Workforce census: Focus on vulnerable children and families paediatric workforce (2020)

This report, published in January 2020, focuses on lead roles concerning safeguarding, the child death service, looked after children (LAC) and special educational needs and disability (SEND).

Work in these sub-groups falls under the umbrella heading of work with vulnerable children and families.1 This is a broad field including other sub-groups that are not included in the RCPCH census, and are therefore not within the scope of this report.

This report is part of a series using RCPCH 2017 census data to highlight key areas of the paediatric workforce. As the census focuses on the paediatric workforce, most of the lead roles discussed in this report are held by paediatricians.

While outside of the scope of this report, the RCPCH acknowledges the important role of other health professionals, such as nurses and primary care doctors, in the care of vulnerable children and families.

Previous publications using RCPCH census data have focused on Specialty, Associate Specialist and Staff Grade (SAS) doctors2 and the workforces of the devolved nations3 This report makes the following recommendations that relate to the vulnerable children and families workforce, the wider paediatric workforce, Governments and stakeholders in England, Wales, Scotland and Northern Ireland:

  • Ensure that lead roles exist without exception
  • Develop guidance for all roles in all countries
  • Review the need for additional lead roles
  • Ensure that holders of lead roles have appropriate competencies
  • Recruit and train more paediatricians

You can download the full report below.

Executive summary

Context

The roles described in this report are determined by the government within each nation. As such the lead roles are subject to variation between England, Scotland, Wales and Northern Ireland. Differences and similarities in the roles mandated for safeguarding, child death service, looked after children and SEND are presented in the appendix. The responsibilities of each lead role, associated standards and employer are described in section 5 of the report.

The vulnerable children and families lead roles are filled by paediatricians that deliver these responsibilities alongside other work, as part of their overall job plans. The challenges facing the paediatric workforce are therefore of high relevance to the vulnerable child and families workforce.

The paediatric workforce

As noted in previous RCPCH reports, the entire paediatric workforce is facing increasing levels of demand that they must meet with decreasing resources. For example, the RCPCH workforce census overview report concluded that demand for paediatric consultants outstripped supply by 21% in 2017.4

Furthermore, the paediatric workforce pipeline is not strong; across the UK 87.5% of ST1 posts were filled in 2019. This is a reduction from an already low fill rate of 89.6% in 2017.4

Workforce shortages are perceived by medical staff to be associated with increased risk for patients; 84% of 2017 census respondents said that paediatric vacancies and gaps in training posts pose a significant risk to their service or to children, young people and their families.4

The majority of lead roles discussed in this report, particularly those filled outside of hospitals, Trusts or Health Boards, are held by community child health paediatricians. Their workforce is therefore discussed in depth below.

The community paediatric workforce

Community child health (CCH) is the largest paediatric sub-specialty and lead roles supporting vulnerable children and families are a crucial part of CCH,1 as their work safeguards the wellbeing of vulnerable young people, children and babies. They help to ensure that all children’s needs are met and to protect wider society.

The 2017 State of Child Health short report on the community paediatric workforce concluded that the number of career grade community paediatricians must increase by 25% in order to meet current and anticipated demand, which is growing.

Rising demand is partly linked to trends concerning special educational needs provision. For example, between January 2018 and January 2019 the number of school pupils with an Education, Health and Care Plan (EHCP) in England rose by 17,500. This equates to an increase of 17,500 medical assessments that must be conducted by a medical professional, such as a CCH paediatrician.5

The challenges presented by increasing patient demand are compounded by a trend towards less than full time (LTFT) working. Additionally, the RCPCH census results show that the proportion of consultants in CCH posts decreased from 18.5% of the consultant workforce in 2015 to 17.4% in 2017.4

The trends affecting the CCH paediatric workforce, and the wider paediatric workforce, are closely linked to the specific challenges facing the vulnerable children and families workforce.

Concerns surrounding the vulnerable children and families workforce

RCPCH census data shows that there are vacancies in vulnerable children and families lead roles across the UK. The cause of these vacancies is likely to be a complex mix of local, national and supernational factors, but UK-wide paediatric workforce shortages and increasing patient demand can be assumed to be major contributors.

In addition to widespread vacancies, some Trusts, Health Boards, Clinical Commissioning Groups (CCGs) and other employers have not yet developed roles that should exist in their organisation as per relevant guidance. For example, the lead roles for safeguarding in England, Wales and Scotland exist in over 90% of organisations. This is not the case for child death service, looked after children or special educational needs lead roles where the non-existence of roles (filled or vacant) appears to be a greater problem; in England, 23.1% of Trusts do not have a Designated Doctor for Child Deaths role (provided at CCG level), 45.1% of Trusts do not have the Named Doctor for Looked After Children role, and 36.2% of Trusts do not have the Designated Medical Officer for Special Educational Needs and Disability role (also provided at CCG level). The non-existence of roles, coupled with widespread vacancies where roles exist, leaves a concerning gap in service provision for vulnerable children and families.

Where roles do exist and are filled, the post holder is often awarded insufficient time to fulfil their responsibilities. These gaps and inconsistencies are part of a larger issue of variation among and within nations regarding lead roles. A lack of clear guidance from Governments and other decision-making bodies increases the risk of local misinterpretation and of vulnerable children and families not receiving the care they require. Guidance should clearly state the population that each role would serve, the person specification and job content. This should include suggested time allocation. Employers must align practice to the latest available guidance and ensure that healthcare professionals appointed to lead role positions are equipped with the necessary competencies and experience.

Some employers appear to have developed vulnerable children and families lead roles that are not stipulated in their nation’s statutory guidance or code of practice. This may be in response to population need. Governments and membership bodies should explore whether new statutory roles for vulnerable children and families need to be developed across their nation to close existing gaps in service provision and to better care for the most vulnerable members of the population.

RCPCH census data also points to trends within the Speciality, Associate Specialist and Staff Grade (SAS) doctor group. SAS doctors hold vulnerable children and families lead roles to a variable extent across the UK; for example, it was reported that in Wales 16.7% of Named Doctor for Child Protection roles were filled by SAS doctors, whereas in England 3.1% of Named Doctors for Child Protection were SAS doctors.

The RCPCH census report on SAS doctors concluded that the number of lead roles held by SAS doctors increased by 0.6% between 2015 and 2017.2 The number and whole time equivalent (WTE) of SAS doctors declined during this time, however, by 3.7% and 3.6% respectively. This drop is part of wider downwards trend; a fall in SAS doctor headcount and WTE has been found in the results of every RCPCH census since 2001.2 A continued reduction in SAS doctor headcount and WTE is likely to exacerbate existing vacancies in vulnerable children and families lead roles and to increase workload on post holders, especially in countries and lead role areas where SAS doctors hold the relatively higher proportions of lead roles.

In addition to the findings already outlined, qualitative census data reveals instances across the UK of long-term vacancies, a lack of strategic leadership, a scarcity of funding for backfill and cases of one individual possessing more than one role in an effort to meet demand. Role holders and employers should be commended for their hard work in the face of rising demand and relatively decreasing levels of resource. The clear commitment and compassion of the workforce should not be exploited to deliver a full service with only limited resources.Governments, employers and professional bodies must act to ensure that vulnerable children and families’ safety is not compromised by the concerns outlined in this report.

  • 1. a. b. Royal College of Paediatrics and Child Health and British Association of Community Child Health. Covering all bases: Community child health – a paediatric workforce guide. 2017.
  • 2. a. b. c. Royal College of Paediatrics and Child Health. Workforce census 2017: Focus on SAS doctors. 2019.
  • 3. Royal College of Paediatrics and Child Health. Nations. Date unavailable; Available from www.rcpch.ac.uk/nations
  • 4. a. b. c. d. Royal College of Paediatrics and Child Health. RCPCH State of child health: short report series. 2017 workforce census overview. 2019.
  • 5. Department for Education. Special educational needs in England: January 2019. 2019.