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Who should provide primary care for children?
  1. C M Ni Bhrolchain
  1. Correspondence to:
    Dr C M Ni Bhrolchain
    Huntingdonshire PCT, Primrose Lane, Huntingdon PE29 1WG, UK; Clionaniblineone.net

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“Primary health care is essential health care ... made universally accessible to individuals and families in the community ... It is the first level of contact of individuals ... with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process”.

Traditionally,1 UK general practitioners (GPs) have provided primary care for all age groups. However, the Royal College of Paediatrics and Child Health (RCPCH) has recently proposed that paediatricians should take on primary care for children. This article assumes that this proposal includes all the elements of primary care paediatrics as seen in those countries where primary care paediatricians already practice: assessment and management of acute illness, ongoing management of chronic conditions including disability, and primary prevention including immunisation and “well child” visits. Does this proposal withstand scrutiny?

The increase in hospital admissions for acute illness appears to be due to primary care problems managed by secondary care doctors

There has been a significant increase in the number of children admitted to hospital for acute illness.2 Those who promote the concept of primary care paediatricians often cite poor primary care as the reason.

The evidence challenges this theory. Boyle et al showed that referrals from primary care to Derbyshire Children’s Hospital showed no increase between 1994 and 1998.3 MacFaul et al found that admission in Yorkshire was more likely after self-referral to A&E.4 Admission was also related to social disadvantage and presentation at night. In 1996, Dale et al showed that GPs were significantly more cost effective in dealing with primary care presentations to a London A&E, when compared with senior house officers (SHOs) and registrars.5

The problem here therefore seems to be one of access on the one hand and secondary care doctors who are less skilled in managing primary care problems on the other. Inappropriate use of secondary care services is likely to be worse in city areas and where there is a children’s hospital with a reputation for knowing about children. Parents’ lack of experience in managing acute illness in small children may also generate anxiety, fuelled by regular headlines about deaths from meningitis.

Solutions might include GPs in A&E to manage primary care problems, training in primary care for specialist trainees, and redesigning services in ways that avoid admission, for example, hospital at home schemes run by nurses.6,7

Community paediatricians have until recently provided primary care services and may not be too keen to go back to it

Community paediatricians have spent the past decade extracting themselves from providing primary care. We have redesigned services to meet the increasing need for specialist care for children with non-acute conditions. We have been forerunners in supporting clinical nurse specialists (we call them health visitors and school nurses), improving access by referral protocols from screening and surveillance to manage demand and delegating to our specialists nurses those tasks that do not need medical training. With our primary care colleagues we have reduced or all but eliminated a number of fatal conditions through preventive programmes, and have ensured that all GP registrars have access to protected training in child health and development through the child health surveillance courses run for GP registrars.

The committed paediatricians who provided primary care in preceding decades had few career opportunities. They belonged neither to the paediatric “club” nor to general practice and lived largely in no man’s land. Much of what they did has now been delegated to primary care nurses and allied health professionals (AHPs) or remains a secondary service within community paediatrics.

Demand management techniques such as protocol driven investigation could significantly reduce outpatient referrals

About 2% of children are referred to general paediatricians in any year and this rate has not changed for the past decade.8–10 The commonest conditions referred are heart murmurs, urinary tract infections, and constipation.10 Asthma—the single commonest condition referred in the 1988 study8—no longer features in the top five. This suggests that GPs can successfully manage childhood conditions when supported to do so by clear guidelines. GP access to echocardiograms, renal ultrasound, and management protocols for constipation could reduce outpatient demand by 30%, releasing paediatric time for other things. Progress on improving GP access to such investigations has been slow, with a tendency to expand secondary care services to meet demand rather than redesigning services. Yet, the yield from investigations requested by GPs has consistently been shown to be as good as the yield from those requested by specialists.11

There is some evidence that community paediatricians are experiencing increased demand and see more complex children.10 There may also be less opportunity to transfer care to GPs. While GPs are confident in managing some issues such as immunisation with advice, they are not confident in managing children with special needs without secondary care support (Mindlin M et al, unpublished data).12

We need to train the next generation of primary and secondary care practitioners to meet the needs of children and families first

Children and families need good access to appropriate services as close as possible to home or school. Primary care is the point of first access and the evidence suggests that primary care nurses and doctors do a good job: they manage about 90% of children presenting to them without referral, and GPs are consistent about what they wish to manage and what should go to secondary care (Mindlin M et al, unpublished data) for non-acute presentations at least. The pressure on secondary care services comes from patient demand, a need to control working hours and, in my view, a need to redesign and modernise services. I do not believe that paediatricians should take on the 90% of patient contacts now seen in primary care. I think we do need to consider which patients need secondary care services and which can be seen safely and more effectively in primary care. This may require us to challenge existing beliefs about how, where, and by whom services should be provided.

The training needs I perceive for each level of child health practitioner are outlined in Table 1. I have not presumed to comment on nurse or AHP training. The concept of GPs with a special interest (GPwSI) could foster links between primary and secondary care, as will community paediatricians’ move into Primary Care Trusts (PCTs) alongside GPs. Hospital based paediatricians need to strengthen ties with primary care based on mutual respect for their different talents. It is unlikely that many GPwSIs could maintain their skills to contribute to acute hospital rotas. Community paediatricians are already finding this difficult and withdrawing from them, concerned about clinical governance issues.

Table 1

Training needs for each level of child health practitioner

Hospital paediatricians will need to find other solutions to maintain essential acute services for ill children who need them. Primary care paediatricians, in my view, are not it.

“Primary health care is essential health care ... made universally accessible to individuals and families in the community ... It is the first level of contact of individuals ... with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process”.

REFERENCES

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Footnotes

  • The author is an FRCPCH and MRCGP. She is currently developing training materials for primary care on child development topics with the RCGP but these are equally applicable to any group delivering primary care to children in the community.

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