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The future of community children’s nursing
  1. M Whiting
  1. Chair, on behalf of the RCN Community Children’s Nursing Forum
  1. Correspondence to:
    Mr M Whiting
    Chair CCN Forum, Royal College of Nursing, 20 Cavendish Square, London W1G 0RN, UK; mwhiting.familytinyworld.co.uk

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The time is right for children’s nurses and paediatricians to work more closely together

The Royal College of Nursing Community Children’s Nursing Forum was delighted to see the collection of articles on community paediatrics in the February edition of Archives,1 though one thing that did concern us greatly was the failure in most of the articles to acknowledge the role of the community children’s nurse (CCN) in supporting children with an increasingly complex range of health care needs within the community. While Hall and Lowson’s examination of the role of the nurse practitioner2 provided one example of innovative practice in primary care, for many, many children the mainstay of care in the community is the CCN!

Over 50 years ago when the Rotherham Community Children’s Nursing Service,3 Paddington Home Care Team,4 and the Birmingham Children’s Home Care Service5 were introduced, the work of pioneering community children’s nurses owed much to the inspiration of paediatric medical staff based in the children’s hospital services in those areas. In the early days of these services, the availability of an “acute paediatrician” to visit children in their own homes was arguably key to the acceptance of the nursing teams within the community care arena.

In the Paddington Home Care Team, the continuous appointment of registrar grade paediatricians during the past 50 years has “tested the water” on many facets of the general practitioner paediatrician (GPP)/primary care paediatrician (PCP) debate. It is perhaps surprising, therefore, that in spite of the pioneering spirit of Reginald Lightwood, Freddie Brimblecombe, and Tom Opeé,6,7 and a succession of paediatricians who have worked creatively and imaginatively across the primary/secondary care divide in the Paddington area of northwest London, this model has not provided a template for others to follow. Indeed, there is not a single model equivalent to the Paddington approach to community paediatric medicine anywhere else in the UK!

THE GPP?

As a number of the authors of the Archives “Primary Care” symposium acknowledge, the one recommendation of the Court Report8 which failed to even get off the starting blocks was the development of the role of the general practitioner in paediatrics (GPP). While community paediatrics has made great progress since Court, particularly in the fields of developmental paediatrics and child protection, the provision of more “general” paediatric practice in the community, both in terms of acute disease management and involvement in the care of children with more long term conditions, has remained rather elusive. In stark contrast, the nursing element of the Paddington Home Care Team has provided a clear lead to many others, as community children’s nursing services across the UK have expanded dramatically—particularly in the last 20 years (fig 1). A variety of service models have developed during this time, including:

Figure 1

 Growth in UK CCN services provision 1954–2004.9

  • Hospital based outreach nursing teams

  • Community based in-reach nursing teams

  • Tertiary or secondary care based specialist nurses working across the hospital/community interface; for example, diabetes care, palliative/symptom care, cystic fibrosis nurses, neonatal care, disability care, HIV care

  • Hospital-at-home or ambulatory care teams.

In general, local teams have developed in response to local demands, and no one model of service provision has yet become clearly established as the preferred option.

Throughout most of its life, the Paddington Home Care Team has been based in the secondary care sector, in Paddington Green Children’s Hospital, Princess Elizabeth Hospital in Kensington, and latterly at St Mary’s Hospital, with medical and nursing staff holding a shared patient caseload and “shared” clinical notes. In the early days of the service, the majority of referrals to the team were made by general practitioners in the Paddington area, but in recent years, there has been a predominance of hospital based referrals and a steady shift away from “acute” paediatric work and towards the care of children with more long standing problems.

As noted above, community children’s services may have their primary work base in either hospital or community, though all teams work closely with local hospital paediatric units, through A&E departments, in outpatient clinics, and with short stay assessment, minor injury/treatment centres, and across a range of ambulatory settings. For the majority of CCN services, referrals from general practice form a relatively small proportion of their workloads. However, with the introduction of Primary Care Trusts, a number of teams, while maintaining a close working relationship with their secondary care based colleagues, have recently taken the opportunity to formally realign their work within primary care. Even the Paddington Home Care Team has now relocated into a local health centre!

CCN services work closely with both health visitors and school nurses. The crucial difference, however, is that while HVs and SNs have a population based public health and health promotion role, community children’s nurses who, by definition must be registered as children’s nurses (unlike HVs and SNs), provide care only to children who are referred to the CCN service.

AMBULATORY CARE

The introduction of ambulatory paediatrics in the mid 1990s perhaps offered a new opportunity for “acute” paediatricians to establish a stronger foothold in primary care and to supplement the by now well established work of the consultant community paediatricians and their teams. It is perhaps apposite to reflect at this point on what was arguably the key message from two key RCPCH publications in the late 1990s10,11 which argued that ambulatory care was primarily “a philosophical approach to care” encompassing “assessment and management of acutely ill children, traditional outpatient paediatric practice including the care of children with a range of chronic disabilities, carried out in a variety of locations, hospitals, general practitioner surgeries, at home, child development centres or child health clinics or schools”. While the number of ambulatory paediatricians remains disappointingly small, this philosophy coincides with the rationale behind much of the dramatic expansion in CCN services provision outlined above.12

While we were somewhat disappointed at the almost total absence of reference to the massive expansion in CCN provision in the discussion in the February issue of Archives, we wholeheartedly support the spirit of our medical colleagues’ challenge to re-look at the whole notion of paediatric/primary care. We would welcome the opportunity to share our own experience of a journey that has seen the number of nurses employed within community children’s nursing teams expand from just 45 nurses in the whole of England in 1988 to almost one thousand CCNs in the UK in 2004.

This growth in CCN services provision was at its peak in 1997, when the Health Select Committee Report on Child Health Services recommended “that each health authority should be required to contract for a Community Children’s Nursing Service”.13 While the incoming Labour Government’s response to this particular recommendation14 might be described as, at best, lukewarm, the fact of the matter is that the total number of CCN services has continued to expand to the point where the Royal College of Nursing now estimates that over 90% of PCTs will have access to the service in one form or another. It is quite staggering that from an original list of 23 names in 1987, the RCN Community Children’s Nursing Forum now has a membership of almost 1500.

2004 is likely to see the publication of both the Children’s National Services Framework15 and the new Children Act.16 With the planned roll-out of Children’s Trusts, and the development of Advanced Nursing Practice roles including Non-Medical (Nurse) Prescribing,17 the time is surely right for children’s nurses and paediatricians to work together to put children at the very centre of the Primary Care agenda.

The time is right for children’s nurses and paediatricians to work more closely together

REFERENCES

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Footnotes

  • Mark Whiting is Chair of the Royal College of Nursing Community Children’s Nursing Forum

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