 The proposals to change the arrangements for education and training are in principle sound because they enable staff across specialties to train together. Because funding and placement arrangements are not clear however, the College is cautious that without detail, there are risks which may affect the capability of the paediatric workforce.

4.3 The differences between medical education and other health professions need to be recognised. HEE must recognise that medical training is different from other health professions, ie doctors are not autonomous practitioners when they graduate as is the case, for example, for physiotherapists.

4.4 Training in the paediatric subspecialties including neonatology is organised on a national grid providing competition for places which are matched against service need. This function must be sustained at national level.

5. Local Education and Training Boards

5.1 If education and training roles and responsibilities are taken over by Trusts, there is potential conflict of interest with the requirements of service delivery, ie need to fill gaps in rotas at expense of training.

5.2 LETBs need to work closely with the Royal Colleges to understand the drivers towards developing safer services and the need for reconfiguration. For the RCPCH in particular, the new structures need to take on board the breadth of paediatric training and the variety of environments in which training takes place eg community, DGH, specialist centres. Decisions should not be taken in isolation and must acknowledge that some paediatric specialist services need to be commissioned at national level.

5.3 Excellence in training will attract excellent trainees. This must be supported by the NHS and act as a guiding principle. Our concern is that financial pressures will make it difficult for consultants and trained staff to contribute to training, and that any qualified providers may not regard Training and Assessment as high priority.

5.4 In hospital based medical training, the vast majority of consultant and trained doctors provide clinical supervision, and a large proportion of doctors provide educational supervision, structured delivery of training and education and carry out work based assessments of trainees in work based placements. About 10% are involved in the delivery and assessment of structured examinations. A further small number are further involved in quality management and assurance of training. These roles need to be protected to continue improvement in education, training and assessment when faced with service provision priorities of commissioners.

5.5 Health and Wellbeing Boards should include the views of parent/guardians, children and young people. These views can in turn influence the model of service and workforce delivery and of training and should link to LETBs.

5.6 The voice of trainee doctors needs to be heard, included in education, training and workforce planning structures Trainee doctors have valuable insight into the quality and delivery of training, and in paediatrics have significantly contributed to the development of our strategic service and workforce models.

6. The future of Postgraduate Deaneries

6.1 The key roles for deaneries are recruitment to, delivery and quality assurance of training. These roles must not be lost in the new structure. Their role in the organisation of rotations is crucial and they must work closely with the Royal Colleges to ensure that training numbers reflect actual and planned changes in service configurations.

6.2 The independence of postgraduate deans is essential to drive up the quality of training.

6.3 There are opportunities in any potential restructuring for postgraduate deaneries to align medical training, not only between the Royal Colleges of General Practice and Paediatrics but also with the Royal College of Nursing in order to expand the numbers of General Practice Specialty Trainees (GPST) and trained nurses with advanced or extended roles so that the RCPCH Facing the Future vision can be implemented effectively.

6.4 More foundation trainees need to be exposed to paediatrics as highlighted in Foundation for Excellence (Professor John Collins, October 2010).

6.5 Specialty, Staff and Associate Specialist Grade (SSASG) doctors are an important part of the paediatric workforce, and a consistent approach to their training, competency development, CPD and deployment should be adopted by postgraduate deaneries and LETBs. Each postgraduate deanery already has a nominated lead for SSASGs .The core functions and roles carried out by these doctors are particularly relevant for paediatrics which is a highly feminised profession. A significant number of consultant equivalent roles are currently filled by these staff and a new system needs to be flexible enough to develop these doctors, and enable transition back into training grades where appropriate.

7. How the new system will relate to healthcare, education and training and workforce planning in the other countries of the UK

7.1 The RCPCH has a remit for training, education and planning in all four UK countries and will apply the same standards in each UK country.

8. Participation in the Development of Curricula

8.1 RCPCH support the Academy stance that Colleges remain best placed to have lead responsibility for development of curricula for postgraduate medical training.

8.2 We also support the Academy’s assertion that patient input to curricula is important and valuable. Our engagement with patients and parents has for example, been an integral part of e-learning packages developed for child protection and adolescent health.

9. Balancing the workforce requirements of NHS and non-NHS healthcare

9.1 Currently private providers do not contribute to the cost of specialty training and use NHS trained staff so they are likely to be cheaper. It is important that all providers pay a national levy.

10. National Education and Training Outcomes Framework

10.1 We support the Academy view that metrics for education and training should be common across the UK to ensure consistency of quality. They also need to capture the impact of service and workforce redesign.

11. Centre for Workforce Intelligence

11.1 CfWI should be accessible to the professions and take account of the evidence provided by RCPCH and other Colleges. Current systems of collection may not be accurately monitoring the current workforce, and so the College needs to agree a methodology with CfWI to ensure that we have a high quality workforce of the future.

11.2 There need to be formal governance arrangements between CfWI and the RCPCH so that we have a system for mutual agreement and understanding of the methodology for workforce modelling and planning which is based on sound evidence.

11.3 CfWI should work collaboratively with HEE and LETBS to ensure they fulfil their duties regarding sharing of data. They will also need to take a lead in facilitating that such data collection exercises are meaningful, streamlined, consistent and accurate.

12. How future healthcare workforce needs are being forecast.

12.1 Currently the emphasis in workforce planning appears to be based on supply side modelling ie how the existing workforce and those in training can be utilised. The College believe a longer term view based on standards and the maintenance of safe services is more sustainable in the longer term and will allow for the development of a non “boom or bust” approach to numbers. This is at the root of our vision in Facing the Future.

12.2 The RCPCH regularly collects a range of good quality workforce planning data eg the biennial census which has in 2009, a 98% return from its members. This data has informed the Facing the Future strategic vision for its paediatric service and workforce and we consider that College data can be an effective tool for both providers and commissioners of education, training and services.

12.3 It should be recognised that workforce planning in paediatrics has probably been more influenced than other large medical specialties by the growth in the number of female doctors and its impact on working patterns. Nearly 47% of paediatric consultants and around three-quarters of new trainees are women.

13. Impact of retirement and leavers from healthcare professions

13.1 Early retirement is not currently a major issue in paediatrics, but there are anxieties that proposed pension changes may force earlier retirement, or drive experienced consultants into private practice. The RCPCH is currently researching this among its members.

13.2 A cohort study the RCPCH is undertaking has shown that attrition from the first three years of training is approximately 5% per annum. We are also aware of regional variations where attrition is higher. This means that there needs to an awareness that the number beginning their training in a specialty needs to be higher than those completing their certificate of training (CCT).

13.3 Early data from a study of new CCT holders indicate that almost 10% of newly qualified paediatricians obtain posts outside of the UK.

14. Overseas Healthcare Staff

14.1 Overseas healthcare staff have been an integral and important part of the paediatric workforce. The RCPCH Census of 2009 shows that 29.8% of consultants and 48.3% of SSASG doctors are non-UK graduates.

14.2 Recent changes to immigration laws combined with the EWTR have left serious gaps and recruitment problems in paediatrics and neonatal care. The RCPCH survey of December 2010 indicated that 20% of all middle grade posts were vacant.

14.3 The RCPCH support a re-introduction of the Medical Training Initiative (MTI scheme) and has re-introduced the scheme to begin recruiting from March. The RCPCH believe this scheme will enhance knowledge transfer internationally in addition to contributing to workforce solutions without generating over-supply of trained doctors, and should be widely supported.

December 2011

1 Ev w39–42

Prepared 22nd May 2012