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Compared with 17 other high-income countries since 1970, the UK has failed to match the equivalent reduction in deaths among children and young adults.1 Two further reports have recently commented on the unsatisfactory child mortality rates in the UK.2 ,3 These reports highlight the contribution of injury and mental health to death statistics and the importance of accurate recognition of the signs of acute, serious illness. Since around five million children require emergency or urgent care each year in the UK, and children form 25% of emergency department (ED) attendances, the issues highlighted in these reports are core business for EDs.
Provision of emergency care has been a high-profile issue for British healthcare, the UK Government and the media for a number of years, yet there remains considerable variation in service provision between hospitals. Set against this, most governments of developed countries, including ours, aim to reduce health inequalities. While the NHS Centre for Workforce Intelligence has a remit to project the UK's requirements for the future healthcare workforce, and Health Education England was set up with the remit of training the right staff to match the population's requirements for healthcare, getting more paediatric emergency medicine (PEM) specialists, in the right geographical distribution, is difficult when employment of staff is largely determined by local factors.
We must remember that children form 25% of ED attendances. By the late 1990s, EDs started to provide child patients with designated space and staff, in line with national guidelines first published in 1999.4 These state that all EDs seeing more than 16 000 children per year should have a PEM-trained consultant. UK-wide, this translates to around 50% of EDs. UK EDs are generally larger than most international EDs, and so, this is a reasonable ambition. By the early 2000s, PEM was recognised as a subspeciality of either emergency medicine (EM) or paediatric specialist certification. Stand-alone children's hospital EDs and the largest centres now have PEM consultants and advanced nurse practitioners, and they train doctors and nurses who go on to become champions of child-centred care in other departments. This is all welcome news, but as a child would ask, are we there yet?
At the end of 2013, the Royal College of Emergency Medicine undertook a census of practising PEM consultants achieving a 100% return rate, with assistance from the Royal College of Paediatrics and Child Health. The information was collected to inform workforce planning and to allow international comparisons. Subspeciality PEM recognition on the specialist register is available to both paediatric and EM doctors in training. The census counted consultants from both specialist backgrounds, including older consultants without official subspeciality status.
At that time, there were 222 practising PEM consultants in the UK, with an almost 50:50 male-to-female split. This is a 10-fold increase within a decade. Two-thirds had their base specialist certificate in EM and one-third in paediatrics. The majority of job plans worked in day-to-day practice were a mixture of adult and paediatric emergency work, reflecting the base-speciality bias of EM. Both Australasia and the USA have around double the number of PEM consultants per capita. In Australasia, there is a 50:50 split of base speciality, while in the USA, 89% of consultants are from a paediatric background (personal communication).
Most strikingly, the data confirmed the wide geographical variation of provision of PEM specialist consultant posts in the UK, with a 12-fold variation between 0.45 consultant per million population at the lowest and six consultants per million in London (figure 1). This new information emphasises the gap between the aim of national policy to reduce geographical healthcare inequalities for children and young people, and the actual provision of emergency care personnel.4
Number of paediatric emergency medicine consultants per million population in each region. HE, Health Education; KSS, Kent, Surrey, Sussex; Ire, Ireland.
For context, data from the General Medical Council regarding regional variations for doctors (all specialities) was sought, and while not directly comparable due to slight differences in regional boundaries, the trend for higher number of doctors for the London population was seen, but other regional variation was less than for PEM (figure 2). Even in regions with higher numbers of consultants, these were clustered in one or two hospitals. Inevitably, these include the stand-alone children's hospitals and larger mixed (adult and paediatric) departments.
Number of qualified doctors per region in the UK (General Medical Council data).
The national standards of care for children in emergency care settings in the UK5 state that all EDs seeing more than 16 000 children per year should have a PEM-trained consultant. UK-wide, this translates to around 50% of EDs. While the clustering seen in the data allows for development of the speciality, and drives research and training, which is welcome, it leaves many large EDs currently with no PEM-trained consultant.
Does PEM consultant provision really act as a surrogate marker of investment in good paediatric emergency care? Only one relevant study exists,6 which focused on hospital admission rates, and showed that the presence of PEM-trained consultants decreased hospital admissions by 27%. Consultant provision, however, probably reflects the value that locality places on high-quality paediatric emergency care, and it is commonly seen that appointment of consultants is usually followed by skilling-up of junior doctors and nursing staff, and improvement in facilities. Emergency physicians have core training in paediatric skills, and provide a good level of care to children, but PEM specialists are more likely to improve paediatric skills in the whole medical and nursing team, and liaise closer with paediatric inpatient and community services.
ED work is very much team-based, with consultants providing leadership. How then might the difficulties experienced by smaller or more rural EDs, or those without paediatric cover, be overcome? Other solutions have been successfully implemented. These include employing paediatric advanced nurse practitioners (PANPs) to improve the skill mix. Also, in small departments, a good standard of paediatric emergency care can be provided by a lead consultant who is not PEM certified, top-up training can be given to middle-grade doctors, PANPs can be employed and liaison acute paediatric consultants can work in the ED. In fact, with a constant stream of doctors finishing training with full PEM certification, perhaps even small EDs in the future should proactively seek a PEM consultant rather than be held back by the traditional view that PEM consultants will only work in larger centres.
The Royal Colleges in the UK serve to train doctors of the future, and, therefore, have a role in creating the staff base for the future. Both colleges promote PEM as a career, and the Royal College of Emergency Medicine has had a good success rate in generating PEM-trained consultants. Too few paediatricians are being attracted to the speciality, possibly due to low exposure in early training or the negative press currently associated with EM. There are early signs of improvement in filling training posts with a concerted effort of some regions to rotate more junior paediatricians through the ED, and regional careers events about PEM. Consultant posts for paediatricians are increasingly available as ED size increases, and, therefore, a non-participant in the EM consultant on-call rota has less impact. Consultant paediatricians with PEM training can also provide a general practitioner hotline service and rapid access clinic, as recommended by a recent report.7
The national minimum staffing recommendations were set down because 25% of ED patients are children. Reducing the wide variation in provision of expertise for these children requires coordination and planning within a joined-up NHS workforce strategy, which has influence over local commissioners and providers to translate policy into practice in EDs. Given the UK's child mortality rates, we should aspire to having the same number of PEM-trained consultants per head of child population as other similar countries. It is very much to be hoped that a positive recruitment drive over the next few years will be successful with support from Royal Colleges of Emergency Medicine and of Paediatrics and Child Health.
Acknowledgments
David Greening helped the authors amalgamate the data.
Footnotes
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
Data sharing statement There are unpublished data related to each hospital and each region. Anonymised data are available from the Royal College on request, via the authors.