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1 Health Workforce Directorate Health Workforce Planning and Development abcdefghijklmnopqrstu T: F: E: To: Medical Directors Regional Workforce Directors Nurse Directors HR Directors NHS Education for Scotland National Delivery Plan Implementation Group abcd Copied to: Workforce Planners Chief Executives 17 August 2009 Dear Colleagues REPORT BY THE SHORT LIFE WORKING GROUP LONG TERM SERVICE MODELS FOR PAEDIATRIC SERVICES Pleased find enclosed the report from the short life working group on the long term service models for paediatric services. I am aware there are ongoing difficulties with levels of medical staffing in paediatric services. The enclosed report suggests the way ahead for services in the medium and longer term. I commend its contents and look forward to seeing progress towards sustainable solutions for paediatric staffing in due course. Yours sincerely DR ALASTAIR COOK Senior Medical Officer St Andrew s House, Regent Road, Edinburgh EH1 3DG abcde abc a

2 Long term service models for paediatric services A report by the short-life working group commissioned by the chief nursing officer August 2009

3 Table of contents 1. Introduction The Short Life Working Group Reshaping the medical contribution to the clinical workforce 4. Background: Current acute paediatric services in Scotland Neonatal Units Medical Workforce Nursing Workforce Paediatric Nursing Specialist Training Current Service Models - From Visits 8 3. Planning - where do we want to be? Increased Number of Trained Doctors Alternative ways of recruiting additional doctors in training Rota Redesign Role Substitution Pathway Redesign Inter-dependencies Conclusions 15 2

4 Introduction In 2008, there were reported difficulties in recruitment to middle grade locum medical training posts in several Scottish NHS Boards. These difficulties are a result of higher than expected vacancies (due to trainees transferring to other locations, maternity leave and time out of programme) and low numbers of applications for locum posts (possibly reflecting low numbers of international graduates seeking employment in the UK). In addition Deaneries reported lower than anticipated levels of competition for training posts. The Chief Nursing Officer (CNO) met with representatives from paediatrics services across Scotland. It was clear that there was concern across the service, that Boards were not confident in their short term ability to provide acute paediatric services, nor of meeting the Working Time Regulation requirements in summer Furthermore, little planning had been undertaken for the longer term changes in workforce initiated by Modernising Medical Careers (MMC) and the implications it will have on the way services are delivered. In response to these concerns, the CNO requested that a short life working group should be established to explore the challenges faced by paediatric services. The immediate need to increase recruitment efforts was taken forward by a number of different bodies, and was not part of the remit of this group. In addition some of the possible changes to the way in which services could be provided in the future relate to job titles, terms and conditions of service, and contracts for all medical staff. As these are much wider issues for the healthcare professions this working group did not have a remit to review them. These issues are acknowledged as highly relevant to the future planning of services but are not explored in detail in this paper. The work of the group focussed on acute services, and did not address community paediatrics. Thus the aim of this short life working group was, in the light of MMC changes to paediatric medical training numbers, to: Develop pan-scotland thinking on long term acute general paediatric and neonatal service models to support service redesign; Consider the development of skill and staff mix, and non-medical training approaches to provide emergency paediatric and neonatal services. This paper summarises the groups findings, deliberations and conclusions. 1.1 The Short Life Working Group The group comprised of the three Regional Workforce Directors, representation from the Chief Medical Officer, Chief Nursing Officer, and Workforce Directorates in Scottish Government, the Royal College of Paediatrics and Child Health and NHS Education for Scotland. The group met between September 2008 and February 2009 and undertook visits to three units across Scotland: Raigmore Hospital, Inverness, Wishaw General Hospital and Forth Park Hospital, Kirkcaldy. In each visit the group met with key staff: those providing paediatric and neonatal services across numerous disciplines primarily medical and nursing staff and management and Board representatives. The group also collated data and evidence on current service activity, staffing numbers and skills, and training courses available and undertaken. 3

5 1.2 Reshaping the medical contribution to the clinical workforce It is clear that current service models in paediatrics are dependent on the availability of a 24/7 on-call rota of doctors in training. It has been a policy intent to move away from this model of service delivery for several years and the changes in training resulting from Modernising Medical Careers provide a significant opportunity to resolve the difficulties created by the current service model. In the current model the loss of small numbers of doctors in training can have a huge impact as most services are dependent on a small rota of 6 to 8 trainees. Any gaps/vacancies have significant impact on the medical staff working in the team: both career grade staff and other trainees have found themselves having to increase their working hours and make unplanned changes to working patterns and services just to cover gaps in rotas. Currently there are 200 NTN and 34 FTSTA posts in paediatrics in Scotland. From August 2009 the FTSTA posts will be converted to full (NTN) training posts in either paediatrics or General Practice. The number of middle grade posts have not decreased with the introduction of Modernising Medical Careers and have in fact led to a higher number of recognised training posts. This has involved recruitment at the middle grade (>ST3 level) and maintaining the number of posts on offer. These have not always been able to be filled as outlined above. However, the intake at ST1 to training posts will mean that as the current group of middle grade doctors move through to CCT the total number of trainees in the system will fall. Services should expect to see relatively high numbers of CCT holders around 2011/13 accompanied by reduced numbers of trainees. By 2013 it is expected that there may be between 116 and 189 NTN posts in paediatrics across Scotland. It is important to note that these numbers are estimates and discussions are ongoing to confirm future trainee projections. Changes in training numbers are to a large degree dependent on the model of service introduced to replace the community child health workforce that is currently predominantly delivered by specialty doctors. However, at worst case there is a potential drop in trainee numbers from the current 234 to 116, a drop of almost half. The question for Boards is how will services deliver 24 hour care when they can no longer provide a 24/7 on-call rota made up of doctors in training? 4

6 2. Background: Current acute paediatric services in Scotland Fourteen hospitals across Scotland provide acute general paediatric inpatient services. Of these, four hospitals are specialist dedicated children s services: in Glasgow, Edinburgh, Dundee and Aberdeen. The population and activity levels of services are shown in the Annex in Table 1. For the purposes of this review the main points of note are the wide variations in catchment populations and thus size and activity levels in different locations. On the basis of ISD data, services can be very roughly split into three groups: Admissions / Est. catchment pop. Locations Year Large > 8,000 >100,000 RHSC Edinburgh, Yorkhill Glasgow Medium > 4,000 < 8,000 50,000 < 100,000 Ninewells, Aberdeen, Wishaw, Crosshouse Small < 4,000 <50,000 St Johns, Borders, Fife, Paisley, Stirling, Dumfries & Galloway, Raigmore, Dr Grays 2.1 Neonatal Units Across Scotland there are 16 neonatal units, of these 9 have a dedicated middle grade medical rota and 7 have a dedicated consultant rota. More detail is shown in Table 2 in the Annex. There is variation in the levels of service offered by units (from special care to intensive care) and the number of births served by each unit. The working group was aware that Scottish Government was due to publish a review of neonatal services. The pressures of recruitment to middle grade trainee posts occurred after the work of the neonatal review group. Thus it is likely that these additional workforce pressures will need to be taken into consideration alongside the neonatal report. Health Board Unit location Est. catchment area births Ayrshire and Arran Ayrshire 3714 Borders Borders 1087 Argyll and Clyde Royal Alexandra 3057 Fife Forth Park 3512 Greater Glasgow Queen Mother's 3437 Southern General 3113 Princess Royal Maternity Unit 5267 Highland Raigmore, Inverness Lanarkshire Wishaw 4828 Grampian Aberdeen Dr. Gray's, Elgin 971 Lothian Simpsons, Edinburgh 5999 St John's, Livingstone 2750 Tayside Ninewells 4191 Forth Valley Stirling 3163 Dumfries and Galloway Dumfries & Galloway 1373 Total 53, Includes special care baby units, high dependency units and intensive care units. 2 - Raigmore data includes Western Isles, Aberdeen includes Shetland and Orkney. 5

7 2.2 Medical Workforce Consultants & Other Career Grades The North of Scotland Workforce Planning Group, along with the Royal College of Paediatrics and Child Health, undertook a census of the medical paediatric workforce in The data was updated for this working group in October 2008 This census identified 421 career grade posts of which 12 posts which are vacant. Of these posts 237 are consultants, 153 are Staff Grade and Associate Specialist doctors and 31 are other grades, mainly academic. These 421 doctors represent 0.50 paediatricians per 1,000 population aged <16 years in Scotland. In Modelling the Future the Royal College of Paediatrics and Child Health estimate a need in the UK for about 0.58 career grade paediatricians per 1,000. Of the total 421 career grade posts, 119 work entirely in community paediatrics and 302 work for at least some of their time in secondary or tertiary care. Consultants comprise 56% of the paediatric medical workforce (just over 60% of the workforce is female). 85.7% of consultants work full-time, with the majority of those (87.3%) working more than 10 PAs. The number of consultants reported to exceed 48 hours per week is 3.8%, although data is not reported for 13.1% of the total. There are 61 doctors over 55 years of age: this amounts to 14% of the workforce. If it is assumed that those doctors who are aged over 55 years and work full-time are replaced by doctors working 10 PAs, about 6 WTE additional doctors will be required to maintain the current contracted capacity Trainee Rotas and Training NHS Education Scotland (NES) report 29 training rotas in 20 locations; training locations vary in size and speciality from Yorkhill in Glasgow with 48 trainee posts across 6 rotas, to Dr Gray s in Elgin with 3 of their 14 GP trainees, who have an interest in family medicine, on a single rota covering paediatrics (see Annex Table 3). Overall there are about 176 people working on first on-call rotas and 188 on second on-call paediatric rotas. First on-call rotas are staffed by foundation year trainees, GP trainees, advanced neonatal practitioners and specialist nurse practitioners, in addition to trainees with an NTN in paediatrics in their early years of training (ST 1 and 2). The middle grade rotas are provided by higher specialist trainees (ST3 +, FTSTAs and SpRs) and by Staff Grades and clinical fellows. It is not possible to disaggregate the data available to give numbers of each staff group. There are concerns that the recruitment issues and vacancies being experienced in this specialty are having a detrimental effect on the experience and quality of training of the remaining doctors in training. PMETB surveys doctors in training across the country on their training experiences, survey results published in April 2009 showed a number of areas of concern, some of which are thought to be related to workload and covering of gaps. PMETB will visit Scottish deaneries to assess quality of all training programmes during

8 2.3 Nursing Workforce General Paediatric Nursing In autumn 2008, during the implementation phase of the Nursing & Midwifery Workload and Workforce Planning Programme, a paediatric workload tool was rolled out across the children s hospitals in Scotland and information was gathered on current staffing. This data showed that there were approximately 1,050 paediatric nursing staff working in hospital settings, and more specifically within inpatient, assessment, respite, day case and short stay areas. This did not include specialist nurses or community nursing staff. Approximately 150 WTE specialist nurses were identified, 1% of the paediatric nursing workforce. Specialist paediatric nurses work across a huge range of sub-specialities - about 30 were identified. The most commonly cited areas were diabetes, cystic fibrosis and oncology (see Annex Table 4). Only 5 specialist nurses worked at a specialist level in general paediatrics Neonatal Nursing There are 678 WTE neonatal nurses working within the neonatal units across Scotland, with the majority working at Agenda for Change Band 6. This does not include other nursing and specialist nursing posts such as community liaison, neonatal clinics, practice development or management. It is not possible from the data to identify the proportion of neonatal nurses who are working at a specialist level (excluded from the 678 wte) and are Qualified in Speciality [see below regarding qualifications and training arrangements]. There are about 35 WTE Advanced Neonatal Nurse Practitioners (5% of the total neonatal workforce). This includes 2 WTE who were in training at the time of the census. Those currently working as ANNPs work at 1 st on level but there is a view that with experience many will gain the competences required to cover the on-call work currently provided by middle grade. Such increased responsibility may not be attractive unless there is a mechanism for increased recognition through development of a career structure Physicians Assistants The group briefly considered physicians' assistants (PA s). It is possible that once this role has developed, and associated training and regulation have been instituted, that PA s may be a useful addition to the provision of paediatric services. In the short term there is some interest in whether experienced PA s might be attracted from the US or other countries to support services and help develop the role. 2.4 Paediatric Nursing Specialist Training Development of the Advanced Nursing Practitioner Role Within nursing, the role of the Specialist Nurse has emerged, often to provide specific expertise in specific fields of practice. In addition, there are also Advanced Practitioners, who are at a more senior level. As noted above, in general paediatrics the majority of nurse specialists work at the Specialist Nurse level in specific fields of practice, for example, in cystic fibrosis. A very low proportion of specialist nurses are working in general acute settings. With such a wide range of different sub-specialities each with very small numbers of specialist nurses working in that field, it is difficult to discern common themes or approaches by Boards, nor is it straightforward to identify arrangements for training for higher level of practice. There are also examples of Nurse who work at the Advanced Practice level but there are fewer in paediatrics than in other neonatal services. There is a need to ensure that appropriate education is available for these different programmes. 7

9 One course that is provided in Scotland is the two week paediatric clinical decision making course at RHSC, Edinburgh. This course is aimed at developing clinical decision making skills in nursing across the range of general medical common emergencies including clinical assessment, X-ray, blood test and ECG interpretation Advanced Neonatal Nurse Practitioner (ANNP) Training Neonatal nurses work at one of three levels: 1. Foundation - those qualified as nurses or midwives, often in their first 3 years; 2. Specialist neonatal practitioners - are 'Qualified in Specialty'. Training to this level is offered by Napier and Glasgow Caledonian Universities; 3. Advanced neonatal nurse practitioners (ANNPs) - have completed an ANNP course (one year full time). Training to this level is offered by Napier University and is a postgraduate course which can be taken as a diploma course or, with the submission of a dissertation, an MSC. Concern has been expressed that this course is not easily accessible, particularly from remote and rural areas; that it is lengthy and does not actually deliver a skills set appropriate to need. To increase the number of ANNPs, NHS Education for Scotland have been asked, and funded, by Scottish Government to lead the development of neonatal education courses in Scotland to improve access and sustainability. 2.5 Current Service Models - From Visits The group visited Raigmore, Inverness Wishaw, Lanarkshire and Forth Park, Kirkcaldy. These three units were chosen bearing in mind recent experiences in recruitment of trainees, and to seek a range of experiences, locations and services. The group would have liked to undertake further visits but had to work within time constraints. On this basis the learning from these visits is a snapshot and it is recognised that there are many other examples and experiences from across Scotland that could be used to inform this exercise. The group chose not to visit the larger children s teaching hospitals as pressures are most marked in the District General Hospital settings where there are fewer total numbers of paediatric staff General Issues and Medical Staffing Raigmore Hospital in Inverness has an estimated catchment population of about 40,200 children and young people aged 16 or less, with about 2,500 admissions and 2,500 deliveries a year. Doctors in training working in Inverness cover services on a combined general paediatric and neonatal, two tier rota. Fife has an estimated paediatric population of 34,000 with about 3,225 admissions and 3,500 deliveries a year. They run separate general paediatric and neonatal rotas, both with two tiers. Wishaw is larger with an estimated catchment population of about 65,000 and about 6,800 admissions and 4,800 deliveries a year. Again, they have separate general paediatric and neonatal rotas, both with two tiers. In all three locations staff reported pressures from vacancies in trainee rotas, difficulties in recruiting trainees to fixed-term posts (FTSTAs) and high costs from short-term locum bills. These pressures are on the middle grade or second tier of on-call rotas. The first on rotas are generally staffed by foundation doctors, General Practice ST doctors, ST1 and 2 Paediatric trainees and some advanced nurse practitioners. There are no major threats to this tier of rota at this time. All three locations were dependent on the availability of on-call doctors in training to provide out of hours cover. In addition, both NHS Lanarkshire and NHS Fife reported additional pressures working across split sites for A&E services in their area. In Highland the rural setting and long travel distances added additional challenge. 8

10 In Raigmore vacancies in trainee rotas had been covered by consultants, associate specialists and staff grades, trainees and locums in an ad hoc, unplanned way often at very short notice. Consultants reported high levels of stress and fire fighting with increased amounts of time spent on administrative tasks. They also noted a reduced availability for other activities including outpatients, training and involvement in national activities. Across all three units there was increasing awareness of the reliance on doctors in training to provide emergency receiving cover, and there was concern about service viability when vacancies appear in middle grade rotas. In addition the relationship between acute hospital and community rotas (particularly asking trainees in the community to join acute on-call rotas) and between paediatrics and other specialities (especially anaesthetics and obstetrics) were being considered. The group did not identify a working model for Hospital at Night in maternity or children s services in the DGH setting. All three units are starting to consider whether the service model needs to move towards a greater proportion of activity being delivered by career grade doctors with, for example, evening and resident overnight sessions. There was also evidence of advanced neonatal Nurse practitioners providing first on-call, sharing the 1 st on junior rota with doctors in training. However there is still some way to go to, to develop a strategy and service models that are not dependent on doctors in training. This development will be necessary as doctor in training post numbers reduce as implementation of MMC progresses General Paediatric Nursing Services NHS Fife has developed a model in which two Advanced Paediatric Nurse Practitioners work alongside the doctors in training providing assessment of acutely unwell children in an ambulatory care unit based on the paediatric ward. Both nurses are trained in clinical decision making, prescribing and can order investigations. Staff felt that both their role and responsibilities were clear and they provided an important contribution to the paediatric team. This working arrangement was well received and highly regarded by everyone the visiting group spoke with from the unit. Wishaw reported that they had nurses who were undertaking the clinical decision making course, with a view to implementing a similar assessment model to that seen in Fife, although, there was concern that this would further deplete the nursing compliment. NHS Highland had not developed advanced general paediatric nursing roles within Raigmore and there appeared to be no intention to do so. It is interesting to note that all three locations have specialist nurses working sub-speciality areas in outpatients. In the census of paediatric nursing NHS Fife reported 3 WTE specialist nurses covering diabetes, asthma and ADHD; NHS Highland reported 8.2 WTE covering cystic fibrosis, epilepsy, diabetes, oncology, child and adolescent mental health and looked after children; and NHS Lanarkshire reported 4 WTE covering diabetes, epilepsy and asthma. None of these specialist roles were noted by the acute services teams when the group visited Neonatal Nursing Services All three units had Advanced Neonatal Nurse Practitioners (ANNPs) on their teams. However, the roles and day to day activities varied between the units. In NHS Highland, the advanced neonatal nurses rotate between duties on the postnatal ward (examining newborn babies), teaching, and ward rounds in the special care unit. In addition, they provide education support to the midwives in Wick. 9

11 In NHS Fife and Lanarkshire the ANNPs participate in the first on-call rota alongside the more junior doctors in training. In both locations some were of the view that the ANNPs should be able to progress to the more senior middle grade second on-call medical rota but questioned the time it would take to achieve the appropriate level of competence and also challenges whether some nurses would wish that level of responsibility. The reasons for this included the importance of opportunities for career progression for these highly skilled clinical staff and recognition of their skills at this more senior level. Whilst the training and skills development of ANNPs better established than for Advanced Paediatric Nurse Practitioners, the need for better access to training, career structure and workforce planning for ANNPs was noted. 10

12 3. Planning - where do we want to be? The visits demonstrated some efforts to reshape the way that paediatric services are provided but did not identify a shared vision for the future of acute general paediatrics. The Group considered a number of possible options for the future provision of acute general paediatrics and neonatal services including: Increasing the number of trained doctors; Alternative ways of recruiting additional doctors in training; Rota redesign Role substitution Pathway redesign Inter-dependencies between areas of practice and service delivery. 3.1 Increased Number of Trained Doctors Scottish Government has stated its intention to increase the proportion of care that is delivered by trained doctors and will do this through the Reshaping Medical Workforce project. Planning will begin in 2009 and the project is scheduled to continue until During this period there will be higher than usual numbers of doctors gaining CCT and the aim of the project will be to capitalise on this opportunity to increase the proportion of care delivered by fully trained doctors and reduce services reliance on doctors in training. During the period of the reshaping project it is estimated that around 146 doctors will achieve CCT in medical paediatrics in Scotland. During the same period, estimates from age-group data suggest there will be in the region of 33 retirements from current consultants in the workforce. The rest of the UK will experience a similar proportion of doctors above those predicted to retire so from a workforce perspective there will be significant scope for trained doctor expansion in paediatrics over the period to The trained doctor expansion is likely to involve a mixed economy of specialty doctor and consultant posts, the proportions of which will be determined by the degree of flexibility and therefore affordability that can be achieved around consultant working. Discussions about how this will be achieved are beyond the scope of this report but delivery of 24/7 services by trained doctors will require significant shifts away from traditional models of working at consultant level. Some funding for expansion will be achieved through transfer of resource from training posts to trained workforce. In paediatrics reductions in training numbers may be less than in many other specialties as the run-through model of training to CCT is currently the only credible source of a replacement workforce for the Community Child Health service that is largely staffed by specialty doctors. Expansions in trained workforce in paediatrics will therefore encompass both hospital and community services and there may be a need to consider increased flexibility of working across that boundary. 3.2 Alternative ways of recruiting additional doctors in training Scottish Government is committed to develop workforce planning tools and methodology that allow us to estimate training numbers based on future requirement for trained doctors. Services that currently rely on doctors in training for aspects of service delivery are already experiencing difficulty in sustaining that position. That difficulty will heighten with implementation of Working Time Regulations in 2009 and as training numbers begin to reduce from

13 There will be some scope to consider alternative groups of doctors in training to replace some of the service previously delivered by paediatric trainees. There is already some interest in the Medical Training Initiative, a scheme that enables paediatricians from outside the EU to come to the UK for a time limited period of training. Such doctors will normally be competent to work at middle grade level after a suitable period of induction normally six months. This initiative may be of mutual benefit to services in Scotland, to the doctors who participate and in due course to services in their home countries but is not seen as a sustainable long term solution to Scotland s workforce issues. NHS Highland, together with NHS Grampian have a pilot programme running at the current time. General Practice training in Scotland has developed a number of four year programmes as well as the previous three year ones. There is considerable interest in increasing the proportion of programmes that can offer paediatric placements. There is also potential interest in developing some GP programmes with a special interest, where a longer period would be spent in a particular specialty such as paediatrics, allowing a GP to function at a higher level of competence in that specialty within a practice after CCT. Such trainees would probably only be able to function at junior level and are likely to need posts that are tailored towards general and community paediatrics but they will still be able to make a contribution to the paediatric workforce. It is highly likely that there will be further changes in postgraduate medical training that will allow more broad-based core programmes to develop, some of which may include paediatric placements. If such programmes do develop they will inevitably be at the junior post level and are unlikely to resolve middle grade rota concerns. 3.3 Rota Redesign All out-of-hours cover is provided through on-call rotas that are either resident or nonresident. In most services there are resident on-call rotas consisting entirely or nearly entirely of doctors in training, often at two levels offering junior and middle grade cover. As can be seen from annex 1 most middle grade rotas work with between 5 and 8 doctors. This makes achieving compliance with 48 hour average working week extremely challenging and leads to significant fragility if a single doctor goes on unexpected leave. It also has considerable impact on training quality as the proportion of time each trainee has to spend working in the acute service out of hours is maximised. Sustainable rotas that are both working time compliant and enhance training quality can only be achieved by significantly increasing the number of doctors that take part in that rota. That can be done in two ways by reducing the number of rotas overall, or increasing the numbers of staff that are able to take part in the rota. Some locations have double rotas in trainee grades (in other words a general paediatric rota and a neonatal rota). Might it therefore be possible to consider reducing the number of rotas across the country? The main driver for two separate rotas is size of the service with any Neonatal service providing level 3 cover required to have a resident middle grade tier as well as a separate Consultant rota to provide safe care and meet the recommended standards of the British Association of Perinatal Medicine. In some areas of Scotland maternity and therefore neonatal services are provided on a different site from general paediatric services making any possibility of amalgamation of rotas impractical. In most cases any possible amalgamations of rotas have already been implemented and where there is further scope, such as in Fife, there are plans in place to implement as soon as practical. 12

14 Increasing the numbers of staff available to take part in a rota without amalgamation will require a different approach to rota design. In the current model rotas are required at middle grade level because individuals at that level are competent to make treatment decisions, using telephone support from senior colleagues and only sometimes requiring their actual presence on-site. Sustainable decision making level rotas in future will need to be staffed with a mix of middle grade and senior doctors in training, specialty doctors and in most services consultant staff as well. Experienced ANNP s may in due course be able to step up to working on a decisionmaking rota in neonatal units but it is likely to be some time before there are sufficient numbers of ANNPs trained and suitably experienced to make a major contribution at this level. In North West England, paediatric services are trying to establish rota cells (the number of doctors participating in a rota) of eleven or above. Eleven doctors in a cell means that each doctor needs to contribute one 12 hour shift to the out-of-hours rota per week. With prospective cover the average weekly contribution to out of hours rises to around 15 hours leaving at least 3 full days a week for each doctor to participate in normal daytime working. Those 3 days allow better participation in training, developmental or special interest activities as part of routine working. Very few services in Scotland have numbers on rotas anywhere close to eleven and such numbers will only be achieved by adding specialty doctors and consultants, or in some cases ANNPs, to the pool available for this work. In small services a regional approach will be required. It might be attractive and reasonable for a post to involve split-site working, with daytime working including special interest sessions and developmental support at a specialist centre twinned with shift working in a peripheral DGH. Services that require resident medical cover should begin to consider as a matter of some urgency how they can develop more robust solutions to out-of hours working that reduce dependency on doctors in training. 3.4 Role Substitution Increasing the number of advanced nursing roles has the potential to improve patient care, increase multi-disciplinary working and help develop more clinically based career promotion for nursing staff. However, the group found very little evidence of strategy in developing advanced general paediatric nursing skills and there is anecdotal evidence that these roles are not always attractive to nurses. The model in NHS Fife should be considered by other units. The widespread practice of sub-specialisation in advanced paediatric nursing was not found to contribute significantly to overarching strategies in the provision of general acute paediatrics services, particularly outside specialist centres. In neonatal services, there is considerable scope to increase both the number and role of advanced neonatal nurse practitioners (ANNPs) across Scotland. Again, however, these roles must be designed as attractive career developments. Common issues to both the development of general paediatric advanced nurse roles and advanced neonatal nurse practitioners were the need: To encourage and support these general paediatric advanced nurse roles as policy Give better access to training Support independent practice and decision making as part of training and follow-on mentoring. Development of advanced clinical career pathways Find solutions to current prescribing issues 13

15 Ensure that a more senior role attracts better remuneration The potential to increase the role of advanced nurses, especially advanced generalist paediatric nurses and advanced neonatal practitioners needs to be better considered. In addition, NHS Education for Scotland has a role in developing both advanced and specialist paediatric nursing training and careers. It was recognised that advanced nurse practitioners will always need to work to a responsible consultant (medical or nursing). However, the group found that advanced nursing roles were increasingly seen as an important part of the development of multidisciplinary services and to the need to move from traditional role to more flexible approaches. 3.5 Pathway Redesign At the time of the group s visit to Raigmore, the unit had instituted a policy of transfer, where possible, of neonates under 30 weeks gestation. The underlying reason for this at the time was to manage the workload whilst there were vacancies in the middle grade rota [very premature babies can remain in patients in neonatal units for considerable lengths of time and require particularly intensive input]. However such a policy is also in line with published evidence on the positive association between specialist care in higher volume units with specialist neonatologists and better outcomes in very premature babies (most research is on babies <29 weeks). This research evidence is noted in the Scottish Government neonatal service report that was published in May 2009, which proposed that Regional Managed Clinical Networks for neonatal services be established and the development of referral pathways of care based on clinical evidence to be a key part of the MCNs remit. In developing pathways, clinical workforce issues will need to be taken into account. 3.6 Inter-dependencies It is noted that obstetrics and gynaecology who converted their entire potential locum (FTSTA) posts into substantive training posts in the first round of MMC, have a larger training cohort at present and so are not faced by the immediate and short-term concerns regarding recruitment, to the same extent as paediatrics. However, as the current bulge of trainees completes their training, O & G will face similar concerns and challenges around transition to a trained doctor provided service. Any solutions for paediatrics need to be sensitive to the need to change service models in obstetrics and gynaecology. The possible Hospital at Night type approaches were considered and we are aware that discussions have been started in several hospitals. These considerations did not identify any successfully implemented models. There are possibilities following models elsewhere in the UK for the large children s hospitals with multiple rotas and in the very small units where cross-cover arrangements could be explored. The group found that there are unlikely to be solutions for most services from Hospital at Night. 14

16 4. Conclusions The current dependence on 24/7 availability of doctors in training to provide acute paediatric services is not sustainable with changes in working hours and the likely reductions in numbers of such doctors. There is an opportunity in the next few years to capitalise on the higher than normal number of doctors likely to achieve CCT to change this. The working group s concludes that NHS Scotland needs to develop strategies to ensure an increased proportion of clinical activity is delivered by trained paediatricians. There is also a need to maximise the potential contribution that can be made by other healthcare professionals developing a multidisciplinary team approach to service delivery. Paediatricians need to engage with this process and identify ways in which children s needs can be met by designing a trained doctor service with the flexibility to withstand fluctuations due to periods of leave and peaks of activity. This will include the need for more flexible arrangements across the working week and increased trained doctor activity outside office hours. In particular, the group concluded that services that require resident medical cover at a decision-making level will only be able to do so in a sustainable way by expanding rotas to include specialty doctors and consultants working to different job plans than are currently regarded as the norm. CEL 28(2009) Guidance on projecting future medical requirements within clinical workforce requires Health Boards to begin a process of developing trained doctor provided service models for Scotland. It is essential that paediatric services embrace this opportunity to develop sustainable workforce solutions that enhance care and improve training quality. In addition to moving to a trained doctors provided service, there is considerable scope to develop advanced paediatric nursing. Increasing accessible training and career opportunities in advanced clinical nursing roles has the potential to benefit both the nursing staff involved and the children needing care in addition to making a contribution to changing service models away from dependence on trainees. In developing such models it is important that the benefits of a different approach are recognised and emphasised. Advanced roles for other professionals should be designed to fulfil their potential contribution to care, not to substitute for doctors in training. There is an urgent need to develop training and structured careers in advanced clinical nursing practice in paediatrics in Scotland, in general paediatrics and also in neonatology. Paediatric services in Scotland need to change to survive. There are opportunities in the next few years to ensure they change in a way that will deliver improved care in a model that will be sustainable for the longer term. 15

17 Membership of short life working group Scottish Government Health Directorate Dr Mags Maguire, Acting Chief Nursing Officer Dr Louise Smith (acknowledge role in chairing and initial draft of report), Senior Medical Officer Dr Alastair Cook, Senior Medical Officer Mrs Kerry Chalmers, Team Leader Regional Workforce Directors Mrs Patricia Leiser, West of Scotland Dr Annie Ingram, North of Scotland Mr Derek Phillips, South East Scotland NHS Education for Scotland Dr Fiona Drimmie, Chair, Specialty Training Board Royal College of Paediatrics and Child Health Dr Jim Beattie, Scottish Officer Dr Kate Mackay, Regional Representative, West of Scotland 16

18 ANNEX Table 1: General Paediatrics: Current Service Activity Board Hospital Estimated catchment population* In patient, and day case discharges 2006/07 (medical paediatrics and 'other medical') Number planned new outpatients ( <16 medical and 'other medical') SEAT Lothian RHSC Edinburgh 111,563 8,655 7,433 St. John's, 38,790 3,038 1,239 Livingston Borders Borders General 17, Hospital Fife Victoria Hospital 34,017 3,223 3,841 Tayside Ninewells Hospital 82,112 6,659 3,680 West GG&C Royal Alexandra 42,824 3,597 1,761 Hospital RHSC, Glasgow 165,900 10,761 9,929 Glasgow other 452 3,327 Lanarkshire Wishaw 64,543 6,811 3,353 Ayrshire Crosshouse 73,408 4,637 2,439 Hospital Forth Valley Stirling Royal 42,767 3,497 2,248 Infirmary D&G Dumfries and 21,418 1,113 1,044 Galloway North Grampian Aberdeen 69,975 4,621 6,005 Children's Hospital Dr. Gray's Hospital 15,558 1, Highland Raigmore Hospital 40,235 2,452 2,312 Islands 2, Scotland 823,523 61,661 50,860 17

19 Table 2: Neonatal units current service activity Unit Births 2006 NNU admissions 2004 Dedicated cons. rota Dedicated 'middle grade' rota No. middle grade posts 2008 Neonatal nurses funded WTE ANNPs WTE SEAT Edinburgh Y Y 7 97 (1.0 training) St. John's, Livingston Borders General Hospital N N N N Forth Park, Fife N Y (+1.0 training) Ninewells Hospital Y Y West Royal Alexandra Hospital Southern General Hospital The Queen Mother's Hospital Princess Royal Maternity Hospital Wishaw General Hospital Ayrshire Central and Maternity Hospital Stirling Royal Infirmary Y Y/N (hybrid) Y Y Y Y Y Y Y Y N Y N N Dumfries and Galloway Royal Infirmary N N (+1.0 on secondment) North Aberdeen Maternity Hospital Y Y Gilbert Bain Memorial Hospital 151 Dr. Gray's Hospital 971 N N Raigmore Hospital N N 27 2 Islands 576 Scotland 53,

20 Table 3: Trainee rotas Region Hospital Rota type 1st on call No. of staff 2nd on call No. of staff North Raigmore Mixed 5 5 Aberdeen General Paeds 9 8 Aberdeen Maternity Neonatal 9 5 Dr Grays Mixed 10* 7* Ninewells General Paeds 7 7 Neonatal 7 6 South East Fife, Victoria General Paeds 7 6 Fife, Forth Park Neonatal 7 6 RHSC, Edinburgh General Paeds 12 9 Specialty rota 12 Edinburgh Simpsons Neonatal 6 5 St John's Mixed 4 1 Borders Mixed 7 7 West Wishaw General Paeds 7 5 Neonatal 7 4 Stirling Mixed 7 7 Princess Royal Neonatal 6 6 Southern General Neonatal 7 5 Queen Mothers Hospital Neonatal 8 6 Yorkhill, Glasgow General Paeds PICU 8 3 Paeds A&E 9 8 Cardiology. 5 Haematology 4 Royal Alexandra, Mixed Paisley 8 9 Crosshouse General Paeds 7 5 Neonatal 6 5 Dumfries Mixed 5 2 Total *Not dedicated to paediatric service 19

21 Table 4: Specialist paediatric nurses in Scotland Specialist Nurse Title Total WTE Specialist Nurse Title Total WTE Diabetes 24.5 Child and Family Psychiatry 1.2 Cystic Fibrosis 11.2 Burns Nurse Specialist 1 Oncology Clinical Educator 1 Epilepsy 8 Looked after Children 1 Community 5.75 Nurse Consultant for Children and 1 Families Home Ventilation 5 Renal Nurse Educator 1 Asthma 4 Research Nurse 1 Continence 4 Stoma Nurse Specialist 1 Cardiac Liaison Nurse 3.1 ADHD 1 Rheumatology 3.1 Home Parental Nutrition 1 Child Development 3 IBD 1 Complex Health Needs 3 Medical Neurology 1 Nutrition 3 Bone Marrow Transplant 1 Pain 3 Haemophilia 1 Respiratory 2.2 Complex Airways 1 Dermatology 2.02 Young People 1 Medical Advanced Nurse Practitioner 2 Stoma 1 Renal Nurse Specialist 2 Neurosurgical 1 Senior Paediatric Research Nurse 2 Gastroenterology 1 UTI Nurse Specialist 2 Spinal 1 Looked After and Accommodated 2 Discharge Liaison 1 Learning Disability 2 Endocrine/Growth 0.9 Medical 2 Diabetes Epilepsy 0.89 Haematology 2 Paediatric Asthma Specialist Nurse 0.8 Pre-admission 2 Growth & Endocrine 0.8 Palliative Care 2 Gastronomy 0.8 Cleft nurse Specialist 2 Growth 0.8 Renal 1.64 Diabetes 0.6 Tissue Viability 1.55 Urology 0.56 Endocrine 1.5 Constipation 0.26 Grand Total