Forensic Paediatrics A Report by the Short Life Working Group

Chapter 2 Medical Workforce in Forensic Paediatrics

1. The current paediatric workforce providing forensic examinations in children comprises;

1. Consultant Paediatricians (who have obtained C.C.T in paediatrics) with additional training and experience in child protection;

2. Specialty doctors and associate specialist paediatricians with additional experience and training (usually as part of Community Child Health) in child protection who may be in consultant led teams.

3. Forensic physicians who are independently contracted to carry out a number of different duties.

These medical staff may have different levels of competence and skills in child protection. Figure 1 shows the relative numbers of paediatricians in each level of competence across Scotland. Actual numbers are discussed in chapter 2 paragraph 5.

Figure 1: Levels of competence and types of paediatricians working in child protection.

3. The RCPCH has not recognised child protection as a subspecialty in its own right, but the 6 levels of competency detailed in the Intercollegiate guidance distinguishes 3 higher levels (levels 4, 5 and 6) where more specialist and expert roles in child protection are defined (annex C). A paediatrician (level 4) with a Special Interest in child Protection is defined as a consultant who has had further training and experience in child protection and is competent in carrying out paediatric forensic examinations, including the interpretation of injury. They undertake CPD and take part in peer review, give advice to non-specialist colleagues and offer mentoring and support to more junior colleagues, and usually work solely in their Board area.

4. As shown in figure 1, there are 2 levels of consultant with additional competencies in child protection. The larger group are usually "Paediatricians with a Special Interest" and will be a consultant paediatrician in general or community child health working in a District General Hospital. The "Specialist Paediatric Consultant in Child Protection" of which there are 6 in Scotland (called tertiary specialists) work within a tertiary centre. In Scotland, these specialists in child protection are usually a consultant paediatrician providing specialist clinical care and forensic opinion in complex cases. While they are likely to have an active caseload, they also perform a mentoring and supervisory role to the developing specialists and provide opinion to colleagues (Annex D). If there is more than one consultant in a Board area with a special interest in child protection there will be the need to have a "lead clinician". These consultants may have Level 6 competencies and work across their region usually leading an MCN and providing national policy advice to government and other bodies. The number of tertiary specialists is falling and the number of paediatricians with a special interest is rising, as the consultants combine secondary and tertiary roles.

Table 1 Paediatric workforce numbers

5. Currently 42 paediatricians provide forensic services (31 consultants and 11 specialty doctors). These paediatricians will include general and community based paediatricians with a special interest in child protection and "specialist" tertiary consultants in child protection. There are 6 considered to work in tertiary centres (3 in GG & C, 1 in Lothian, 2 in Grampian). However, in keeping with the trends in medical workforce in CCH the age range suggests that there will be significant reductions in this number due to retirals over the next 5-10 years. As there are very few CCH sub specialty trainees in the Deaneries and none specialising in the area of child protection, building and sustaining a competent specialist workforce will be challenging in the next 10 years. It is likely that centralisation is inevitable particularly out of hours. In addition, due to paediatric medical workforce changes CCH services are already threatened and it is likely that future consultant posts in community child health will be combined with acute general on call duties. This model already exists in many regions in Scotland, and forensic medical work is carried out by general paediatricians who have received additional training in the evaluation of CSA including the use of colposcopy after becoming consultants. This may lead to a reduction in the number of specialist paediatricians in the future, with more consultant posts having general paediatric duties; and with increasing gaps in middle grade rotas, the amount of time dedicated to this specialist role, may reduce in future job plans. However the present demand for specialist tertiary advice suggests that there is a need for 2-3 tertiary specialists in each MCN.

Forensic Physicians

6. The present forensic physician workforce is contracted by the police authorities/Boards. The following table indicates the total number of doctors employed in each police authority with the numbers employed to carry out paediatric examinations. In addition, in adult practice forensic nurses play an active role and work is underway to investigate the development of the paediatric role. There is no expectation that nurses will replace either the forensic physician or paediatrician but it is clear that their skills can be used more effectively in this area, particularly in an advocacy function.

Table 2 Forensic physician workforce numbers

7. The Scottish Government conducted a pilot of a new partnership model between the local Health Board and Police authority in Tayside. This model did not significantly change the model of two doctor joint examinations in CSA. Although there were Custody Nurses in this model, none of these nurses were involved in the examination of CSA cases.

8. Forensic physicians are encouraged to be members of the Faculty of Forensic and Legal Medicine, but individual police forces recruit their own forensic physicians. The ACPOS Health/Medical Services Reference Group is creating a template for use by NHSScotland and police forces when contracting forensic medical services and it is hoped that NHSScotland will remain one of the employers of forensic physicians, allowing clinical governance processes for paediatricians and forensic physicians to be managed by NHS Board Medical Directors.