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Inferior doctors treat the patient's disease Mediocre doctors treat the patient as a person Superior doctors treat the community as a wholeHuang Lee, 2600 bc
We have long recognised that many health issues affecting children and their families cannot be addressed solely by health service workers. The major health gains of the last century have been determined by changes in life quality, sanitation, and living standards affecting whole populations.1 However, for many years paediatricians working in both community and hospital systems have developed alliances with both statutory agencies (social services and education), government, and voluntary groups to plan and develop appropriate services. The child public health movement is growing in Europe, the USA, and Australia.2 3 In the UK, a number of initiatives have been developed, including a special joint group of the British Association of Community Child Health and the Faculty of Public Health, an advocacy committee within the Royal College of Paediatrics and Child Health, and an advocacy internet based discussion group (CHANT). Paediatricians are fully participating in the health inequalities debate, both in their contribution to the research,4 and in helping to influence wider health policy development.5
The purpose of this article is to explore the value of taking a population perspective on child health and placing paediatric care in context with the “total picture” of child health and illness. It is aimed at the general paediatrician. Other articles in the series explore whether there is a role for a specific “child public health” specialist.
In the UK, the majority of paediatric specialists work in a hospital setting, with their clinical activities usually being carried out in a ward or outpatient setting.6 The service provided is one of a secondary care service, with referrals being made by local general practitioners (GPs), usually in the geographical area surrounding the hospital. This is in marked contrast to the European and North American system of paediatric care with its emphasis on the primary care paediatrician, often based in an “office” setting with or without local hospital admitting rights. Approximately 60% of GPs receive a formal postgraduate training in paediatrics with some partners in the practice taking a special interest in the subject. In the UK, GPs are widely considered to be the primary care providers of paediatric care. Consultant community paediatricians in the UK are also secondary care specialists who are often based in a geographical patch or locality,8 working closely with local agencies, usually with a more social, educational, and developmental bias in their work.9 10 The number of paediatricians in European countries varies from 18 to 120 per 100 000 population. In the UK it is approximately 20 per 100 000,11 and this figure reflects the differences in models of service provision described above.
Much of the work of the acute paediatrician working in a hospital setting is reactive and depends very much on the prevailing epidemiology of childhood morbidity in the community and the skills and abilities of the main carers and primary care services in managing illnesses being presented. Hospital admissions and discharges have increased considerably in the past 10 years, with shorter stays and a higher turnover leading to ambulatory and short stay unit models of care being developed.12 The workload relating to complex behavioural, social, and educational problems is also increasing. How should we react to these trends? I would argue that it is helpful to look at the problem from a population perspective using a number of public health tools. Firstly, this article describes a number of public health concepts including the pyramid of morbidity and types of disease prevention, and how they apply to paediatrics and child health. It goes on to explore what is available in terms of measuring disease and health status and how the data might be used to plan services, and to inform an education and research agenda for future paediatricians.
Pyramid of care
A useful concept used by public health physicians is the “pyramid” of disease (fig 1). If data are added to this pyramid, in terms of GP consultations and paediatric secondary care consultations in outpatients and inpatients, then it is easy to see that a very small increase in GP referral rates or an even smaller increase in primary care consultations, can easily overwhelm the capacity of the system further up the pyramid (table 1). Most paediatricians will appreciate how the annual bronchiolitis epidemic often overwhelms the system as described. This has led to a growing concern about patient demand management.13 The nurse led telephone advice service, NHS Health Direct,14 is one response to this. An understanding of this dynamic does place preventive care as a high priority, in an attempt to reduce the inexorable demand on secondary paediatric care services.
Types of prevention
Three forms of disease prevention are described.
Primary prevention—in which the bodily impairment, whether biochemical, physical, or psychological, is prevented from initiation; such as antenatal folate supplementation, childhood immunisation, fluoridation of drinking water, and road safety legislation.
Secondary prevention—in which the disease is detected at an early preclinical or clinical stage, and is reversed or ameliorated as a result; such as biochemical screening of the neonate, otoacoustic emmission screening for hearing loss, physical examination for cardiovascular disease, and structured questionnaires, for example, the Edinburgh postnatal depression screen.
Tertiary prevention—in which the impact of an established clinical disease is minimised; such as minimising handicap for the individual, for example, constructing a ramp in the playground for a wheelchair bound schoolchild, or teaching independence self catheterisation skills for an adolescent with spina bifida.
This framework has led to my considering every encounter with a patient as an opportunity for health promotion and preventive care, even in the most acute setting. The epidemiological ward round has been a success in the adult setting and could easily be transferred to a paediatric one.15
What problems affect my “community”?—describing the health status of the population
I am referring here to the local community within which we operate as paediatricians and from which we receive most of our referrals. This can be divided up into data collected centrally on a continuous basis, data collected by regular survey, and data collected by special survey. In addition there are district based and general practice caseload as well as local survey data. The General Registrar's Office was established over 150 years ago and led to the development of the Office of Population Census and Surveys (OPCS), and the more recent Office of National Statistics.16 This organisation collects birth registration and death data as well as hospital admission data in the UK. The General Household Survey carries out a regular three yearly survey of households and collects data on childhood disability. The decennial UK wide census due in 2001 is a prime source of demographic data for accurate “denominator” data and will contain a question on long standing and life limiting illness. The GP sentinel practices collect morbidity data every 10 years. Data on infectious disease are regularly disseminated by the Centre for Disease Surveillance and provide a timely assessment of the patterns of disease in the community. A review of all these data sources is given elsewhere,17 18 and a regular annual review of statistics is produced in this journal.19
Lifestyle surveys have been invaluable for collecting data on adolescent health (Trent).20 District based child health systems have been in operation since 1975 and collect immunisation and paediatric screening data, including anthropometric data at key ages.21 Approximately 70% of districts have such a system and although the quality of the data is variable, some valuable information on national child growth and screening has been collected.22 23
Can the data be used for planning services?
Increasingly paediatricians are having to make business cases for the services which they perceive are required and information from the sources above can be very helpful as part of that process. Unfortunately, NHS information strategies so far have not delivered the data required accurately or quickly enough, certainly in the secondary care sector. Child health professionals and others have worked hard to readdress this, with increased involvement in defining clinical terms and lobbying for enhanced system functionality and improved system communication.24 Special needs registers can be used to help plan services for disabled children and their families.25 They are probably best used as sampling frames for further detailed research on the needs of the disabled child population. Comparisons between districts are difficult because of differences in case eligibility, definitions, and recording. A core dataset has been developed by the Child Health Informatics Consortium, an umbrella organisation in the UK for child health information systems, with paediatric and primary care medical, nursing, and public health representation. This dataset is intended to act as an interagency baseline for describing the health of a district's children, to provide the basis for future trend data and some basic outcome data to ascertain the effectiveness of interagency interventions and programmes, for example, child health surveillance, Quality Protects.27 It is becoming evident that outcome measures for services are needed in the area of child health, both from a health service evaluation perspective and also to help inform social care.28 School entry still provides an opportunity for universal coverage of a screening or health status schedule, but it is not being fully utilised using evidence based validated tools. There is a real need to re-examine the data being collected at this age and review its utility for planning and epidemiological purposes.
Community nurses and others have used community profiling and rapid assessment methods to evaluate the needs of a local community and plan services responsively.29 The utility of this approach is in effect to make a community diagnosis as opposed to an individual patient diagnosis, and put into place further investigations and interventions at the population level. A recent review of the health needs of the school aged child has highlighted the value of an annual report at school level with school nurse profiling as its basis, collated at school, district, and national level.30Interestingly, this idea has existed ever since the inception of the school health service in 1906 and is having resurgence at the end of the century!
Implications for education and research
Taking a population perspective is an important driver for the GMC recommendation of “Tomorrow's doctor”. As Stone and Campbell point out: “the main challenge facing medical educationalists is one which the GMC may have underestimated: to provide students with practical preventive and health promotional skills that they can use in clinical settings, rather than merely theoretical knowledge of epidemiology and related fields”.31 As the acute paediatric workload intensifies in terms of greater numbers of admissions and shorter stays, it is easy to forget the public health perspective and the preventive perspective. As the “new” morbidities impact on our services, there is a need to take a broader view of how we can help children and families, and this is increasingly in a multidisciplinary context and across primary, secondary, hospital, and community interagency boundaries. Multidisciplinary education initiatives and training placements of paediatricians in primary and community secondary care settings can only help to build up the trust required between professionals in tackling these problems.
In response to the increasing demands made on the emergency acute services, a number of different service models are being explored in the UK and elsewhere, including ambulatory care and short stay observation units. Evaluation methods are developing alongside these, including the use of tools to assess appropriateness of admission,32 and illness severity scoring methods33; we are beginning to learn more about the way in which parents and professionals deal with a child's illnesses,34 35 and the patterns of morbidity in the population.36 There is a great deal of potential for parent and professional education as a means of reducing demands on services. On a population level, work is progressing in defining functional outcomes in a number of areas, including mental health, against which population based interventions can be measured in future research programmes.37 38
Taking a population perspective on child health is a step in evolving our paediatric care and services in the millennium. An integrated well functioning, well trained paediatric and child health workforce should allow us to provide care for all children by the most appropriately trained person in the most appropriate location. Training and research needs to be informed by the needs of the community in its widest sense.
I would like to thank Mary Rossiter for the quote, Euan Ross for introducing me to the subject, and Leon Polnay for his long standing support.