This report is a workforce profile for Scotland, supported by the Royal College of Paediatrics and Child Health (RCPCH) workforce census 2017. It follows on from the Workforce Census 2017 Overview Report that provides a UK-wide analysis of the census data, and is part of a series of reports focusing on the four UK nations in turn. Further reports will focus on the workforce in the other UK nations, safeguarding provision, the workforce in paediatric specialties and Specialty and Associate Specialist (SAS) doctors.
This report makes recommendations specific to Scotland in four key areas:
- Planning the child health workforce
- Recruiting, training and retaining more paediatricians
- Incentivising the paediatric workforce
- Planning for and expanding the non-medical workforce
The reports are supported by the following Census Resources:
- An interactive dashboard of paediatric workforce data which allows users to apply filters and customise for their own use and interest
- A set of detailed tables in Excel format for those who wish to see further breakdowns of the census data
- An explanation of how we arrived at our estimate of consultant workforce demand and supply of trained doctors
- The census data collection methodology and response rate
Scotland has 11 Health Boards that provide paediatric services across the total 14 Health Boards, and NHS Scotland is responsible for workforce planning in this nation. Consultant growth in Scotland between 2015 and 2017 was 5%, lower than the England growth of 8.2% and the UK growth of 7.8%. Growth of consultant numbers in Scotland has slowed since 2015: between 2013 and 2015 WTE consultant growth in Scotland was 14.2%.
Rates of less than full time consultant working in Scotland have remained lower than the other UK nations, and the average number of consultant Programmed Activities (PAs) is the highest in the UK. In contrast, medical paediatrics in the UK has a trainee workforce which increasingly wishes to work less than full time (LTFT)1 . The LTFT trainee workforce is both female and male. Modelling needs to consider how the shift towards LTFT in trainees may extend into consultant LTFT working patterns in future.
This could lead to a potential dramatic fall in the whole time equivalent (WTE) workforce in Scotland unless there is an increase in the head count of doctors in training.
The shortfall in medical paediatric staffing across Scotland is clearly seen in rates of rota gaps and vacancies, which are higher than the UK overall. To meet the RCPCH standards set out in Facing the Future, Scotland needs to appoint an additional 82.5 whole time equivalent (or 100 headcount) consultants. This would be an expansion of the current workforce of 25%, which contrasts with the 5% actual rise.
There are particular concerns in Scotland about workforce provision to remote and rural areas. As in the rest of the health service, remote and rural areas face higher costs2 , and paediatrics faces issues of recruitment and retention and a reliance on a small number of paediatricians in smaller centres.
The general paediatric workload is shifting, and we report a year-on-year upwards trend of admissions. A more effective way of working across primary and secondary care, as described in Facing the Future Together for Child Health, is needed to keep up with this surge in admissions.
The number of paediatric trainees and consultants are unlikely to rise by the amount needed to meet demand any time soon, especially as only 6% of foundation year 1 (F1) doctors consider specialising in paediatrics3 . Therefore, workforce planners need to develop non-medical workforces, and see their potential in helping paediatric services meet standards and demand. For example, the current lack of children’s community nurses in Scotland, and absence of post graduate training opportunities in Scotland for this role4 , presents a major gap in the child health workforce.
Furthermore, according to the 2017 census, there are now more specialist than generalist paediatricians in the Scottish workforce. This may reflect the fact that trainees tend to work more in tertiary centres rather than smaller district general hospitals (DGH), where they are able to develop a specialty. However, this leaves them unprepared to work as general paediatricians in DGHs after CCT.
The RCPCH are conducting a Paediatric 2040 project to look at the future of paediatrics and would encourage NES to consider this timeline too. This project will develop predictions and models of children and young people’s health outcomes by 2040 and aims to understand what future requirements for paediatric services may look like and to identify innovations that will change the way paediatric services are delivered.
There are some positives to see in this report from Scotland. First, trainees want to train in Scotland, and there is twice the national average of applicants for each available post. Second, UK (and likely Scottish) trainees want to be consultants in Scotland since 78% of consultants and SAS doctors in Scotland are UK graduates, compared to 64% across the whole of the UK. Third, the paediatric community is keen to work to address the problems we all face, and Scottish centres had a 100% 2017 workforce census return. The Scottish government and Transition Group acknowledged the need to increase the number of paediatric trainees and will fund an additional eight posts for 2019.
1. Plan the child health workforce
There has been an incoherent and inconsistent approach to planning for the child health workforce.
NHS Education for Scotland (NES) must develop a bespoke child health workforce strategy.
The strategy must identify all the child health workforce which provide care to infants, children and young people (ICYP) including medical, midwifery, nursing, allied health professionals, pharmacists, health visitors and school nurses. RCPCH wants to continue to work with NES in a constructive and collaborative manner to develop the workforce strategy.
The plan must model the paediatric and child health workforce at least up to 2030, based on what future services will look like and existing service demand projections.
The strategy must be sufficiently robust to deliver professional and service standards.
The strategy must acknowledge and support differential participation rates and the development of portfolio careers to enable retention of staff.
2. Recruit and train more paediatricians
The RCPCH supports the Royal College of Physicians call to Scottish Government to double the number of medical students5 . In addition, the RCPCH wants to see:
- The Scottish Government maintain the 2019 uplift in the number of paediatric trainee places in Scotland.
- The Scottish Government to fund an additional year of General Practice (GP) training. This additional year must include paediatric and child health training for all GP trainees as proposed in the Royal College of General Practitioners (RCGP) curriculum submission in 2016. The extended programme would be subject to approval by the General Medical Council.
- NES and the Deaneries in Scotland must support existing Specialist and Associate Specialist (SAS) grade doctors and their professional development, ensuring that this important part of the child health workforce is recognised as a viable, attractive alternative career pathway. Improved recognition of SAS doctors’ experience, professional and clinical skills is important to improve attitudes, morale and retention. The RCPCH is also recommending that the SAS grade is included in workforce planning.
3. Incentivise the paediatric workforce
Pay premia have been used in other hard to recruit medical specialties. Paediatrics is now facing severe shortages with falling applications and recruitment challenges.
The Scottish Government, NHS Boards and NHS Education Scotland must improve recruitment and retention to rural areas of Scotland, for example by using pay premia in those areas.
4. Plan for and expand the non-medical workforce
The delivery of paediatric services to children and young people and their families requires a multidisciplinary workforce.
NES must develop a national career strategy for advanced clinical practitioners including Advanced Nurse Practitioners in neonatology and paediatrics, and Physician Associates.
Health Boards should implement new models of care which deliver general paediatrics across primary and secondary care (as described in RCPCH Facing the Future) and include the use of modern technologies including consultation over video link.
Scotland’s managed clinical networks (MCN) are a good example of clinical staff working together, across the boundaries between the different professions and parts of the health service6 .
- 1General Medical Council, The state of medical education and practice in the UK 2018. 2018: www.gmc-uk.org/-/media/gmc-site/about/what-we-do-and-why/data-and-research/somep-2018/version-one---0412pm/somep-book-20187.pdf
- 2Nuffield Trust, Rural health care: A rapid review of the impact of rurality on the costs of delivering health care. 2019: www.nuffieldtrust.org.uk/research/rural-health-care.
- 3UK Foundation Programme Office, F2 Career Destinations Report 2018. healtheducationengland.sharepoint.com/sites/UKFPOT/WebDocs/Forms/AllItems.aspx?id=%2Fsites%2FUKFPOT%2FWebDocs%2F6%2E%20Resources%2FReports%2FF2%20Career%20Destination%20Reports%20%282010%2D2019%29%2FF2%20Career%20Destinations%20Report%5FFINAL%202018%2Epdf&parent=%2Fsites%2FUKFPOT%2FWebDocs%2F6%2E%20Resources%2FReports%2FF2%20Career%20Destination%20Reports%20%282010%2D2019%29&p=true&ga=1
- 4The Queen’s Nursing Institute Scotland (QNIS). Community Children’s Nursing Standards. [cited 2019 18/02/2019]; Available from: www.qnis.org.uk/what-is-community-nursing/standards/community-childrens-nursing-standards/.
- 5Royal College of Physicians, Double or quits: calculating how many more medical students we need. 2018: www.rcplondon.ac.uk/news/double-or-quits-calculating-how-many-more-medical-students-we-need.
- 6NHS Education for Scotland. Managed Clinical Networks - Children and Young People's Services MKN [cited 2019 18/02/2019]; Available from: www.cen.scot.nhs.uk/national-managed-clinical-networks/