Introduction

Many United Kingdom National Health Service (NHS) Trusts have recently experienced considerable difficulties filling paediatric trainee posts leaving rotas, especially at middle grade level, understaffed. This is due to the uncertainty of International Medical Graduates’ regarding the application process and the annual instead of staggered recruitment introduced as part of Modernising Medical Careers (MMC). These problems have been exacerbated by fewer experienced paediatricians available to fill the training posts created by the Hutton review 2003 - 2005. This review encouraged an increase in training posts to enable compliance with the European Working Time Directive (EWTD) which limits the working week to 48 hours in August 2009.

A British Medical Association (BMA) survey in mid March 2008 revealed that 29.2% of respondents (across all grades of Junior Doctor) reported there were gaps in their current rota¹. This survey was not specialty specific and had a response rate of 16%.

At the 2008 Spring Meeting of the Royal College of Paediatrics and Child Health (RCPCH) trainees expressed concerns that the gaps in rotas and subsequent lack of staff were causing problems with training and patient safety. In order to quantify these problems the Trainees Committee conducted an online survey of paediatric trainees.

Aim

To quantify the extent of shortfalls in paediatric rotas and assess the impact this was having on training and clinical practice.

Methods

Trainee paediatricians in the English, Scottish, Northern Irish and Welsh deaneries whose e-mail addresses were available to the members of the Trainees Committee were sent an e-mail containing the website of an online survey via QuestionPro^TM, a specialist survey tool. QuestionPro^TM enabled real-time viewing of the results in a confidential manner. The survey began collecting data on 5th May 2008 with trainees asked to relate their answers to the week of 5^th-9^th May 2008 to ensure uniformity between respondents. The full content of this survey designed by the Trainees Committee of the RCPCH is available on request.

Results

547 trainees commenced the survey with 471 completed forms. The results by deanery and training grade can be found in table one. 336 respondents were at ST4 or SpR 1 and above representing 22.7% (336/1477²) of level 2 and level 3 trainees.

Figure 1

Table One – Deanery and Year of Training of Respondents

The paucity of responses from London and Northern deaneries represented difficulties in e-mailing trainees in those regions.

Over 50% of trainees (280/495) replied that there were gaps on their current rota with 10% of respondents stating the rota was more than three doctors short (table two)

Figure 2

Table Two – Number of persons short on rota

The reasons for the shortfall in the rota and reasons for the failure to replace those gaps are shown in table three. These represent the trainees’ views and not necessarily the actual difficulty encountered by the hospital or Trust in question. Multiple responses were allowed to answer the question ‘why is there a shortfall on the rota’ therefore the total number of respondents is higher than the number reporting an actual shortfall.

Figure 3

Table Three – reasons given for shortfall in rota and for no replacement

Table four shows responses to questions on the effects on having gaps in the rota caused by failure to replace substantive posts and also failure to obtain locums. 354 trainees (75%) responded that Trusts had difficulty obtaining locums With regards to gaps created by failures to replace a substantive appointment over a third of trainees (162/471) reported they had been required to work more hours than they were banded for and over 20% felt the working environment was unsafe. Training opportunities such as clinic exposure were noted to be reduced by a third of trainees.

Figure 4

Table Four – effects of gaps in the rota

Open text comments from trainees can be grouped into four main categories.

Detrimental effect on daytime work:

Fewer educational opportunities:

Problems with recruitment and locum provision:

Emotional wellbeing:

Discussion

Although the overall response rate was low and those replying may represent the most disaffected trainees the raw numbers indicate this is a problem of significance. There are 3 major issues which have arisen from this survey:

1. Paediatric training due to staffing and service issues has been severely compromised

2. The provision of service by trainees is potentially in breach of EWTD regulations

3. The additional provision of service with a limitation in training potentially compromises patient safety

Over half of all paediatric trainees reported there were gaps in their current rota. Solutions to this problem are not immediately obvious and simply increasing the numbers of junior paediatric doctors is not the answer. Workforce planning, the role of IMGs and consultant expansion needs to be taken into consideration. However, a strategy is needed as in August 2009 the European Working Time Directive reduces the working week to 48 hours and it is almost certain training opportunities will be reduced further³. The frequency of trainees required to work above their current pay bandings and the sizeable percentage of trainees reporting concerns with safety across multiple deaneries indicates the problem is a national one. It is not possible to identify individual Trusts from the online responses and therefore responses may only be coming from trainees from the most affected Trusts in each particular deanery. Even if this is the case, and the number of responses per deanery makes this unlikely, a sizeable percentage of the paediatric workforce is affected. It is noteworthy a significant number of trainees didn’t know the reasons for gaps in their rotas or why they gaps had not been filled. This may represent a failure of communication to trainees regarding rotas and requires further investigation.

The RCPCH have taken this situation seriously and have recently published a document advising trusts on how to deal with these issues⁴.Six themes to address the problems were discussed:

1. Increase training opportunities for junior (level one) paediatric trainees

2. Develop level one training programmes for international medical graduates

3. Develop an excess of level one training programmes

4. The Australian model (intentionally contracting those on rotas to work one or two more shifts a month to cover gaps)

5. Reducing middle grade rotas via role substitution

6. Reconfiguration of services i.e. amalgamation of units

The effect on clinical competencies, doctors assessments, clinical errors and job satisfaction are more objective measures of the effects of recruitment shortages but they are difficult to ascertain. The RCPCH recognise there is going to be no easy short term solution however if the issues highlighted by the survey cannot be addressed albeit by even short term measures, it would be reasonable to presume a deterioration in these more robust outcome measures will be seen.