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The changing UK paediatric consultant workforce: report from the Royal College of Paediatrics and Child Health
  1. Martin McColgan1,
  2. Rachel Winch1,
  3. Simon J Clark1,2,
  4. Carol Ewing1,3,
  5. Neena Modi1,4,
  6. Anne Greenough1,5,6
  1. 1Royal College of Paediatrics and Child Health, London, UK
  2. 2Neonatal Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
  3. 3Manchester Children's Hospital, Manchester, UK
  4. 4Neonatal Unit, Chelsea and Westminster Hospital, Imperial College London, London, UK
  5. 5Division of Asthma, Allergy and Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
  6. 6NIHR Biomedical Centre at Guy's and St Thomas’ NHS Foundation Trust and King's College London, London, UK
  1. Correspondence to Professor Anne Greenough, Royal College of Paediatrics and Child Health, 5-11 Theobalds Road, London WCI 8SH, UK; anne.greenough{at}kcl.ac.uk

Abstract

Objectives To determine if there had been changes in the size of the UK paediatric workforce and working patterns between 1999 and 2013.

Design Analysis of prospectively collected datasets.

Setting UK consultant paediatricians.

Interventions Data from the Royal College of Paediatrics and Child Health's workforce census from 1999 to 2013 and the annual surveys of new paediatric Certificate of Completion of Training (CCT) and Certificate of Equivalence of Specialist Registration (CESR) holders between 2010 and 2013.

Main outcome measures Paediatric consultant numbers, programmed activities (PAs) and resident shift working.

Results The UK paediatric consultant workforce grew from 1933 in 1999 to 3718 in 2013. Over the same time period, there was a decline in the number of consultants with a primary academic contract from 210 to 143. There was an increase in the proportion of consultants who were female (40% in 1999 to 50% in 2013, p<0.01). The median number of PAs declined from 11 in 2009 to 10 in 2013 (p<0.001) as did the median number of PAs for supporting professional activities (2.5–2.3, p<0.001). In 2013, 38% of new consultants in general paediatrics or neonatology were working resident shifts. Between 2009 and 2013, the proportion of less than full-time working consultants rose from 18% to 22%, which was more common among female consultants (35% vs 9%).

Conclusion The paediatric consultant workforce has doubled since 1999, but more are working less than full time. The decline in those with a primary academic contract is of concern.

  • Paediatric
  • consultant
  • workforce
  • workforce planning
  • gender
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What is already known on this topic?

  • There has been implementation of a 48-hour working week.

  • UK service standards require an increased consultant presence.

  • There has been reconfiguration of acute paediatric services to fewer units.

What this study adds?

  • Paediatric consultant numbers have doubled since 1999.

  • More consultants are working less than full time.

  • There has been approximately a halving of those with a primary academic contract.

Introduction

There have been changes to the UK policy landscape and to service delivery. These include implementation of a 48-hour working week,1 UK service standards requiring an increased consultant presence,2 the UK government's manifesto promise for a 7-day National Health Service (NHS) delivery,3 migration (both professional and population), reconfiguration of acute services to fewer units and greater integration between community/primary care and hospital/secondary care.4 We, therefore, hypothesised that the composition and characteristics of the paediatric consultant workforce would have changed. Our aim was to test that hypothesis by analysing data from two main sources, namely the biennial workforce censuses of the Royal College of Paediatrics and Child Health (RCPCH)5 and studies of doctors achieving Certificate of Completion of Training (CCT) or Certificate of Eligibility for Specialist Registration (CESR).6

Methods

Data were analysed from the biennial workforce censuses that have been undertaken since 1999.5 For each census, clinical leads/directors in each UK organisation providing paediatric medical services were asked for details of their staff and services. The questions asked included the sex, full-time status, job type, place of primary medical qualification and the number of programmed activities (PAs) and supporting professional activities (SPAs) for each paediatric consultant. The consultant contract of 20037 redefined consultant contracts in terms of PAs. A PA is a unit of work lasting 4 hours during core time (7:00–19:00 weekdays) and 3 hours at all other times. PAs are allocated into two groups, namely direct clinical care (DCC) and SPAs.7 In paediatrics, DCC includes outpatient clinics, ward rounds, emergency duties, on-site medical cover, multidisciplinary meetings about patient care and administration directly related to patient care. SPAs include continuing professional development (CPD), teaching and training, audit, job planning, appraisal, research and clinical governance activities. Data were also gathered from new CCT and CESR holders in paediatrics and paediatric subspecialties in the UK between 2010 and 2013. They were contacted by email and invited to participate in a survey using SurveyMonkey approximately 12 months after the end of their CCT award year. Information on the grade and specialty of the CCT holders, the location and full-time status of their work, their views on resident shift working, future career expectations, transition to consultant roles and support required from the RCPCH was obtained. Data from those sources and the RCPCH training records were analysed. Data on trainees' intentions to work less than full time on completion of training were obtained from the RCPCH 2007 Cohort Study.8 In addition, the number of international medical graduates (IMGs) and less than full-time trainees in the workforce were obtained from the General Medical Council (GMC) and less than full-time career intentions of foundation doctors from the UK Foundation Programme Office.9 To examine trends in the job types of consultant paediatricians, we determined from the GMC records, the registered specialty of every doctor who obtained a CCT or a CESR in paediatrics and paediatric subspecialties between 2010 and 2013. The specialties were divided into the following three groups: general paediatrics, community child health and specialist paediatrics (which comprised 16 subspecialties).

Analysis

To determine whether differences were statistically significant, the Z-test, the Mann-Whitney U test or χ2 test was used as appropriate.

Results

The response rates to the eight censuses undertaken between 1999 and 2013 ranged from 95% to 99%. A total of 1148 doctors obtained a CCT (n=1067) or CESR (n=67) in paediatrics or paediatric subspecialties between 2010 and 2013. The response rate to the annual surveys varied from 57% to 82% (table 1).

Table 1

CCT and CESR holders’ survey response rates by year

Paediatric consultant numbers

Between 1999 and 2013, the number of paediatric consultants in the UK grew by 92%, from 1933 to 3718, an average annual growth of 5%. During the same period, there was a decrease in the numbers of consultants with a primary academic contract from 210 to 143 (figure 1). In the 2013 census, there was an average of 8.4 whole time equivalents on the 198 acute general or combined general/neonatal consultant paediatric rotas. Only 8% (n=69) of new CCT/CESR holders moved abroad between 2010 and 2013, 62% (n=43) of whom went to Australia, India or Canada. Seven hundred and twelve doctors (88%) had obtained consultant posts within the first year of being eligible to do so. The mean number of applications made before obtaining a substantive consultant post was 1.4 for female doctors and 1.9 for male doctors. Only 30% of doctors used the 6-month grace period of employment at the end of their training time.

Figure 1

Paediatric consultant growth in the UK: 1999–2013 (adapted from RCPCH, Medical Workforce Census 2013.21 ▴ Total number of consultants. ♦ Consultants without an academic contract. ▪ Consultants with an ‘academic’ contract.

Gender

There had been a rise in the proportion of consultants who were women from 784 (40%) in 1999, 1522 (47%) in 2009 and 1851 (50%) in 2013 (p<0.01). In 2014, 2743 (76%) of doctors in paediatric training were female compared with 72% in 2012 and 74% in 2013.9 Fifty-four per cent of new CCT/CESR holders in 2010–2013 were female.

Full-time and less than full-time working

There had been an increase in less than full-time paediatric consultants from 564 (18%) in 2009 to 555 (22%) in 2013 (p≤0.001). A greater proportion of female compared with male consultants were working less than full time (35% vs 10%, p≤0.001).

International medical graduates

In the consultant paediatric workforce, IMGs increased from 861 (25%) in 2009 to 1126 (30%) in 2013 (p≤0.001). Fifty-three per cent of respondents to the survey of new CCT holders in 2010 and 52% in 2013 were graduates from outside of the UK and European Economic Area.

Programmed activities

The median contracted PAs declined from 11.0 in 2009 to 10.0 in 2013 (p<0.001), and the median PAs for SPAs declined from 2.5 in 2009 to 2.3 in 2013 (p<0.001).

Future career expectations

Seventy-nine per cent of new CCT holders in 2013 expected that they would in the future be more involved in trust/service management and 40% to be undertaking roles for the RCPCH.

Resident working

Data from the CCT/CESR follow-up surveys demonstrated that it was common for newly qualified consultants in general paediatrics or neonatology to work resident shifts (table 2).

Table 2

New Certificate of Completion of Training holders’ working resident shifts

The RCPCH rota vacancies and compliance survey of winter 2014/2015 highlighted that 443 (30%) of the overall general paediatric and neonatal consultant workforce were working resident shifts.

Type of paediatrician

Comparison of the GMC specialty registration of those achieving CCT/CESR between 2010 and 2013 to the job types of the consultant workforce recorded in the 2013 census demonstrated significant differences in the specialty of the new consultants to the overall consultant workforce (table 3). A greater proportion of new CCT/CESR holders (65%, n=740) were registered for general paediatrics than the proportion of the overall consultant workforce (41%, n=1543) (p≤0.001), but a lower proportion (6%, n=68) were registered for community paediatrics compared with (19%, n=608) the overall consultant workforce (p≤0.001). In addition, a lower proportion of new CCT/CESR holders (30%, n=334) were registered for subspecialties compared with the overall consultant workforce (41%, n=1487) (p≤0.001). CCT/CESR registration, however, may not accurately reflect the final specialty as 16 of 148 new holders who were registered in general paediatrics were showed in the 2013 survey to be in subspecialty roles.

Table 3

Comparison of type of paediatrician of new CCT/CESR holders with the overall workforce by specialty

Discussion

We report an almost doubling of paediatric consultant numbers between 1999 and 2013, increases in the number of female consultants and less than full-time consultants, a reduction in the length of the average working week and an almost halving of the number of consultants with a primary academic contract. The latter reduction is of concern and was previously highlighted in the RCPCH's Turning the Tide report.10 The RCPCH has taken a number of steps to address this problem, including supporting the British Association of Perinatal Medicine's initiative to develop research training for all trainees.11 The RCPCH launched an Infant, Children and Young People's Research Charter at the 2016 RCPCH Annual Conference to support all those who wish to engage with children and young people in research. A research funding database has been established, which is available on the RCPCH website. The RCPCH has supported the establishment of the UK Child Health Research Collaboration to explore how funders of child research could work together to support increasing research capacity.

Our results suggest that opportunities to obtain a consultant post have not diminished as reflected by the low numbers of applications required by new CCT holders to obtain a consultant post. Furthermore, relatively few of new CCT holders had relocated to posts outside the UK. Similar data were obtained from CCT holders of the Royal College of Physicians demonstrating that over the period 2009–2015, the proportion of new CCT holders going overseas was between 3% and 5%.12

In 2001, 1410 (76%) of consultants were exceeding the European Working Time Directive of 48 hours per week1 and 1527 (70%) were in receipt of intensity payments.13 The British Medical Association described a model contract for full-time consultants of 10 PAs of which 7.5 should be for DCC and 2.5 for SPAs such as CPD, supervision of trainees, research, audit, leadership and management and clinical governance. This model was supported by the RCPCH14 and has been widely adopted by trusts employing paediatricians. Using that model and to meet RCPCH safety standards for acute general paediatric services,2 taking into account greater awareness of work–life balance among trainees and new consultants,15 recognising the risks of excessive hours16 and allowing for prospective cover of 20%, at least eight general paediatric consultants are required for a full rota. That calculation was based on a consultant being present and available 12 hours a day and 7 days per week at times of peak activity. In addition, a consultant would lead two medical handovers per day and the ‘unit’ had 15 consultant-led general paediatric clinics a week. The 2013 census demonstrated overall the recommendation had been met with an average of 8.4 whole time equivalents on the 198 acute general or combined general/neonatal consultant paediatric rotas in the UK.

Data from the GMC17 highlighted that in 2014, 10% of all doctors in training were less than full time, but 21% in paediatrics. In paediatrics between 2012 and 2014, there has been an increase of 20% in non-full-time working. An increased intention to work less than full time was highlighted by data from the RCPCH Cohort Study of doctors who began paediatric training in 2007.18 After 7 years of training, 48% of the cohort said that they would like to work less than full time on completion of training and 60% of female trainees wished to work less than full time.

We have demonstrated 27% and 43% of new CCT holders in 2010 and 2013, respectively, were working resident shifts. Several drivers have led to an increase in consultant resident shift working including compliance with the European Working Time Regulations, the RCPCH acute service standards to provide timely senior care,2 recommendations from a number of Coroner's reports into the deaths of infants and children, the publication of NHS 7 days a week forum in 20133 and as a sustainable solution to the crisis of gaps in paediatric Tier-2 (middle grade) rotas.18 Paediatrics has, and continues to be, at the forefront of using resident shift working systems for consultants and encourages services to use team job planning as a way of addressing the balance between resident shift and non-resident shift consultant working patterns.19 A survey in 2014 found that among all levels of paediatric trainees, there was an acceptance of the need for more consultant presence in the hospital, but many commented that this makes paediatrics a less attractive specialty for lifestyle reasons.20 There is, however, an expectation that a paediatrician's career will develop and change as it progresses and the RCPCH has set out options for a phased career in the Paediatrician's Handbook.21

The RCPCH census demonstrated a significant rise in the proportion of IMGs in the consultant workforce between 2009 and 2013 with over 30% of the consultant workforce in 2013 being an IMG. It is, therefore, of concern that the RCPCH's ST1–ST4 (specialty training posts) recruitment data for 2015 show that only 100 (20%) of those recruited were IMGs. Recent changes to immigration legislation, such as the removal of the higher ST4 in paediatrics from the UK shortage occupation list in April 2013,22 may lead to fewer IMGs in the workforce. Indeed, data from the 2015 GMC's State of Medical Education and Practice in the UK Report17 highlighted a decrease in the proportion of IMGs in the paediatric training workforce from 26% in 2012 to 19% in 2014.

We have demonstrated a reduction in the average number of PAs for SPAs. This runs counter to new consultants' expectations of their future involvement in trust/service management and undertaking roles for the RCPCH. The RCPCH with the Nuffield Council has emphasised the importance of paediatricians having protected time to be part of research ethics committees.23

Compliance with standards for acute general paediatric services has increased the demand for ‘generalists’24 and hence the high numbers of general paediatricians gaining CCT is, therefore, welcome. The reduction in the proportion registered for community paediatrics, however, is worrying. Hopefully, the introduction in 2015 of community child health to the RCPCH scheme to allow trainees to compete for nationally available subspecialty training programmes (the National Training Number Grid Scheme)25 will eventually increase the numbers of community child health subspecialists. In addition, the RCPCH has developed a number of post-CCT special interest modules enabling consultants to develop their specialisms post-CCT.

This study has many strengths. Data were available biannually from 1999 and from new CCT/CESR award holders annually over a 4 -year period. The response rates from the eight censuses ranged from 95% to 99%. Data were used from supplementary sources to ensure that the results reflected those from the whole workforce.

In conclusion, we have demonstrated a doubling of paediatric consultant numbers since 1999, but more are working less than full time. The reduction in both the numbers of consultants with a primary academic contract and the average number of PAs for SPA is of concern. Paediatricians may be less able to engage in research, educational, quality improvement, leadership and advocacy activities designed to improve the outcomes of infants, children and young people may be limited.

Acknowledgments

Dr Melanie Simpson, RCPCH, advised on the statistical analysis of the data.

References

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Footnotes

  • Contributors MM and AG designed the study. MM and RW collected and analysed the data.

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data sharing statement Data can be open for sharing if required.

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