Paediatric Cardiology - CfWI Medical Fact Sheet and Summary Sheet 2013 August 2011

Paediatric Cardiology

This summary sheet contains recommendations

informed by the facts collated by the CfWI in close

collaboration with specialty stakeholders. The

references in this summary sheet refer to the

reference section at the end of the fact sheet for

this specialty, available at http://www.cfwi.org.uk/.

http://www.cfwi.org.uk/

Medical Specialty Workforce Summary Sheet Paediatric Cardiology

CfWI | August 2011 1

Specialty group: Paediatric

Specialty: Paediatric Cardiology

Recommendation

The CfWI recommends that no change is made to either the number

of training posts or the current geographical distribution of training

places over the next three years.

Although no geographical changes are recommended, there is

evidence of geographical inequality which may need addressing.

Work should continue to improve the attractiveness of the specialty.

There remain significant recruitment issues in this specialty and the

CfWI recommends a deep review in 2012 with a further review of

progress against these recommendations in 2013.

Introduction

The purpose of this document is to make recommendations relating to medical training

numbers in Paediatric Cardiology in England over the next three years. When formulating a

recommendation, the CfWI considered factors including demography, lifestyle issues and the

views of stakeholders.

Key issues affecting the service are:

Several service model options for surgical centres have been proposed, which vary

in number and location (NHS Specialised Services, 2010). These may or may not

have an effect upon workforce plans in the specialty.

It has been proposed that the curriculum be formally extended to five years of

training. Previously an optional one or two years in addition to mandatory training

of three years was required (JRCPTB, 2010). Discussion on this continues.

The Department of Health (DH) report from the Paediatric and Congenital Cardiac

Services Review Group recommended two consultants in Paediatric Cardiology per

million population (DH 2003). Based on the Office for National Statistics (ONS)

population statistics for England in 2010 (ONS, 2010), this generates a need of 104

consultants.

Key findings

According to the NHS Information Centre Census for Health and Social Care (IC) there are 77

members of staff (75 full time equivalent), of which there are 59 males (59 per cent).



This is a relatively small specialty.

Data taken from the IC census indicates that the workforce has a significant proportion of staff

working in the 50-to-54 age bracket, and that there is a plentiful supply of younger members

of staff.

College /specialty

views

At the time of publication, the CfWI fact sheet on the Paediatric Cardiology

workforce, which has been used to form this recommendation, has not

been confirmed by clinical representatives of the specialty.

Figure 1 shows cumulative, historical full-time equivalent (FTE) workforce supply and future

consultant supply in 2010.

Figure 1: Historical workforce supply (FTE) and future consultant supply and estimation of the number of filled posts for

service delivery – Paediatric Cardiology

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Cumulative historical workforce supply (FTE) and future consultant supply &

estimation of the number of future filled posts for service delivery - Paediatric

Cardiology

Consultants (FTE) Historic Supply

Specialty Trainees

Staff, Specialty and Associate Specialist Grade (SSASG) Doctors

Consultants (FTE) CfWI Supply Forecast

Royal College estimation of the number of filled consultant posts to deliver service with forecast based on pop growth only

Estimation of future number of consultant posts to deliver service due to population growth only (0.5% for 0 -59 yr olds)



The charts show that the consultant workforce expanded by 82.9 per cent (considering FTE)

from that of five years ago, based on the IC census (NHS IC, 2011a). The trend is reflected by

middle-grade medical staff together with trainees (which are defined as those in the senior

house officer and registrar groups).

This supply forecast model suggests that the supply of consultants is forecast to increase to

112 FTE in 2020 (114 headcount) an FTE increase of 49.3 per cent.

This is a small specialty. There is a large centre for cardiac care in London.

Recommendation

The CfWI recommends that no change is made to either the number of training posts or the

current geographical distribution of training places over the next three years. The CfWI

forecasts that the numbers of consultants will meet the current (2011) estimation of demand

for the year 2011 in the year 2020.

In the long term, there is potential for a bulge in retirements over a relatively short period of

time when members of the current 50-to-54 age bracket approach retirement age.

A key risk to the workforce is that while there is uncertainty surrounding the length of

training, workforce planning is especially challenging, as the length of the pipeline of supply

remains unclear. This may affect groups including employers and workforce planners in the

short, medium and long term.

It has recently been proposed that the specialty training pathway should be extended to five

years of training for all trainees. In the past, it was possible for a trainee to undertake a three-

year course, with the option of extending their training in a special interest over an additional

one or two years. Any move to a formally extended length of training in order to attain CCT for

all trainees may have an effect on supply.

A key risk in this recommendation is that it is automatically adopted for longer than it is

intended to be valid. Because the specialty is small, workforce planning is important in order to

enable adequate levels of supply.

The CfWI recommends a deep review of this specialty in 2012 and a further review of progress

against these recommendations in 2013.


MEDICAL SPECIALTY WORKFORCE FACT SHEET

PAEDIATRIC CARDIOLOGY

This fact sheet considers the factors influencing the future demands of the specialty (section 1) and the current and forecast workforce supply

(section 2). This information forms part of the body of evidence used to advise recommendations on future medical training numbers. Conclusions

and recommendations are in the accompanying summary sheet. The Centre for Workforce Intelligence (CfWI) welcomes contributions to both the

content and interpretations of this information. This fact sheet covers the following:

Section 1 - Considerations for future demand

Current training route

Specialty viewpoints

Policy drivers

Demographics

Health and lifestyle

Changes in practice

Changes in activity

Section 2 – Current and forecast supply

Existing workforce

Recruitment

Consultant projections

Medical Specialty Workforce Fact Sheet Paediatric Cardiology


CONSIDERATIONS FOR FUTURE DEMAND

Current training route

Higher specialty training in Paediatric Cardiology commences at ST3, after the trainee has completed either Core Medical Training (CMT) or Acute

Care Common Stem (ACCS) themed under Acute Medicine or basic paediatric specialty training.

Specialty viewpoints1

The Royal College of Physicians (RCP) Consultant Physicians Working for Patients does not identify an optimum size for the Paediatric Cardiology

workforce (RCP, 2008). However, the report does identify that this specialty will work in ‘supra-regional’ cardiology units.

The NHS Specialised Services (SS) 2010 document Overview of safe and sustainable review of paediatric cardiac surgery services in England

reports that there is to be an overview of services (NHS SS, 2010). The review will assess whether service could be improved by reconfiguration, for

example by concentrating surgical expertise into fewer, larger specialist centres. This will determine where centres will be, and therefore will

impact on the Paediatric Cardiology workforce demand, since paediatric cardiologists care for patients post-surgery. Consultation for the review is

open until July 2011.

1 The CfWI conducted a series of stakeholder engagement meetings with representatives from each specialty. This report will use the term specialty representative to credit

information presented during these meetings. Although in some cases the source is not explicitly named, this information is available on a case by case basis. Please contact the

CfWI if more information is required.



The Department of Health report from the Paediatric and Congenital Cardiac Services Review Group recommended two Paediatric Cardiology

consultants per million of the population (DH 2003). Based on the Office for National Statistics (ONS) population statistics for England in 2010

(ONS, 2010), this generates a need of 104 Paediatric Cardiology consultants.

The NHS Information Centre (IC) census recorded 77 consultants (headcount) and 75 Full Time Equivalent (FTE) as at September 2010 (NHS IC,

2011a).

Policy drivers

The NHS Specialised Services review (NHS SS, 2010) reports on the pending review of services, which is likely to result in their reconfiguration.

Several options for surgical centres have been proposed, varying in number and location. This is likely to drive changes in the Paediatric Cardiology

workforce demand, as physicians follow up with patients after they have undergone surgery. The review comes in response to concerns that

expertise is currently being spread too thinly across small surgical centres, which are at risk of closure. The review also considers additional

demand coming from patients with adult congenital heart disease who have survived into adulthood and require further complex surgery.

Demographics

The charts in Figure 1 display the population age distribution for England for 2011 and 2031 according to Office for National Statistics (ONS)

forecasts for both males (left chart) and females (right chart). Hospital Episode Statistics (HES) data from the NHS Information Centre (IC) for first

attendance data (NHS IC, 2011b) were analysed to identify the age range(s) which appear to use the specialty the most. The shaded bars show the

subgroups of the population which are more dependent on the specialty. The darkest shaded bars represent those that fall in the upper quartile

(the top 25 per cent) of the most dependent parts of the population, when compared with the equivalent age bands of the overall population. The

unshaded bars indicate the population percentage for that age group in 2031.

Figure 1 indicates that, based on first attendance data, males aged 19 and under and females aged 30-34 and 19 and under are the patients who

use the service provided by Paediatric Cardiology the most. Additionally the data suggests that males aged 20-29 and females aged 20-29 and 35-



49 also use the service, but to a lesser degree. Persons outside these age ranges do not appear to use the service on a regular basis and account

for only occasional use. Figure 1 2031 population estimate and indication of age and gender of the 2011 population using paediatric cardiology

Source: HES Data provides the specialty specific age range that is applicable to the population using paediatric cardiology (NHS IC, 2011b). Population statistics updated July 2008 (ONS, 2010).

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2031 Female population % ONS forecast



Figure 1 indicates that the younger population is most reliant on Paediatric Cardiology and will drive the demand for those services. Service is also

known to be delivered to patients of 20 and over, as paediatric cardiologists look after patients with adult congenital heart disease as a special

interest. This age group is likely to require a growing level of service in the future, as more patients survive into adulthood. The graph shows that

women aged 30 to 34 significantly rely on paediatric cardiologists; this could be due to the added pressure of pregnancy on the heart, which

requires specialist attention.

Health and lifestyle

Congenital heart disease (CHD)

The incidence of congenital heart disease in full-term live-born infants is between 4 and 9 per 1,000 in the UK. It is the most common congenital

condition diagnosed in newborn babies.

As children with CHD are now surviving to have children of their own, this contributes to the overall prevalence of CHD. The incidence of mothers

with CHD having affected children is between 2.5 per cent and 18 per cent, and the incidence of fathers with CHD having affected children is

between 1.5 per cent and 3 per cent. Both of these figures are significantly higher than for the general population. It is unusual for more than one

child in the same family to have CHD. Additionally, there are some genetic conditions that are also associated with a higher incidence of CHD

including Down's syndrome and Turner's syndrome. As more of these individuals survive into adulthood to have children of their own, the

prevalence of CHD may increase. (Patient UK, 2011).

Adult women with congenital heart disease may also require specialist attention when pregnant, as this places an increased pressure on the heart

and increases the chance of complications. For healthy women, the risk of complications is 1 in 8000, whereas for women with CHD the chance is

usually between 1 in 100 and 1 in 1000, but can be as high as 50 per cent. This is dependent on which category of risk a pregnant woman with CHD

falls into, which is assessed on an individual basis (NHS Choices, 2009).



Changes in practice

The Joint Royal College of Physicians Training Board (JRCPTB, 2010) has updated the training curriculum for Paediatric Cardiology to include the

development of a new area of special interest in advanced echo cardiology. This has been introduced as a result of workplace needs and the

duration of foetal training changing from 1 to 2 years.

Previously, 3 years of general training was undertaken, followed by an optional 1-2 years of special interest training. There were difficulties entering

special interest training and there was also feedback that the initial 3 years training was not adequate. The curriculum has therefore been changed

to 5 years, with the first 3 years as core Paediatric Cardiology training, followed by 2 years of special interest training, to mirror the adult cardiology

curriculum (JRCPTB, 2010). Workforce planning is therefore likely to be impacted by this change, as it now takes longer to complete a CCT.

Further changes are likely in the near future, as there are trainees currently in the system who do not know whether they will choose to undertake

a 3- or 5-year training programme, which makes workforce planning more difficult because the expected year of CCT completion cannot be

predicted with certainty. Currently, trainees receive the same CCT whether they undertake 3 or 5 years’ training.



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Changes in activity

Finished consultant episodes (FCEs)

Figure 2a: FCEs per year for paediatric cardiology

Figure 2a shows finished consultant episode (FCE) data for Paediatric

Cardiology over five years up to 2009. It is assumed that the recording

and definition of FCEs in this speciality has not changed significantly

over this period, and therefore the rise in FCEs indicates an increase of

activity in the speciality. It should be noted that the data in the chart

does not represent all the activity in this speciality; outpatient data is

not covered, which makes up a significant proportion of the Paediatric

Cardiology service.

Source: (NHS IC, 2011c) The data shows annual number of FCEs. FCEs were recorded in the tax

year in which they finished, the date on the graph indicates the starting year for each tax year.

Potential sources of data include historic outpatient attendance data (see Figure 2b) that may highlight changing demand within the speciality.

However, verification that the data is appropriate for workforce analysis needs to be undertaken.



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First appointment Subsequent appointments All appointments

Outpatient attendances

Figure 2b: All outpatient attendances per year for paediatric cardiology

Figure 2b shows outpatient data for Paediatric

Cardiology, which indicates an increase in outpatient

attendances over recent years. Note: The main specialty

is defined by HES as follows: ‘Treatment specialty reflects

the specialty under which the consultant with prime

responsibility for the patient is working’.

Source: (NHS IC, 2011d) OAs were recorded in the tax year in which they

occurred, the date on the graph indicates the starting year for each tax year.



CURRENT AND FORECAST SUPPLY

Existing workforce

Supply and age profile

According to the 2010 IC census (NHS IC, 2011a) there are 75 FTE (77 headcount) consultants. The latest available data from Electronic Staff

Records (ESR) records 80 FTE consultants and 85 headcount including locums (ESR, January 2011. Extracted via iView, 14 April 2011).

The age profile of the current consultant workforce as at September 2010 is shown in Figures 3a and b.

Figures 3a and b: (a) Consultant age profile (FTE), and (b) Consultant age profile (HC) – Paediatric Cardiology

Source: (NHS IC, 2011e)

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Figures 3a and b show that the highest proportion of staff falls into the 50-54 age bracket and that there is a strong supply of younger staff. Also, a

number of consultants are working beyond typical retirement age. This suggests a possible impending retirement bulge.

Vacancies and locum staff

Data extracted via iView from Electronic Staff Records (ESR) for December 2010 (ESR, 2010), records that 5.9 per cent of the practising consultant

workforce are locums (5 locums in total).

The NHS Information Centre (IC) vacancy survey (March 2010) records a three-month vacancy rate of 0 per cent for paediatric cardiology

consultants in England; the three-month vacancy rate for all paediatric consultants is also 0 per cent (NHS IC, 2011f). The CfWI acknowledges that

this low vacancy rate could be due to Paediatric Cardiology being a small speciality, and trusts only offering posts when the post could realistically

be recruited to.

Geographical distribution

Tables1a and 1b below show the geographical distribution of doctors and trainees in absolute values and in relation to the weighted capitation of

each strategic health authority (SHA) (a definition of weighted capitation is given below*).

Tables 1a and b suggest that, out of the ten SHAs, NHS London is ‘over-capitated’, i.e. the only area with a significantly greater proportion of

England’s doctors in training and consultant-grade doctors than if provision were to follow weighted capitation. This indicates a skewed

geographical distribution of the workforce. However due to the small numbers working in this specialty and the presence of large cardiac centres

in London, it is to be expected that the workforce is not distributed according to weighted capitation.

*The Department of Health uses a weighted capitation formula (WCAP) to distribute resources to primary care trusts (PCTs) based on the relative

health needs of each PCT’s catchment area (DH, 2011a). If qualified doctors and trainees were equitably distributed according to the formula, all

other columns in Table 2b would be zero. Values greater than zero indicate that the SHA has more doctors than would be included by WCAP; values

less than zero indicate that the SHA has fewer doctors than would be included by WCAP. However, the CfWI recognises that weighted capitation

does not reflect that specialist services are not equally distributed throughout England. It is also important that all training posts are of high quality,

and high-quality training placements may not be equally available across England.



Tables 1a and b: a) Actual number of doctors by grade and SHA, across ten SHAs for Paediatric Cardiology, b) Number of FTE above or below that recommended by weighted capitation alone

Number of doctors (FTE) by grade and SHA,

shown for Paediatric Cardiology - Based on IC

census data for 2010 and deanery monitoring

data for 2009

Number of doctors (FTE) over or under the

number recommended by weighted capitation

alone

Table (a) Table (b)

SHA Weighted

Capitation

Doctors

in

training

SSASG Consultant Doctors in

training

SSASG Consultant

North East 5.80% 2 0 5 0 0 1

North West 15.00% 6 0 7 1 0 -4

Yorkshire & The Humber 10.70% 2 0 10 -2 0 2

East Midlands 8.60% 2 0 3 -1 0 -4

West Midlands 11.00% 4 1 7 0 1 -1

East of England 10.30% 0 0 0 -4 0 -8

London 14.20% 13 0 30 8 0 19

South East Coast 7.70% 0 0 0 -3 0 -6

South Central 6.80% 2 0 8 -1 0 3

South West 9.90% 6 0 6 2 0 -1

Total 100.00% 36 1 75

Source: Weighted capitation (DH, 2011b), Consultant/SSASG numbers (NHS IC, 2011a) and deanery monitoring (NHS IC, 2009).

Note due to rounding sum of data may not match presented totals



Recruitment

The level of recruitment to further medical training is shown in Table 2. The table illustrates the situation at point of entry in 2010.

Table 2: 2010 Specialty Recruitment for Paediatric Cardiology at ST3

Given the small size of the speciality, the table shows the geographically uneven

distribution of posts available. Out of the three available posts, the data suggests

that none were accepted. For Paediatric Cardiology, recruitment is not carried

out nationally, but by individual deaneries.

Source: (DH, 2010)

Note: London recruitment includes recruitment to London, London/KSS and London/KSS/EoE.

Deanery Available Posts Accepted Posts Fill Rate

East Midlands 0 0 -

East of England 0 0 -

Kent, Surrey and Sussex 0 0 -

London 0 0 -

Mersey 1 0 0%

North West 0 0 -

Northern 0 0 -

Oxford 0 0 -

Peninsula 0 0 -

Severn 0 0 -

West Midlands 0 0 -

Wessex 0 0 -

Yorkshire and the Humber 2 0 0%

Total 3 0 0% (avg.)



Consultant projections

The supply and forecast of doctors in Paediatric Cardiology is shown in Figures 4a and b. Historical data is taken from the NHS Information Centre

medical census (NHS IC, 2011a). The objective of the medical workforce configuration data in Figures 4a and b is to show historically how the

service has been delivered in Paediatric Cardiology with a combination of consultants, staff, specialty and associate specialist grade (SSASG)

doctors, and trainee doctors (who may be in training towards another specialty, but are providing service in Paediatric Cardiology).

The figures are based upon the latest data available (SSASG data dates back to 2005).



Figures 4a: Historical workforce supply (HC) and future consultant supply and estimation of the number of filled posts for service delivery – Paediatric Cardiology

The charts show that the consultant workforce FTE

expanded by 82.9 per cent from that of five years ago,

based upon the Information Centre (IC) census (NHS

IC, 2011a). It should be noted that this is a small

speciality. The trend is reflected by middle-grade

medical staff together with trainees (which are

defined as those in the SHO and registrar groups).

Source: Historical Supply Data (NHS IC, 2011a), Supply forecast (ESR,

2010), (NHS IC, 2009) and workforce assumptions. Estimates of number

of posts to achieve full service delivery use population projection (ONS,

2010) and RCP estimated number of posts to achieve full service

delivery (2008).

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Figures 4b: Historical workforce supply (HC) and future consultant supply and estimation of the number of filled posts for service delivery – Paediatric Cardiology

This supply forecast model suggests that the supply of

consultants is forecast to increase to 112 FTE in 2020

(114 headcount) an FTE increase of 49.3 per cent,

based on the following assumptions:

Total National Training Number (NTN) holders

in training are split evenly across the higher specialty

training years, and NTNs are recycled upon trainees

gaining a CCT. All recycled NTNs are assumed to be

filled in the next application process.

Higher specialty training of 5 years (ST4 to

ST8) after trainees complete core training (CT1-CT2)

in core medical training and Level 1 paediatrics

training (ST3).

Every new CCT holder is assumed to start work

as a consultant within the same year.

The only source of joiners to the consultant

workforce is through the training system. The

modelling of this route takes into account the age of

trainees, length of training, likely delays and attrition.

The only leavers modelled are permanent

leavers from the consultant workforce, e.g.

retirements. A distribution of retirements is modelled

which reflects the variation in age of retirement

between consultants.

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Consultants (HC) CfWI Supply Forecast


Estimation of future number of consultant posts to deliver service due to population growth only (0.5% for 0-59 yr olds)



REFERENCES

Department of Health (2003) Paediatric and congenital cardiac services review group. [online] Available at:

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4070817.

Department of Health (2010) Monitoring of Recruitment, October 2010, unpublished.

Department of Health (2011a) Resource Allocation – Weighted Capitation Formula (seventh edition). [online] Available at:

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124947.pdf [Accessed 10th June 2011].

Department of Health (2011b) Weighted capitation values for 2011-12, 8 March 2011 on DH website.

Electronic Staff Record (2010) Data Warehouse data extracted from NHS Information Centre’s iView, December 2010.

Joint Royal College of Physicians Training Board (2010). Paediatric cardiology: Quick start curriculum guide.[online] Available at:

http://www.jrcptb.org.uk/SiteCollectionDocuments/2010%20curriculum%20guides/Quick%20Start%20guide%20to%20the%202010%20Paedi

atric%20Cardiology%20curriculum.pdf.

NHS Choices (2009) Congenital heart disease and pregnancy. [online] Available at:

http://www.nhs.uk/Planners/pregnancycareplanner/Pages/Congenitalheartdisease.aspx .

NHS Information Centre (2009) Deanery Monitoring Data 2009 as at 31 March 2009. [online] Available at:

http://www.cfwi.org.uk/resources/data/deanery-monitoring-2009 [Accessed 2 June 2011].

NHS Information Centre (2011a) Medical and Dental Staff Census as at 30 September 2010. [online] Available at:

http://www.ic.nhs.uk/webfiles/publications/010_Workforce/nhsstaff0010/Medical/Med_and_Den_Detailed_Results_Tables_2010.xls [Accessed

June 2011].

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4070817



NHS Information Centre (2011b) Hospital Episode Statistics for England: Main specialty First Attendance for England 1998-2009. [online] Available

at: http://www.hesonline.nhs.uk [Accessed May 2011].

NHS Information Centre (2011c) Hospital Episode Statistics for England. Main specialty Finished Consultant Episodes for England 1998-2009.

[online] Available at: http://www.hesonline.nhs.uk.

NHS Information Centre (2011d) Hospital Episode Statistics for England: Outpatient attendances (main specialty) 2003-2009 February 2011.

[online] Available at: http://www.hesonline.nhs.uk.

NHS Information Centre (2011e) Workforce data, consultant headcount and Full Time Equivalent breakdown by age band as of 30 September

2010. [online] Available at: https://iview.ic.nhs.uk/.

NHS Information Centre (2011f) Vacancies Survey March 2010. [online] Available at: http://www.ic.nhs.uk/statistics-and-data-

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www.cfwi.org.uk

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Paediatric Cardiology - CfWI Medical Fact Sheet and Summary Sheet 2013 August 2011

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