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The future of paediatric primary care and child health
  1. S Court
  1. Correspondence to:
    Dr S Court
    Community Paediatric Department, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE, UK;

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Child care teams are well placed to deliver needs led primary care paediatrics

The central objective of paediatric primary care (PPC) should be the integration of preventative and curative health services. Delivering this objective will not be simple or the same in different health districts, but it would achieve a level of primacy if managerially it was the responsibility of the Primary Care Trust (PCT). In my opinion there should no longer be any distinction between the community paediatrician and the conventional DGH based generalist. Both need to be confident working in hospital and community; in order to understand chronic illness clinicians need to have a familiarity with home, community, and school. We need evidence based pathways of care so that a child’s need is met by the most appropriate health professional in a convenient child friendly environment and where the outcome reflects the quality of decision making at each stage. Much “secondary” care previously undertaken in hospitals is now undertaken by general practitioners, specialist nurses, and consultants in the community. The boundaries of ambulatory primary/secondary care are becoming increasingly blurred.

In 1976 the role of a general practitioner paediatrician was described but found little favour.2 Even so in many practices now, certain partners are assuming a greater responsibility for children, and are recognised by parents as the children’s doctor. Within Newcastle upon Tyne (with 40 practices distributed between three localities), there are practitioners who have a declared paediatric interest. Within localities these primary care paediatricians (PCPs) should be part of multidisciplinary Locality Child Care Teams. Team members should include.

  • PCPs

  • Clinical medical officer/staff grade/associate specialist

  • SHO(s)

  • Registrar(s)

  • The consultant(s)

  • Dietician

  • Paediatric nurse practitioner (PNP)

  • Community paediatric nurse (CpaedN)

  • School health advisers (SHA)

  • Health visitor(s) (HV)

  • Physiotherapists, speech therapists, and occupational therapists

  • Education welfare officer (EWO)

  • Social worker (SW)

  • Police

  • Named child protection personnel

  • Psychologist

  • Pharmacists.

Any service has to be needs driven and delivered by a team with complimentary skills. Each locality has its particular mix of social and clinical challenges. If practical, teams should work from children’s day care centres (CDCCs)3 or polyclinic within the locality. The following would be the responsibility of locality child care teams:

  • Public health of all children in the locality (to include health promotion/accident prevention/immunisation)

  • Initial diagnosis and investigation of children with developmental delay

  • Recognition and management of child protection (CP)

  • Initial management of acute illness and uncomplicated chronic illness.

  • Management of growth problems

  • Responsibility for looked after children and adoption medical service

  • School health.

Of necessity the service will be delivered in different sites (home, school, CDCC) by members of “functional teams” drawn from the above list of professionals. Examples of locality functional teams might include:

  • Behaviour/mental health (ADHD, autism, truancy, bullying)

  • Child protection (parenting, sleep and crying management, social exclusion/LAC/adoption)

  • Disability

  • Nutrition

  • Illness (acute, chronic).

Co-location of core staff within functional teams is important, perhaps particularly for child protection (teams will include SW, police, EWO, and named CP health professionals). Extending the model of community based management of growth faltering,4 the “functional nutrition team” would include consultant plus trainee, dietician, HV, CpaedN, PCP, SHA, SW, and behaviouralist. This would allow the team to encompass breast feeding, weaning, healthy eating, healthy schools, height screening, constipation prevention, eating disorders, obesity prevention, and gastrostomy care. A constipation service, for example, requires an initial “medical” review; with frequent contact by CpaedNs providing necessary support. Attendance at a consultant or PCP clinic can be minimised by scheduled notes review of the locality case load by all involved practitioners, identifying patients needing an appointment. This model of empowered nursing plus joint medical review could be applied to other chronic illness, reducing clinic review in hospital for children who remain well, for example, asthmatics or epileptics.

Members of the “functional illness team”, particularly community based generalist trainees together with their consultants, could “in reach” into local hospitals by rotation. Much acute work is/could be dealt with by junior paediatric staff5 and PNPs. The day to day running of the acute unit (A&E, day ward, short stay unit) would be undertaken by PNPs,6 together with registrar/staff grade doctors, overseen by the consultants who would have both hospital and community responsibilities. The “acute” pathway of care starts with parents, some using NHS Direct, and ends with a consultant; triage remains an essential element undertaken by PCPs or PNPs. In the community, consultants would work alongside PCPs and other members of the illness team (PNPs, CpaedNs) undertaking clinics within a locality CDCC, covering general referrals (for example, headache, abdominal pain, growth problems, enuresis, constipation, asthma, behaviour and development problems, fits and “funny turns”, or possible congenital anomalies). In progressing along the care pathway it should only be necessary to see a tertiary specialist once accepted thresholds for onward referral have been reached.

Until recently children were not seen as politically important; the climate is now changing. The government, in the recent green paper,7 identifies accountability as a priority. If health professionals are to be accountable, they need appropriate training to meet defined responsibilities; outcomes should be audited and training updated.

We know that a sizable minority of GPs receive little further postgraduate training. If the generalists of tomorrow are to work in managed networks and multiple small focused teams, trainees need to be exposed to this model from the start.

Child care teams that include general paediatricians, paediatric nurse practitioners, primary care paediatricians, as well as other disciplines are well placed to deliver needs led primary care paediatrics working from a locality base. Some members will “in reach” into the local hospital unit undertaking secondary care. Training should be largely community based. Pathways of care should be followed, with referral to tertiary services only when accepted thresholds have been reached.

Despite our best efforts hospitals remain frightening, unfamiliar, and at times dangerous places for children. In the broad context of childhood illness, only in a small percentage of cases are hospitals the necessary forum for care. Most childhood illness is or should be dealt with outside hospital. The essence of this proposal has been reviewed in Strengthening the care of children in the community.1

Child care teams are well placed to deliver needs led primary care paediatrics