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• Re: Strengthening the links between paediatrics and primary care
  Cliona M Ni Bhrolchain
  Published on: 2 March 2004
• Strengthening the links between paediatrics and primary care
  Philip MJ Wilson
  Published on: 19 February 2004

• Published on: 2 March 2004

  Re: Strengthening the links between paediatrics and primary care

  • Cliona M Ni Bhrolchain, Consultant community paediatrician

  Dear Editor

  There is further evidence supporting Wilson’s view that general practitioners (GPs) who are well supported can safely manage childhood illness. Wilson cites Vernon’s paper from Newcastle showing how GPs did not always manage childhood urinary tract infections (UTIs) well.[1] The same group proceeded to a RCT of direct access to investigations for GPs, with a nurse practitioner who supported and educat...

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  Dear Editor

  There is further evidence supporting Wilson’s view that general practitioners (GPs) who are well supported can safely manage childhood illness. Wilson cites Vernon’s paper from Newcastle showing how GPs did not always manage childhood urinary tract infections (UTIs) well.[1] The same group proceeded to a RCT of direct access to investigations for GPs, with a nurse practitioner who supported and educated the intervention practices.[2] They concluded that intervention practices diagnosed twice as many UTIs, had a more robust approach to diagnosis and started prophylaxis in young children twice as often as control practices. The incidence of scarring was reduced by half in study practices and no infants in these practices developed renal scars, compared with 12 in the control group.

  Another study tested whether GPs could use direct access to renal imaging appropriately.[3] Comparing 100 referrals with historical controls, this study demonstrated that protocol-guided direct referral for imaging decreased waiting time for imaging, had comparable yield, caused no increase in imaging requests and improved follow up. 141 outpatients appointments had been saved.

  Evidence for direct access to echocardiography is less robust. Nonetheless, a Leeds study published in 1992 found 11% of 129 GP referrals had pathological murmurs compared with 20 (53%) of 38 referrals from paediatricians and suggested that GP direct access to paediatric cardiology was justified.[4]

  We must consider alternative methods of service delivery where these are supported by robust evidence. Further trials may be needed to replicate these results, but there seems to be good reason to believe that training and supporting primary care to take a greater role in managing common childhood conditions may have advantages for children and their families and result in saving health service time.

  References

  1. Vernon S, Foo CK, Coulthard MG. How general practitioners manage children with urinary tract infection: an audit in the former Northern Region. BJGP 1997; 47:297-300.

  2. Coulthard MG, Vernon SJ, Lambert HJ and Matthews JNS. A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial. BMJ 2003; 327: 656- 9

  3. Polmear AF, Kenney IJ and Barnard SA. Should GPs have direct access to imaging for children with urinary tract infections? An observational study. BJGP 1999; 49: 115-117.

  4. Rushforth JA, Wilson N. Should general practitioners have access to paediatric cardiologists? BMJ 1992; 1264 – 1265.

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  Conflict of Interest:
  None declared.

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• Published on: 19 February 2004

  Strengthening the links between paediatrics and primary care

  • Philip MJ Wilson, General Practitioner

  Dear Editor

  Court’s plan for the installation of primary care paediatricians in child care teams working from day care centres [1] would waste resources and harm children.

  Ni Bhrolchain [2] presents evidence for the skills of general practitioners in the management of acute paediatric illness. Experienced GPs, even those without hospital paediatric training, become very good at managing risk and uncert...

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  Dear Editor

  Court’s plan for the installation of primary care paediatricians in child care teams working from day care centres [1] would waste resources and harm children.

  Ni Bhrolchain [2] presents evidence for the skills of general practitioners in the management of acute paediatric illness. Experienced GPs, even those without hospital paediatric training, become very good at managing risk and uncertainty, using ‘time as a diagnostic tool’ and providing ‘safety nets’.[3] It is no surprise that junior A&E staff are less efficient than experienced GPs in the management of medical problems. GPs do, however, make mistakes and sometimes fail to ensure appropriate investigations – urinalysis in the case of the febrile infant is just one example,[4] and there may be serious consequences of such mismanagement. The solution is not to transfer care wholesale to specialist services, but to work to improve the quality of primary care.

  The divorce of primary care paediatrics from the rest of family medicine would have other adverse consequences. Take an example from my own experience, slightly modified to prevent any possibility of identification. My practice received a paediatric teaching hospital A&E discharge note for a two year old boy stating simply “Head injury – discharged with HI instructions”. We knew the child and the family well. The mother was a problem drug user we had been treating in the practice with methadone maintenance therapy, and some, probably minor, illicit drug use had recently been noted. There certainly did not appear to be grounds for immediate referral to the Social Work Department on the basis of the A&E slip – there was no major suspicion of neglect, and referral would simply have alienated the mother. The situation was easily resolved through a discussion between GP, health visitor and drug counsellor – the health visitor simply visited the family the next day and established that the child was being well cared for. The situation could have been much worse – but the potential risk to the child would not have been detected by a dedicated paediatric service without access to knowledge of the family.

  General practices have become highly competent in the management of a variety of chronic diseases. Although the prevalence of asthma is rising, referrals of asthmatic children to paediatricians are falling.[5] Most cases are now being managed by practice nurses and GPs according to BTS guidelines. No benefit would accrue to children if their parents had to travel greater distances to a specialist child health centre for this aspect of chronic disease management.

  So, what is the alternative to separation of primary care paediatrics from family practice? It is a closer, more effective relationship. In my view, too little attention has been given to opportunities for consultation and support for GPs by paediatricians. Instead there seems to be a strategy of building increasingly high barriers between GPs and paediatric services, at least in my area. GPs in Glasgow have lost the right to arrange any paediatric imaging investigations, despite the fact that guideline-based investigation by GPs works well, saves time for patients, and can probably save resources.[6] Systems for open access to investigations are being developed apace by many hospital departments in the National Health Service – why should paediatric services be any different? Ease of personal contact is crucial to the improvement of the primary/secondary care interface – in my view paediatric services should prioritise the development of consultant-based telephone or email consultation systems for GPs. This approach could enhance the skills of GPs, reduce the number of unnecessary referrals, and, most crucially, provide an improved service delivered locally to children.

  References

  1. Court S. The future of paediatric primary care and child health. Arch.Dis.Child. 2004;89:119-20.

  2. Ni Bhrolchain CM. Who should provide primary care for children? Arch.Dis.Child. 2004;89:116-7.

  3. Neighbour R. The Inner Consultation: How to Develop an Effective and Intuitive Consulting Style. Kluwer Academic Publishers, 1987.

  4. Vernon S, Foo CK, Coulthard MG. How general practitioners manage children with urinary tract infection: an audit in the former Northern Region.[comment]. British Journal of General Practice 1997;47:297-300.

  5. Holmes NR,.Ni Bhrolchain CM. Case mix presenting to paediatricians in a UK district (1998). Public Health 2002;116:179-83.

  6. White PM, Halliday-Pegg JC, Collie DA. Open access neuroimaging for general practitioners--diagnostic yield and influence on patient management. British Journal of General Practice 2002;52:33-5.

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  Conflict of Interest:
  None declared.

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