Written evidence submitted by the Royal College of Paediatrics and Child (RTR0087)
Steps to recruit extra staff
1.1. The UK child health workforce suffers from the same planning problems, underfunding and staffing issues as the rest of the health workforce.[1] Our Paediatrics 2040 project makes projections based on recent trends observed in our paediatric workforce census. Trainees choosing less than full time (LTFT) working is forecast to increase from 30% in 2019 to over 60% in 2040[2]. A recent General Medical Council (GMC) report highlighted that nearly two fifths of trainees in paediatrics (39%) are choosing to work LTFT.[3] This flexible approach is welcomed and encouraged. However, it is a concern with regards to paediatric trainee whole-time-equivalent (WTE) numbers if the current cap on the number of training places is not reviewed.
1.2. Community Paediatricians play a critical role working with vulnerable children, including those with developmental disorders and disabilities, complex behavioural presentations, and at risk of abuse or are being abused, all growing areas of concern. [4],[5] It is therefore especially concerning that the proportion of paediatricians working in this sub-speciality is forecast to decrease from around 18% to 12% of the workforce in 2030, based on the last ten years of trends.[6]
1.3. With paediatric pressures set to worsen and with projected decreases in the SAS doctor role and community paediatric workforce, and more doctors working LTFT, RCPCH believes that the number of medical school places needs to be increased and requires consistent review.[7]
1.4. We want to see the funded expansion of new workforces to support doctors in their practice, such as Advanced Clinical Practitioners (ACPs) and Physician Associates (PAs). The College is working with Health Education England (HEE) on developing a UK-wide ACP curriculum to set clear standard and flexible routes for entry for this important workforce. We are also working with the Faculty of Physician Associates to develop a framework to clarify the educational pathways for PAs working in children and young people (CYP) services. However, based on the longer established new workforces, such as ACPs, the RCPCH recommends there is a national funding plan to help develop these roles and ensure they are utilised everywhere, in all parts of the UK, and in smaller or rural district general hospitals (DGHs) as well as tertiary centres. It is vital that any approach to workforce planning takes a whole system approach that considers the sustainable workforces of nurses, pharmacists, Allied Health Professionals, and support roles.
1.5. There is notable variability in the provision of the child health workforce across sub-specialities and geographical areas. Whilst regional variability of training post distribution is recognised by HEE, there is less focus on variability between types of hospital (i.e. tertiary centres and remote, rural or smaller district general hospitals) and areas of service. Moreover, within paediatrics, whilst there is general evidence of rota gaps and increasing levels of stress, we know that specialist areas have specific resource struggles, such as Paediatric Intensive Care Medicine and Paediatric Palliative Care. Therefore, we recommend that the NHS considers what it can do to incentivise doctors to work in areas which are deemed less attractive (e.g. because of their lack of proximity to cities) or with more disruptive working patterns (e.g. night work or on call).
1.6. National recruitment for doctors in training is high stakes and must ensure appropriate standards. However, there is a concern that inadequate resourcing of deanery recruitment teams is making the experience unnecessarily difficult, confusing, and unpleasant for potential applicants. This is a key milestone in retaining doctors from Foundation or Core training, and it should be as supportive and welcoming as possible.
Balance between international and domestic recruitment
2.1. International recruitment should not come at the expense of lower income countries. Mechanisms like the Medical Training Initiative (MTI) allow us to support these countries with training without looking to permanently poach their staff into the NHS.[8] It is regrettable that the Health and Social Care visa is creating a situation where it is becoming increasingly attractive for Health Boards and Trusts to bypass mechanisms such as the MTI and recruit directly without due consideration for the impact in lower income countries.
2.2. We recognise international recruitment is important to support the NHS and should be done holistically and supportively to ensure that whether people stay in the UK, return to their home country or go elsewhere, they have a positive experience that supports them and their patients. Reciprocity with the home nation should be considered.
2.3. The CESR (Certificate of Eligibility for Specialist Registration) process allows doctors who have trained either in non-traditional ways or overseas to reach the UK specialist registrar. This process is complex and time-consuming for doctors. Whilst we understand the importance of protecting standards and ensuring equal levels of experience, our members have written to us to complain about the lengthy and opaque process, which may be deterring applicants.
2.4. The RCPCH is working with a group called Soft Landings who support International Medical Graduates (IMG) when they begin working in the NHS. The group give IMGs a clearer understanding of NHS ways of working, recruitment, and how to make the most of their careers whether they stay in the UK or work elsewhere. Given the benefits of this process, the RCPCH believes it should be funded at national level. It seems inevitable that a good foundation for IMGs at the start of their careers will help close the gap on differential attainment.[9]
Initial and ongoing staff training
Adequate systems for determining long-term need
3.1 The system for determining how many paediatricians and other child health professionals should be trained to meet long-term need is inadequate. Our discussions with HEE around their distribution project and the preparations for Progress+ indicate there is an approach in development which we hope will consider all aspects and data points. At this stage of the project, we cannot comment on its effectiveness.
3.2 Paediatrics 2040 summarises the future burden of need for paediatric services with there likely to be higher proportions of mental health, other adolescent health issues, neuro-disability, and long-term conditions. This data is important when determining the number of doctors, nurses, and allied health professionals that will be required to plan for and deliver child health services in the long-term.
3.3 Our forecasts suggest that, if drivers, such as poverty, are not addressed, there will be further rapid increases in CYP emergency and outpatient activity over the next 20 years, requiring investment in services and the workforce, so as not to reduce quality.
Curricula and skill mix
3.4 The curricula for doctors, nurses and allied health professionals are already updated to reflect the changing needs of the healthcare system. Curricula are designed by users, academics and educationalists with the latest information on what is required for safe and effective training. The RCPCH curriculum, Progress+, was approved by the GMC in July 2021.[10] It attempts to give increased flexibility to trainees, to shorten training and to focus more time in programme on direct training rather than service. It is one of the few postgraduate curricula that aims to address the concerns raised by the original Shape of Training report.
3.5 The current curriculum approval process through the GMC is effective, but increasingly elongated. The process of early review, extensive and phased evidence gathering, Curriculum Oversight submission and Curriculum Advisory Group submission, mean that curricula changes increasingly struggle to be timely and proactive.
3.6 Training, cross-speciality and UK-wide, needs to have a clear intelligible strategy. The principles of the GMC’s Excellence by Design have helpfully refocused training on overall outcomes and moved away from tick-box competency training. However, this has not been accompanied by the same support for supervisors undertaking that training. Colleges have tried to support wherever they can, but they are ultimately not responsible for the day-to-day education of supervisors. Training a more ‘global’ curriculum is harder than a more specific and limited curriculum. The result is a growing number of ‘competency frameworks’ which are being developed by various bodies to essentially recreate lower-level competencies. These currently include asthma, obesity, mental health, and patient safety.
3.7 The quality of training varies between training sites and deaneries. This means the standards of protected time and direct education are not always kept to. The RCPCH has produced the Trainee Charter to indicate the founding expectations of paediatricians in training.[11]
3.8 Time needs to be identified within the training curriculum for doctors to acquire and hone skills in areas that support and enhance clinical care such as research, teaching, leadership, and management. Not only does this enhance clinical care, but it is beneficial for retention as it provides greater opportunity for development. Our report Turning the Tide highlights that just 4.2% of the total consultant workforce consists of clinical academic consultant level paediatricians, compared to 9.6% in 2001.[12]
Training period
3.9 Progress+ has reduced the indicative training length by one year showing that it is possible for the training period to be reviewed. This is aimed at encouraging an individualised, creative approach to training, based on capability rather than time. However, we note this approach has some level of risk. The Academy of Medical Royal Colleges (AoMRC) acknowledge that some trainees prefer a longer training time, so they gain sufficient confidence and competence to manage patient complexity and risk. Current discussions with HEE indicate that we may stand to lose up to one eight of our trainees because of the reduced training length unless posts are recirculated. This would create significant problems in staffing rotas across CYP services and would set a concerning precedent for any other specialities considering reducing the length of their own training. Our FAQs on Progress+ sets out the rationale for making the changes.[13]
Factors driving staff to leave the health and social care sectors
Staff stress and burnout
4.1. Across the whole NHS workforce, between October 2020 and December 2020 anxiety, stress, depression and other psychiatric illnesses were the most reported reasons for sickness absence, accounting for 511,000 full time equivalents days lost and 26% of all sickness absence in December 2020.[14]
4.2 An RCPCH report on the impact of COVID-19 on child health services found that 15% of services reported staff were absent due to stress, and 45% of respondents were concerned that there would be future absences due to stress over the next few months.[15]
4.3 A GMC report on the state of medical education and practice in the UK found that 11% of trainees and 8% of trainers in paediatrics and child health were at high risk of burnout. Over one third of trainees (36%) reported ‘heavy’ or ‘very heavy’ workloads.[16]
4.4 The uncertainty caused by rota gaps can be especially stressful. In paediatrics, vacancies and gaps continue to raise concern about the sustainability of services and to trainees’ wellbeing. Data from 2017 highlights the rota vacancy gap in paediatrics was 14.6% on tier 1 rotas and 23.4% on tier 2 rota representing an increase in the vacancy rate from 14.9% in January 2016 to 18.6% in January 2017.[17]
Pension taxation and freezing of the lifetime allowance for pensions
4.5 The Chancellor’s announcement that the Government would freeze the lifetime allowance for pensions will disproportionately affect doctors and, as a result, many now plan to leave the NHS or reduce their hours.[18]
4.6 To gauge the impact of UK pension tax legislation on RCPCH members, RCPCH ran a survey in November 2019. This found that 79% of the 715 members asked said they were more likely to retire early because of their pension related tax bill. 59% thought paediatric services had been reduced due to measures introduced by the Government.[19]
On call requirements
4.7 An AoMRC report found that on call commitments was one of the main factors affecting early retirement.[20] This is a particular issue within paediatrics where there has been a significant increase in the number of consultants resident on call either at senior or middle grade level.
Addressing staff attrition
4.8 While we accept there will always be a degree of attrition, we recommend steps are taken on the following:[21],[22],[23]
4.8.1 Urgently explore ways to offer greater opportunities for flexible working. We know from our Trainee Network that future generations will expect greater flexibility in the workplace.
4.8.2 Improve retire and return arrangements by ensuring clearer and more consistent policies, and facilitate flexible approaches including through access to remote working and portfolio job plans. The RCPCH want the GMC’s COVID return to practice registration easements to be made permanent.
4.8.3 Invest in provision of mental and physical wellbeing services for staff. There is a need to get the basics right’, including through providing facilities for rest (e.g. after night shifts), spaces to carry out non-clinical work, and easily accessible hot food and drink. Resources for wellbeing initiatives should be ringfenced and staff should be consulted on these.
4.8.4 Ensure job planning at all levels facilitates flexible training and working and recognises and rewards professional activities such as research, education and training, clinical leadership, quality improvement, and governance.
4.8.5 Support the optimisation of multi-professional teams through valuing the contributions of colleagues in nursing, pharmacy, ACPs, PAs, and other allied health professionals. The regulation and recruitment of Pas must be accelerated.
4.8.6 Facilitate improved work-life balance through helping clinical employees access flexible, affordable childcare and school holiday playschemes and ensure staff can take time off for significant life events, enabling the right to a planned private life.
4.8.7 Rotas should be standardised, and consideration should be given to annualising them to have extra staff in winter and reduce/restrict residency duty hours. We are developing a framework for Health Boards and Trusts to use to ensure they are following best practice when it comes to rota development, staff communication and measuring/protecting wellbeing. This should be published in Summer 2022.
4.8.8 Managers and leaders should use lessons learned techniques to share positive practice examples relating to the investigation of adverse events to shape the way the process evolves to reduce impact on wellbeing and morale.
4.8.9 NHS organisations and departments should set up Equality, Diversity and Inclusion initiatives and groups to provide constructive challenge in ensuring the workforce and leadership reflects the diversity of the population that it serves. RCPCH also wants to see progress on the implementation of a fully funded occupational health service and efforts to stamp out bullying and incivility ramped up.
4.8.10 Departments should support a diverse workforce by establishing inclusive working models for those who have physical and/ or hidden disabilities and reducing the barriers to develop their career.
4.8.11 Role models make a speciality more attractive to join but burnt-out consultants struggle to be positive role models to the next generation. Therefore, there needs to be a method to measure and protect the wellbeing of clinicians. Moreover, there is likely to be considerable variability in wellbeing risks between specialities, but the RCPCH is not aware of any work that has been done to try to understand this risk in-depth.
4.8.12 The medical profession should create ways for senior clinicians to work safely and in a fulfilled manner, through to retirement. There should be a general appreciation of the value that senior clinicians bring to managing complex clinical cases, ethically difficult situation, leadership, research and education.
The next iteration of the NHS People Plan
5.1 We welcomed the focus of the previous NHS People Plan on staff wellbeing, but without a fully costed implementation plan to recruit and retain, this was no substitute for a proper workforce strategy.
5.2 RCPCH supported an amendment to the Health and Care Bill requiring the Government to publish independently verified assessments of current and future workforce numbers every two years.[24] In order to develop a long-term strategy to address recruitment and retention it is essential for there to be an assessment of current workforce numbers and regular, independently verified projections of future demand and supply.
5.3 RCPCH calls for a workforce strategy specific to CYP that will ensure professionals have the right knowledge and skills to meet the unique needs of this population. Any strategy relating to workforce should be informed by the needs of the population it serves including CYP. Paediatrics 2040 includes data from RCPCH & US on what nearly 900 CYP want to see from paediatricians and paediatrics.[25]
5.4 Within the NHS People Plan should be a whole system approach optimising sustainable, multi-professional workforces that include doctors, nurses, pharmacists, Allied Health Professionals, and other roles across the system. Examples can be found in paragraph 1.4.
5.5 There is a need for any future workforce model to reflect the desire for and impact of increased flexibility and LTFT roles, has a progressive approach to LTFT, out of programme and inter-denary transfers. The flexibility offered by these frameworks should be available to all staff. Increased opportunities for career breaks and flexible working patterns should be available to all clinicians at all stages of their careers, along with re-entry paths at every level for taking training or career breaks.
Contractual and employment models
6.1 RCPCH is a professional body playing a major role in postgraduate medical education, professional standards, research and policy. Our charitable status and specific objectives as an organisation prohibit us from commenting on the terms and conditions of NHS employees, and we would urge the inquiry to consider the views of trade unions and other medical membership bodies on this question.
6.2 However, we do play a role in advocating for paediatricians and CYP, especially if terms of employment are impacting the working lives of our members and the services received by CYP.
6.3 RCPCH historically described our concerns on the negative impact pensions taxation was affecting workforce capacity and service provision to the detriment of safe patient care. We urge the Government to consider how it can reform pension arrangements to best support doctors to deliver high-quality patient care.[26]
The role of Integrated Care Systems (ICSs)
7.1 A key factor in the success of ICSs is likely to be their ability to attract and retain staff with the right skills to deliver services that meet the needs of their populations.
7.2 NHS guidance ‘Building strong integrated care systems everywhere’ lays out the people functions they would expect NHS leaders and organisations to work to deliver with their partner in the ICS.[27] These functions cover most of the roles the RCPCH would envisage ICSs carrying out in relation to attracting and retaining staff. This includes supporting the wellbeing of staff, growing the workforce for the future and leading coordinated local workforce planning.
7.3 Whilst RCPCH supports these functions and the underlying vision to improve people’s experience of working in the NHS and enable them to provide the best possible health and care outcomes for the population, we would like to highlight:
7.3.1 Coming out of another extremely busy and stressful winter and going into a period of change it is crucial that people functions within ICSs are fully operational and ready to support the workforce. We are concerned that some ICSs may not be completely ready to do this by July 2022.
7.3.2 Effective and compassionate leadership will be essential at all levels to ensure truly collaborative processes are established and there is clear communication with all services and staff.
7.3.3 It is important that time is taken to assess the impact of the pandemic on staff and the learning gained regarding new ways of working.
7.3.4 Despite many functions being taken forward in ICSs it remains essential for there to be a national fully funded long-term workforce strategy.
7.3.5 ICSs should continue to develop models of practice to facilitate integrated care.
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Jan 2022