Discussion

We report the first detailed assessment of consultant congenital cardiologist and consultant congenital cardiac surgeon staffing within the UK and as far as we are aware the first such report of any consultant group within NHS England’s specialised services. The total number of consultant positions has expanded considerably over the last 10 years. A net gain of 44 paediatric cardiologists to 128.5 WTE approaches the required figure suggested by the 2016 NHS England standards of 1 paediatric cardiologist per 0.5 million population (estimated 2020 requirement of 132 paediatric cardiologist for a population of 66 million).4 8 9 However, there is an ongoing shortage of some subspecialty practitioners such as heart failure and inherited cardiac conditions. Many units rely on a single consultant for electrophysiology and cross-sectional imaging. In addition, demand for subspecialists in inherited cardiac conditions and heart failure in children is currently not being met. The total number of congenital cardiac operations carried out in the UK each year is 5500 and the NHS standard is for a minimum number of 125 operations per surgeon per year.8 10 This suggests number of cardiac surgeons is sufficient based purely on caseload. The total number of ACHD cardiologists, however, raises significant concern. More than 95% of infants born with cardiovascular anomalies can now expect to reach adulthood.18 These ACHD patients now make up more than half of the congenital heart disease patients in the UK, with the UK population of ACHD patients increasing by at least 16 000 over this 10-year period.19 20 Many of our most complex patients, in particular single ventricle patients, are only now starting to reach adulthood. Despite this increasing population and complexity there are only 35.5 WTE ACHD cardiologists in the UK. Although three level 1 units did not complete the survey subsequent personal communication with units who did not respond/data on their websites show that were a maximum of 45 WTE ACHD cardiologists at the beginning of 2020. The current standards outline a need for one ACHD WTE for a maximum of 1500 ACHD patients.8 The estimated population prevalence of ACHD is 4 in 1000 and the current UK adult population is 52 million which requires an estimated 138 WTE ACHD cardiologists.1 21 The UK, therefore, currently has less than a third of the desired number of ACHD cardiologists to meet current demand. At least one additional WTE is required each year to manage the ongoing ‘graduates’ from paediatric care with the increase in ACHD cardiologists accounting for this population growth as opposed to a real expansion in the workforce.20

Among all three groups, we have shown that recruitment to these positions has relied heavily on staff who have undergone their higher specialist training outside the UK; more than a third trained abroad. This was particularly marked for congenital cardiac surgeons, with only 45% of new appointments in the last 10 years filled by UK specialist trainees. Others have shown a similar change with all the expansion in UK congenital cardiac surgeons between 1999 and 2014 filled by non-UK graduates and a fall in the percentage of UK graduate congenital surgeon from 70% to 54% over the same time period.22 Reliance on consultants trained abroad raises significant concerns for the sustainability of the service within the UK, particularly with likely changes to both certification equivalence and recruitment from Europe as result of Brexit (see below).23 Willingness of staff from abroad to come to the UK to work may be regarded as positive for the specialty although this needs to be balanced against the numbers leaving UK practice. A 10-year staff turnover rate of 50% (37% excluding retirement), or 5% per annum, appears high. It is double the calculated staff turnover rate among neurosurgeons between 2014 and 2018 for whom similar data are available.14 Some staff movement within the UK (10% turnover rate) is expected with career progression and might be considered desirable to spread expertise between units. However, the majority of those leaving units moved abroad, particularly among surgeons, with a 35% staff turnover rate (55% of all surgical leavers) to work abroad over the 10-year period. Across all three specialties, retirement made up only 25% of all those leaving compared with neurosurgery where 60% of those vacated posts due to retirement. Our observation is that many of those leaving were experienced clinicians resulting in a drain of a highly experienced resource and raising the probability that conditions and opportunities in the UK played a role in their decision making. Inevitably some will leave for personal reasons, but UK professional reasons and financial were more frequently cited. The former included excessive scrutiny (described as ‘hostile’ by one respondent). There have been concerns about breakdown in collaboration between units, due to prolonged attempts to restructure the national delivery of care causing uncertainty and reduced morale, particularly in units believed to be ‘at risk’. In addition, limitations in access to operating time and frustration in lack of adequate postoperative facilities were identified as reasons for surgeons moving abroad, where the resources were perceived as being superior. The new standards have not been matched by resource allocation to congenital cardiac services. The pressure of external enquiries, direct unit comparisons and the requirement to achieve minimum case numbers has forced units to compete against each other for their survival. Furthermore, despite continuing improvement in outcomes, the (although understandable) intense scrutiny of mortality or morbidity and the drive to improve further, adds pressure, especially on the operators, perpetuates anxieties and may encourage risk avoidance.22 The fact that the highest turnover rate was among surgeons and that most left to work abroad suggests that working within the NHS is not perceived as attractive by many congenital cardiac surgeons. This requires urgent attention if the highest quality staff are to be trained and retained within the UK.

There was not sufficient additional information to explore the financial incentives to move. Funding of the congenital cardiac services, NHS funding as a whole and financial packages offered in North America and the Middle East, as well as limited scope for private practice within the UK for congenital heart disease, are likely to have played a part. Erosion of the UKs international reputation and lack of research/developmental opportunities were also identified as reasons to leave UK practice. It is striking that only one quarter of units surveyed held an exit interview for consultant staff leaving their unit. We believe that structured exit interviews should be mandatory for all consultants leaving their unit, if detailed first-hand information is to be available for future analysis and workforce planning.

Many of the reasons highlighted for leaving UK practice are likely to influence the career choices of junior medical staff when considering a career in congenital cardiac services. These decisions are also be influenced by other factors such as early career exposure and delivery of training. The current entry and training requirements are shown in table 5. UK national training numbers in paediatric cardiology, adult cardiology and cardiothoracic surgery are appointed by competitive interview.15 16 There are three formal congenital heart disease surgical training programmes in the UK, often populated by trainees who have undertaken their initial cardiac surgical training outside the UK.17 22 Although there is a degree of competition for certain regional ACHD training programmes, within the UK there is a shortage of applicant for posts for ACHD training particularly in comparison with training posts in other areas of cardiology.24 25 There is now a requirement for 3–6 months ACHD exposure within the first 3 years of paediatric cardiology training, however, the majority of these trainees are derived from paediatric core training and very few turn become ACHD specialists.15 In contrast, in core adult cardiology training, there is only a requirement to complete a nominal 2 weeks of ACHD training, which is often delivered after subspecialty interests have been decided.15 This limited, and poorly timed, exposure to ACHD has been identified by trainees as insufficient to make an informed decision about choosing ACHD as a career path with fewer than 4% of adult cardiology trainees choosing ACHD as their subspecialty.24 UK Medical training curriculums are currently being revised. The Shape of Training report requires all adult medical specialties to dual train in acute medicine which will undoubtedly have a further detrimental impact on recruitment to and delivery of ACHD specialty training.26 If recruitment to, and expansion of ACHD consultant numbers is to be achieved via UK trainees then the training path for such specialists requires immediate review.25 An alternative or complementary strategy has included recruitment of ACHD specialists trained outside the UK. For those doctors the organisation of training is often different; congenital cardiology does not exist as a separate specialty in some healthcare settings. In most instances, substantive UK consultant appointments of non-European-trained specialists also requires judged equivalence of training abroad through the Certificate of Eligibility for Specialist Registration process.27 This is a complex process, is extremely time consuming, and requires considerable peer support. Extension of this process to European Union applicants will impose additional limitations to obtaining consultant staff from overseas whom the specialty is so reliant.23