General paediatric services are the forefront of care for a seriously unwell child or baby. The majority of paediatric trainees qualify in general paediatrics, but only around 42% of paediatric consultants work in general paediatrics, with the remaining in subspecialty roles1 . Emergency paediatric admissions are increasing year-on-year2 , primarily driven by respiratory illnesses in the under 5s and neonatal issues3 . Across all of paediatrics, the Royal College of Paediatrics and Child Health (RCPCH) currently estimates that an increase in 856(22%) whole time equivalent general paediatric consultants would be needed to meet current demand across the UK4 . As such a gap will not be met easily or rapidly, a multidisciplinary workforce is essential to meeting demand.
A general paediatric service usually consists of a children’s inpatient ward alongside outpatient clinics and a neonatal unit. It is sometimes supported by a Children’s Assessment Unit (CAU), where patients are kept for short-term observation. Referrals to general paediatrics are made from the Emergency Department (ED), primary care or other routes such as transfers from another hospital. Children are seen with a range of acute and long-term health conditions, such as respiratory illness, nutrition problems, or safeguarding concerns. There is an increasing need for Allied Health Professional (AHP) involvement due to greater numbers of children with medical complexity.
On a given working day, general paediatric staff may have to cover the inpatient ward, outpatient clinics, the CAU, paediatric cases in ED, as well as neonatal services in some hospitals. Staff will regularly liaise with primary care, intensive care, surgical teams, community teams, paediatric subspecialty teams, social care and in some cases (as in the case study 1, below), police and legal professionals. Shortages in these adjacent areas have a knock-on impact on general paediatrics.
The health needs of children have changed drastically over the past 50 years, and paediatrics has had to adapt accordingly. Overall, threats to child health are moving towards complex and comorbid conditions such as diabetes, obesity, mental illness, and safeguarding concerns. Thanks to modern advances, such as vaccines, children more rarely present with infectious diseases like measles and mumps. However, given the COVID-19 pandemic we must be cautious and not forget about the importance of preventing infectious diseases. To address the breadth of child health needs, we must ensure that care is integrated, with close links to primary care, public health, mental health and community services, as highlighted by the NHS Long Term Plan5 . General paediatrics will be key to delivering integrated care for children.
The findings of the current report are considered against a backdrop of a system recovering after the COVID-19 pandemic, NHS-wide workforce pressures, worsening child health outcomes and increasing inequality in the UK as reported in the recently released State of Child Health 2020 report6 . Whilst the coronavirus SARS-Cov-2 rarely has a serious clinical impact on children, the COVID-19 response, such as social distancing measures, has had a profound knock-on effect to services and especially vulnerable children.
The current survey was conducted with the aim of getting a snapshot of the current state of general paediatric services in the UK. We surveyed services on two days: Wednesday 18 and Saturday 21 September 2019 to allow comparison between a weekday and weekend. This was done in partnership with NHS England/NHS Improvement initiative Getting It Right First Time (GIRFT)7 who conducted a concurrent survey of neonatal services and will also release a report of their findings. 192 general paediatric units were invited to participate and 124 responded (65%). The response rate in England was much better than in the devolved nations, possibly due to greater awareness of the GIRFT programme in England.
Our primary findings were:
- Medical rotas and staffing
- There was an average of 10% of staff missing on the training rotas on weekdays, equivalent to 0.6 people per unit.
- The majority of absences were due to vacancies (weekday 25%; weekend 28%) or short-term sick leave (weekday 19%; weekend 10%).
- A third of the tier 1 medical rota was staffed by GP trainees.
- ST4 to ST8 paediatric trainees were more likely to be on the tier 3 rota on the weekday than the weekend.
- A quarter of units surveyed (25.3%) had at least one locum doctor present.
- Multidisciplinary team
- The general paediatric team is comprised of a wide range of healthcare professionals.
- Non-medical staff tended to be less available at the weekend: 84% of units had a play therapist present on a weekday compared to just 31% on the weekend.
- Similarly, 62% of units had a dietician present on a weekday compared to just 2% on the weekend.
- Route to accessing care
- The majority of referrals to paediatric inpatients were via the Emergency Department.
- Six percent of acute ward beds were occupied by a child admitted due to a mental health problem.
- The presence of a CAU was associated with a reduction in the number of referrals from an Emergency Department and an increase in the numbers of discharges but had no association with the number of admissions.
The recommendations in this report are informed by the RCPCH’s Reset, Restore and Recover8 principles for child health services following the pandemic. When implementing these recommendations, we call on stakeholders to include children and young people in decisions and consider how plans will affect them. The Resources section of this report signposts to material that may help in the implementation of these recommendations.
1. Integrated care
Paediatric emergency attendances and admissions are rising year-on-year9 , and greater intervention at the primary and community level is needed to prevent unnecessary hospitalisation of children.
Our findings show that beds in general paediatric wards are being occupied by children with mental health problems. This is not an appropriate location for children in acute mental distress and reflects a lack of community resources and a need for better integration of care.
We found that a third of junior paediatric rotas were staffed by GP trainees. This is positive as GPs with greater paediatric experience will be better equipped to care for children and young people in their practise. We also found that there is a wide range of healthcare professionals working in a general paediatric team. Allied Health Professionals (AHPs) play a key role in the general paediatric team delivering care for children.
In our findings, the presence of a Children’s Assessment Unit (CAU) had no effect on number of admissions, but hospitals with a CAU had higher discharge rates, and lower numbers of referrals from ED. Further research is needed into the best model for acute paediatric services.
- The RCPCH commits to supporting implementation of the Long Term Plan, for example via our position on the Children and Young People’s Transformation Programme board. The RCPCH also commits to supporting integrated care models across the four UK nations.
- NHS England and NHS Improvement and other bodies responsible for implementing the NHS Long Term Plan, should continue to prioritise integration in the post-pandemic landscape.
- Commissioners and workforce planners should consider the whole multidisciplinary team when commissioning workforce for general paediatrics, as the breadth of experience is essential to delivering integrated care.
- The RCPCH will work with the Royal College of General Practitioners and the Royal College of Psychiatrists to create opportunities for their trainees to experience placements across paediatrics, general practice, and psychiatry.
- The RCPCH will continue to document innovative practises and alternative models of care1 , and we call on all child health professionals to share their ideas across peer networks and apply a QI mindset to their work.
2. Workforce and service planning according to need
To deliver quality care to children and young people, paediatric services must consistently have the right number of staff with the right level of expertise. However, we found a 10% shortage of staff on medical training rotas. We also found a high reliance on locums; over a quarter of all services had a locum present on the days surveyed. Employing locums is an expensive and short-term solution to workforce shortages.
Our data show variation in the availability of staff between a weekday and weekend. The average number of staff on medical rotas on a weekend is around half the number on a weekday. The availability of other essential staff, such as dieticians, physiotherapists and play therapists, is also much lower at the weekend.
As well as a variation in provision between days, there was also unwarranted variation between different units and regions of the UK. Regions with high admissions, referrals and higher populations of children, did not necessarily have more paediatric inpatient beds. Individual units with higher levels of demand did tend to have more beds, but there was also wide variation in this. Children must receive the same level of high-quality care whenever and wherever they present.
- The bodies responsible for workforce planning in the UK (Health Education England; NHS Education Scotland; Health Education and Improvement Wales; and the Northern Ireland Medical and Dental Training Agency) must plan the child health workforce according to demand.
- This should be supported by local-level workforce planning bodies, for example, in England the Sustainability and Transformation Partnerships (STPs) and integrated care systems (ICSs). The RCPCH should be involved in these decisions and commits to supporting workforce planning with data, intelligence, and our Ambassadors programme.
- Medical education bodies, such as HEE and the devolved nations equivalents, should continue to develop generalist Allied Health Professional (AHP) roles, such as Advanced Nurse Practitioner, psychologist, dietitian, and physiotherapist to support the child health workforce.
- Healthcare providers (NHS Trusts and Health Boards) must ensure that child health provision is given parity with adult health, especially in post-pandemic restoration of service.
3. Safety and wellbeing of staff
Our case studies demonstrate that intense workloads can impact staff mental health. During the pandemic, many paediatric staff will have been through an exceptional trial of stress, dealt with unfamiliar and difficult circumstances, and may have been redeployed to adult services. Supporting staff wellbeing during restoration of services is essential.
As part of this, we need to continue to ensure equality for all staff members and better representation at a leadership level. For example, Black and Minority Ethnic (BAME) staff in the NHS are at greater risk to the coronavirus10 ,11 , as well as having less access to Personal Protective Equipment (PPE)12 . All colleagues’ voices must be listened to and their needs accommodated as we restore services.
- Whilst there still is a risk from COVID-19, healthcare providers must conduct staff risk assessments, taking into account factors such as ethnicity, age and underlying health conditions. These at-risk groups must be consulted, and their voices taken into account.
- Service leaders and planners should ensure staff safety, e.g. the right to refuse to work where they feel unsafe or improperly protected. They should also support staff wellbeing in the long-term by ensuring they have access to appropriate resources and support services.
The data and case studies show that some general paediatric services in the UK are struggling due to poor national planning or rapidly increasing demand. Below we signpost to resources from the RCPCH that provide support.
- Reset, Restore, Recover: Principles for paediatric services. This page outlines how we should plan and deliver healthcare for children and young people in the wake of the pandemic. Particularly thinking about how we harness innovation and learning so that it can be shared and maintained and to use this as a basis to train and educate our paediatricians and broader child health workforce
- Where to go for help and support for staff wellbeing. Links to health, support, and wellbeing resources for doctors.
- Invited Reviews service. The RCPCH’s Invited Reviews service provides clinically led peer review and consultancy to healthcare providers. It advises teams and supports them to resolve any concerns about paediatric provision, safety, team dynamics, compliance with standards or proposals for reconfiguration.
- RCPCH Ambassadors. The Ambassadors programme in England is a network of volunteers who advocate locally for children, young people and the staff that care for them. They aim to raise the profile of child health by campaigning, particularly within ICS/STPs. If you are looking to connect with your local ambassador, or are interested in getting involved, please find contact details on the webpage linked above.
- QI Central. This is an online resource that brings together examples of quality improvement (QI) interventions submitted by child health professionals. It also has tools to aid data collection and improvement interventions.
- Workforce data and service modelling. At the bottom of the linked page, you can download the latest data about paediatric workforce and services in the UK, including an interactive Excel dashboard. You can also download a spreadsheet that allows you to model the consultant workforce needed for a general paediatric service to meet Facing the Future standards.
- Contact your Area Officer or National Officer. The RCPCH has seven Area Officers for England and an Officer for each of the devolved nations. Their job is to advocate for their locale, by speaking to decision makers. They are closely linked to RCPCH Ambassadors.
- Facing the Future standards, tools and service models. The RCPCH has standards for general paediatrics in the document, Facing the Future: standards for general acute paediatric services. On the page linked above, you can find a suite of resources relating to paediatric standards.
- Clinical leadership development programme. This is a portfolio of events for new and aspiring paediatricians in leadership positions.
- RCPCH &Us - children and young people engagement. Getting the voice of patients is essential to providing an excellent service. The RCPCH &Us team do extensive work with children and young people, to get their views and experiences.
- Get ready for Shape of Paediatric Training. Shape of Training will change the way paediatricians are changed, with greater emphasis on generalisation and flexibility.
- 1 a b RCPCH. Workforce Census: UK Overview Report. (2019). https://www.rcpch.ac.uk/resources/workforce-census-uk-overview-report-2019
- 2NHS Digital. Hospital Episode Statistics. digital.nhs.uk/data-and-information/publications/statistical/hospital-episode-statistics-for-admitted-patient-care-outpatient-and-accident-and-emergency-data
- 3RCPCH. Paediatrics 2040, forthcoming data. www.rcpch.ac.uk/work-we-do/paediatrics-2040
- 4RCPCH. Shortage of consultant paediatricians – report. (2019). www.rcpch.ac.uk/resources/shortage-consultant-paediatricians-report
- 5 NHS Long Term Plan. (2019). www.longtermplan.nhs.uk/
- 6RCPCH. State of Child Health. (2020). www.rcpch.ac.uk/resources/state-of-child-health
- 7NHS England/NHS Improvement. Getting It Right First Time (GIRFT). gettingitrightfirsttime.co.uk/
- 8RCPCH. Reset, Restore, Recover: Principles for Recovery. (2020). www.rcpch.ac.uk/resources/reset-restore-recover-rcpch-principles-recovery
- 9NHS Digital. Hospital Episode Statistics. digital.nhs.uk/data-and-information/publications/statistical/hospitalepisode-statistics-for-admitted-patient-care-outpatient-and-accident-and-emergency-data
- 10Public Health England. COVID-19 review of disparities in risks and outcomes. (2020). www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes
- 11Health Services Journal. Exclusive: deaths of NHS staff from covid-19 analysed. (2020). www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article
- 12 British Medical Association. BAME doctors hit worse by lack of PPE. (2020). www.bma.org.uk/news-and-opinion/bame-doctors-hit-worse-by-lack-of-ppe