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Introduction

This report focuses on a key section of the paediatric workforce: Specialty, Associate Specialist and Staff Grade doctors (SAS doctors) working in child health. This report is part of a series using RCPCH workforce census 2017 data to highlight key areas of the paediatric workforce, including an Overview Report1 and reports on the workforce in Scotland2  and in Wales. Further reports will focus on Northern Ireland, safeguarding provision and the workforce in the paediatric specialties.

This report makes recommendations specific to SAS doctors in the following broad areas at both national and local level:

1. Plan the child health workforce at the national level
2. Plan the child health workforce at the local level
3. Incentivise and retain the paediatric workforce
4. Recruit and train more paediatricians

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 which 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

Executive summary

Context

SAS doctors are a significant and important part of the paediatric workforce and have important roles in general paediatrics and community child health. This report is concerned primarily with Specialty, Associate Specialist and Staff Grade doctors in paediatrics, i.e. non-consultant, non-training doctors that have at least four years of postgraduate training, two of those years in a relevant specialty, and who are generally employed on national terms and conditions. These doctors are distinct from Trust grade doctors or locally employed doctors (LEDs) who may have less postgraduate training and are usually employed on local terms and conditions. 

The number of SAS doctors in paediatrics has fallen significantly over the last 10-20 years. The RCPCH census reports that there were 778 headcount SAS doctors in the UK in 2017, almost half the number there were in 2001. However, during this time, the number of Trust doctors and LEDs has risen to around the same number of SAS doctors. Therefore, although the total number of Trust grade plus SAS doctors has remained the similar over this time, the experience, competencies and stability of this workforce group has declined.

This trend has led to a change in the perception of the skills of SAS grade doctors. They possess different levels of skills which are suitable to support rotas at various tiers. This can cause confusion to employers, departmental staff and patients. Patients and public are often only aware of consultants and junior doctors in training, and unaware of experienced senior doctors who may or may not be working independently. Career development opportunities and recognition of skills and needs are predominantly determined by local factors and are not uniform across healthcare settings. 

RCPCH welcomes the 2019 report from Health Education England (HEE) and NHS Improvement “Maximising the Potential”3 which offers guidance to recognise and support SAS doctors. The report focuses on England, but RCPCH believes the principles and commitments within are applicable across the whole of the UK. Indeed, SAS doctors numerically represent a greater proportion of the non-training paediatric workforce in Scotland, Wales and Northern Ireland compared to England.

SAS doctors cannot be considered in isolation as they form a significant part of a paediatric medical workforce which is under increasing pressure. Recruitment shortfalls and vacancies due to attrition and out of programme activity are putting both the general and neonatal rotas at all tiers under immense strain. Demand is also increasing, particularly in terms of emergency admissions and referrals for conditions covering emotional health, mental health and complex developmental disorders such as autism. We have documented with the British Association for Community Child Health (BACCH)4 the need for considerable growth in the community workforce, where SAS doctors have historically taken on statutory and important roles and acted as independent practitioners (ie without consultant oversight). This report shows that, on average, at least one SAS doctor takes part in every tier 2 (middle grade) general paediatric or general/neonatal combined rota in the UK and that SAS doctors comprise 38% of the non-training doctors in community child health with 13.1% of lead roles filled by SAS doctors. SAS doctors are therefore an essential part of the solution to the workforce numbers problems and by implication a key to improving services and outcomes for children and young people.

Concerns surrounding the SAS workforce

RCPCH census data clearly show that the SAS doctors in paediatrics are decreasing in number and increasing in age. This appears to run contrary to the national trend for other specialties, as the British Medical Association (BMA) stated in 2014 that “in recent years an increasing number of doctors have chosen to become SAS doctors rather than enter higher specialist training”5 . The SAS doctors tend to work less than full time more than other staff groups. Employers, and sometimes even consultants, can see a SAS doctor’s role is to fill service gaps, rather than helping them develop a meaningful career structure. The lack of provision of minimum number of sessions for supporting professional activities can limit professional development and many SAS doctors report difficulties in accessing training and educational opportunities. These limitations can undermine the workforce and reduce morale.

Since the introduction of the Specialist Doctor grade in 20086 and the moratorium on creating new Associate Specialist Grade posts, career prospects in terms of pay and reward have diminished. Although SAS doctors in paediatrics are included in the National Shortage Occupation List throughout the UK7 , it is not perceived as an attractive career path either by overseas doctors or for those who may not wish to continue in the training scheme. This has resulted in the census reporting SAS doctor vacancy rates at higher levels than those for consultants.

Paediatrics needs staff at all levels; it is unlikely that a single medical model of trainees and consultants will continue to be viable in the future because there is a clear reluctance amongst national planning bodies to increase training numbers to meet evidence of growing demand. Although an increase of 1,500 medical student numbers was announced in 2017 to start in September 20188 , this does little more than stem the decline in the numbers of medical students observed in the UK since 20129 .

Workforce planners and the medical specialties need to embrace the prospect of a more plural workforce while recognising this cannot be achieved at a bargain rate. Excellent work is already being undertaken to develop Advance Clinical Practitioners in paediatrics10 and some Integrated Care Systems, Trust and Health Boards are looking at how to utilise Physician Associates; models from abroad, particularly the USA11 offer inspiration in this respect. It is vital that this important and essential workforce is equally supported.

What the RCPCH offers 

We provide the following to RCPCH members who are SAS doctors:

• Careers advice for those wishing to pursue a SAS career
• Guidance for SAS doctors considering entering or re-entering the paediatric training programme, including information on accessing the national grid for sub-specialty training in paediatrics
• Guidance about the MRCPCH and DCH (Diploma of Child Health) exams
• Guidance on applying for entry to paediatric specialist register either in paediatrics or a sub-specialty of paediatrics through the CESR (Certificate of Eligibility of Specialist Registration) routes
• Access to workplace-based assessments and e-Portfolio accounts to support demonstration of competencies of the paediatric training curriculum, for example for use for CESR applications, if considering entry/re-entry to the paediatric training programme opportunities to get involved as a College Tutor so you can support doctors in your organisation
• Access to a range of educational courses, events and eLearning
• Access to mentoring standards and information about endorsed mentoring schemes across the UK
• Access to the RCPCH CPD diary account to record continuing professional development (CPD) activities (although non-member option is available)
• Access to revalidation advice and guidance
• Access to paediatric parent and carer feedback tool for revalidation

Further, we have taken the following actions over recent years:

• Supported the re-introduction of AS grade on discussions at the Academy of Medical Royal Colleges including ensuring the reinvigoration of professional development for SAS doctors.
• Supported the SAS doctor committee at RCPCH and a SAS doctor meeting at the RCPCH annual conference.
• We are trying to recruit more SAS doctors as members of the RCPCH as presently only around 60% of UK SAS doctors are RCPCH members. 
• Ensuring that the RCPCH Shape of Training model makes provision for SAS doctors to be able to re-enter training.  
• We have successfully lobbied for changes in immigration rules regarding the shortage occupation list and will continue to ensure obstacles are minimised in regard to attracting good quality doctors to the UK while recognising the need to raid low resource countries of their essential medical workforce.
• We will ensure educational supervisor training includes content on how to support SAS doctors. 

Recommendations 

Plan the child health workforce at the national level 

• HEE (Health Education England), HEIW (Health Education and Improvement Wales), Scottish Government, the Department of Health (NI) and other organisations need to include SAS doctors in their workforce planning, and particularly recognise their role when they work at consultant level of responsibility or equivalent to senior trainees.
• The shared commitments and guidance to support SAS doctors set out in Maximising the Potential3 published by NHSI and HEE should be incorporated and implemented in the NHS Long Term Plan in England, and the equivalent child health workforce planning strategies in Scotland, Wales and Northern Ireland.
• The Department of Health should re-introduce the Associate Specialist grade so that career options and pathways are enhanced, as called for by the Academy of Medical Royal Colleges. The NHS Long Term Plan for England published on 8 January 201912  contained a commitment to create a new associate specialist or equivalent grade and this must be implemented.
• The General Medical Council survey of SAS doctors planned for 2019 should include questions to the employers of SAS doctors. This will help identify areas of good practice.

Plan the child health workforce at the local level

• Employers must implement the charter for Staff and Associate Specialist doctors as published by the BMA (2014), and the equivalent charters in the other UK countries.
• Employers must ensure SAS doctor involvement in developing local services to include training and supervising trainees and other staff. Employers and directorates need to maximise the potential of all their workforce.
• Employers and local systems to develop a path for SAS doctors with career potential and where training and development resources and time are readily available.
• Encourage a plural and more sustainable workforce by employing doctors at different stages of their career and non-medical child health staff who can add greater continuity to service delivery for patients.

Incentivise and retain the paediatric workforce

• HEE/NHS Employers need to audit the Charter for SAS doctors. This will identify where it has not been well implemented and promote action in those areas. This audit could include work to determine if SAS doctors are represented proportionately in Local Negotiating Committees (BMA and NHS Employers), that they have the same access to CPD as consultants, that coding of patients and work activity is done under SAS doctors’ name and that they have access to a tutor and are involved in recruitment of other SAS doctors.
• NHS Employers and the BMA must ensure the implementation of the minimum number of supporting professional activities (SPAs) in the SAS doctor contract in order that there is increased scope to develop educational supervision, management and research skills. This is an investment to aid the development of this group of doctors, reduce the burden on consultants and make becoming a SAS doctor a more attractive career option. Good practice guidance in Wales advocates 20% of time for SPAs for all SAS doctors13 . Medical Directors and Clinical Directors need to recognise the potential of SAS doctors by broadening out their role. Include the potential of SAS doctors in team job planning.
• Employers should employ SAS doctors where possible in preference to trust doctors thus increasing the quality of the team. They also need to make jobs more attractive, and not see them as just to support failing rotas. 

Recruit and train more paediatricians 

• Employers and professional bodies must respect doctors’ career choices whether they pursue a training or non-training route.
• Employers must commit to and provide opportunities and support for SAS doctors to develop special interests, so they can work as independent practitioners in the future.
• National and local workforce planners, employers and professional bodies must take these recommendations forward in order to increase the whole-time equivalent number of SAS doctors by approximately one-third to 860.7 WTE.

• 1Royal College of Paediatrics and Child Health, 2017 workforce census overview. 2019.
• 2Royal College of Paediatrics and Child Health, 2017 workforce census: focus on Scotland. 2019.
• 3 a b Health Education England and NHS Improvement, Maximising the Potential: essential measures to support SAS doctors. 2019. https://www.hee.nhs.uk/our-work/supporting-sas-doctors
• 4Royal College of Paediatrics and Child Health and British Association for Community Child Health, Covering all bases - Community Child Health: A paediatric workforce guide. 2017. www.rcpch.ac.uk/resources/state-child-health-short-report-series-community-paediatric-workforce
• 5British Medical Association, A charter for staff and associate specialist and specialty doctors. 2014.
• 6British Medical Association, Introduction of the 2008 contract. 2012.
• 7Home Office, Immigration Rules Appendix K - Shortage Occupation List. 2016.
• 8Department of Health and Social Care, 1,500 extra medical undergraduate places confirmed. 2017.
• 9General Medical Council, Reference tables – medical students, in The state of medical education and practice in the UK: 2018. 2018.
• 10Improving Me. Advanced Paediatric Nurse Practitioners (APNPs). 2019; Available from:
• 11DeWolfe C, et al., Patient Outcomes in a Pediatric Hospital Medicine Service Staffed With Physicians and Advanced Practice Providers. Hospital Paediatrics, 2019. 9(2).
• 12NHS, The NHS Long Term Plan. 2019.
• 13Welsh Assembly Government, Staff Grades and Associate Specialists Group (SAS): Wales Good Practice Guide. 2018.