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Children’s health remains an integral element of general practice
In common with other healthcare services in the United Kingdom, general practice (GP) is faced with an ever increasing pace of change which is best highlighted by the implementation and implications of the new GP (General Medical Services, GMS) contract.
In the light of these changes, the increasing expectations of parents, the escalating presentation of disease, ill health, and mental health issues amongst children, it seems reasonable to ponder the future for child health care provision within GP.
It seems reasonable to expect there to be a comprehensive child health service in GP because the frequency of presentation of acute illness and the ongoing management of certain key chronic diseases are likely to be beyond the capacity of any rational existing and future secondary care/mental health and community paediatric service plan. The Wanless report1 highlights the inadequacy of the doctor population in the United Kingdom for the foreseeable future. It is therefore remarkably unlikely, even with the Children’s National Service Framework (NSF), that the number of paediatricians will expand to any significant extent at the expense of other medical or surgical disciplines where performance targets remain.
The implementation of the European Working Time Directive (EWTD) will have a major impact on the organisation and provision of paediatric services, as will the government’s aspirations for a consultant delivered service.2,3
I would suggest these will prove significant enough challenges without expanding the work of paediatricians into the initial presentation of child illness in primary care.
From a GP perspective, there is also the considerable importance of maintaining a holistic and family based approach. Children remain an integral part of families in the United Kingdom, and cannot be seen as an isolated population. While it will be difficult to maintain historic levels of continuity of doctor delivered care, general practice has a long history of innovative team based approaches to care4 and through this route current services should be both maintained and refined. The key role of the general practitioner as NHS gatekeeper and manager of risk needs careful evaluation before major changes are implemented and these roles potentially lost.
Primary care paediatricians could, however, be seen as a logical extension of the government’s patient choice agenda. If the evidence base were to support this development there could be little objection. However, currently we have little or no evidence that paediatricians based in primary care within UK health services are even as effective as general practitioners. Effective GP is about the synergy of physical, psychological, and social care within the framework of caring for families over time. Artificial separation of children’s health care runs contrary to these principles, and risks the sidelining of child health care issues from mainstream primary care. A risk that already exists with the disappointing lack of emphasis on child health within the new GMS contract.
If we are to accept the premise that there has to be an integral child health care service in GP, then how it will be delivered, and how relevant staff might be trained becomes the area for most productive debate.
This article is too short to consider the critical roles of all relevant non-medical professionals but the future will clearly be multiprofessional and team based. The structure and leadership of these teams will vary across England in line with differences in the population and the available professional workforce. There will be little future for doctors unable or unwilling to work effectively in such an environment.
The following concentrates on a future model for training general practitioners and how child health services might be delivered in primary care organisations (PCOs).
While much has been done to refine general practice vocational training, since its formal inception in 1979, the present arrangements ensure that only one third of training takes place in GP. Therefore, both the context and the control of the educational experience is out with the control of the discipline of GP and its educators. GP is the only recognised specialty for which this is the case.
Unfinished business5 and Modernising medical careers6 provide an opportunity to radically change the arrangements for vocational education for general practice. It may allow the implementation of a three year programme based in GP with planned release to specialist hospital and community settings. This will allow all future GPs to be trained in relevant child health practice, in particular the recognition of acute illness, and experience of working in extended teams managing children with complex and special needs. It will allow some GPs to develop special interests in child health who will provide specialist services within PCOs. Such services must form part of a comprehensive and collaborative local arrangement with community and hospital sectors. To this end care must be taken in defining the roles and responsibilities of community and secondary care paediatricians, and how these interface with primary care.
This leaves the problem of out of hours care. After the implementation of the GMS contract the move to out of hours centres to which parents and children travel will become more prevalent as more general practitioners opt out of out of hours care. It is essential that such units can provide safe assessment and care of acutely ill children. To that end such units will need to be staffed at all times by general practitioners with relevant child health training and most critically of all must have facilities for observation, perhaps by trained nurses for an hour or so, in order that the trajectory of illness can be adequately assessed. In fact secondary care paediatric services probably have a right to expect this level of service to limit the rising tide of admissions that has arisen, at least in part, for want of appropriate opportunities for assessment over time in the community.
The future is clear; it remains a general practice based service but with better and more formalised relationships with both community and hospital paediatric services.
Children’s health remains an integral element of general practice
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