• out of hours care

It is now just over 25 years since Donald Court reviewed paediatric services in the UK. The only major recommendation that was not eventually implemented was the concept of a general practitioner paediatrician (GPP).¹ Court recognised the importance of strengthening the care of children wherever they might be: in the hospital, community, or in general practice. Recent years have seen an integration of hospital and community paediatric services which has resulted in better care, especially for vulnerable and disabled children. The government’s new Green Paper,² which puts an emphasis on integration of education, social care, and aspects of health, does potentially threaten to destabilise the integration of paediatric services. We must be aware of the danger and find a way of working across boundaries. The green paper was driven by the horror of the murder of Victoria Climbié and we must all try to ensure that in a further 25 years we are still saying that we have not learned the lessons that date back to the tragedy of Maria Colwell in the 1970s. Paediatric services are inevitably changing and child protection is just one of the driving forces. The implementation of the European Working Time Directive for trainee doctors in 2004, changes in morbidity, greater public expectation from parents, and the falling birth rate are just some of the issues which force us to rethink how, where, and by whom paediatric services should be delivered.

The most obvious change in recent years has been the vastly increased numbers of children who attend hospital for emergency assessment when they are perceived by their parents to be ill. Many can be seen and immediately reassured that there is nothing seriously amiss, while the majority of the rest can be sent home after a short period of observation. There appears to have been a substantial shift of work from general practice to hospital, although this is difficult to quantify. The greater number of children attending hospital could genuinely be due to greater parental anxiety. But it is also fuelled by difficulty in access to out-of-hours general practice care and by NHS Direct. Most such care is now provided through cooperatives that are staffed by GPs working shifts of six to eight hours. This makes it difficult for a GP to see a potentially sick child and to review them again within the same shift. There is an understandable reluctance to hand on to the next shift so that the safest thing to do is to send the child up to hospital where a short period of observation will be possible. The new GP contract which will allow them to opt out of night-time cover is likely to increase the flow of such patients. We must accept that this change in pattern of referral is inevitable and unlikely to be reversed, at least in the medium term. Services must be designed and staffed to cope with this workload.

The vast majority of children who are perceived to be ill have always been seen in general practice. They form a substantial part of any GP’s workload. Indeed general practice is a fundamentally important part of the NHS in the UK. Over 99% of the population are registered with a family doctor. Ninety five per cent of consultations in the NHS are conducted in primary care, and 80% are dealt with by primary care teams with no involvement of hospital specialists.³ During the day, sick children will continue to be cared for by GPs and this is to be encouraged and supported. However, out-of-hours the situation is different. Although general practice will have a role, the number who are proposing to opt out of night-time cover makes it likely that a different and appropriately funded situation needs to be found.

The basic philosophy must be that services are built around the needs of the child, not of the professionals. The best possible care must be provided as close to a child’s home as possible.

The ideas set out in Strengthening the care of children in the community⁴ and “Paediatrics 2010”⁵ suggest we should be moving towards a model of locally delivered services with rapid access when necessary to whatever care is required.

I envisage each locality having an emergency assessment unit. This is likely to be based in a hospital, within the paediatric department or next to A&E (ideally close to both). The hospital itself may not have overnight paediatric inpatients. It will be staffed during daytime and evening hours by trained staff. These may be a combination of doctors and nurses. Such a facility would be ideal for training but would not rely on trainees to provide the service. When the facility is closed out-of-hours the local public must be educated to try and adjust their time of attendance. There are very few children who suddenly become ill out-of-hours. However a mechanism to deal with such sick children needs to be in place.

The public has been led to expect 24 hour service, whether it be for supermarkets or healthcare. These attitudes must change if we are to staff the health service adequately and economically. We may be able to provide a “Tesco Extra” service in some areas, but others will need to be served by “Tesco Metro”-style facilities. Perhaps “Extra” (24 hours) and “Metro” (8 ‘til late) would be concepts that the public would understand!

Who would staff such a facility? Nurse practitioners or nurse consultants could be involved as the frontline, with consultant back up either on-site or at least rapidly available. We know that a third year paediatric registrar can handle the majority of acute presentations without any back up. The Department of Health’s proposals for shortening the minimum length of training⁶ for award of a CCT entry onto the Specialist Register and ability to apply for a consultant post would suggest that we might modify our training so that by the end of, say, five years post registrate training, we could produce “consultant emergency paediatricians”. An alternative for staffing these emergency assessment units would be to involve experienced general practitioners. There are an increasing number of GPs developing a special interest, known as GPuSI.⁷ With appropriate interest and training there is no reason why they should not be involved as full members of such a team looking after the emergency unit.

Primary Care Trusts are ultimately responsible for out-of-hours primary care, so they might be persuaded to divert funds to appropriately staff an emergency assessment unit.

Emergency assessment is at the hinterland between primary and secondary care. The work perhaps needs to be undertaken by a mixture of those currently designated as primary or secondary care staff. They could both do the job and enhance local services for children.

Perhaps the time for the court’s GPP has arrived at last?