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Primary care trusts are advertising; is anyone listening?
To the armchair pundit, advertisements are always a useful antidote to the soporific parts of the scientific journal or television programme. Brief, dramatic, witty, or sentimental, they painlessly separate us from our hard earned cash. Advertising for new consultants is less sophisticated, subtle, or humorous, remaining largely reliant on “glorious countryside and local good schools” which are apparently endemic in all corners of the British Isles. However, the study of consultant advertisements can be illuminating and should be introduced to all junior doctors as a special study module, since they give invaluable information about how commissioners propose to invest scarce health resources on local children. Have paediatricians read the subliminal messages?
Every year, over 300 substantive consultant posts in paediatrics are advertised in the British Medical Journal. For the past five years, approximately 40% have been for community, neurodisabilty, or ambulatory posts. No other paediatric specialty gets remotely close to this figure. In second and third place respectively were acute general paediatrics and neonatology. The number of advertised posts in every other paediatric specialty rarely achieves double figures. British children seem to need generalists working outside hospital boundaries, not “ologists” working in tertiary centres.
Another useful source of information about British children is the statistics regularly produced by the Department of Health.1 There are 11.7 million dependent children in England and Wales; a number greater than the populations of countries like Sweden, Belgium, Portugal, or Greece. British children are disproportionately present in low income households, 2.6 million live in lone parent families, and 2.7 million live in low income households.
Of the 376 000 children “in need”, 13% have a disability. Local authorities look after 59 700 children. There are 12 600 unaccompanied asylum seeking children.2 Every year, 3600 children are placed for adoption, 27 500 children are placed on child protection registers,1 and 90 000 teenagers become pregnant.2
Of the 320 000 disabled children, 110 000 are severely disabled; 1.7 million children pupils have special educational needs, including 250 000 children with statements of special educational needs.2
At least 250 000 children live with a parent who has a serious drug problem.3 Ten per cent of children aged 11–15 are regular smokers, 24% have tried alcohol, 12% cannabis, 4% stimulants, 1% opiates, and 35% had been offered drugs.4 The prevalence rate for problematic psychological conditions in childhood is 20%, increasing to 68% in deprived areas.5
Non-acute, non-hospital work is growing rapidly. Increasing numbers of low birth weight babies survive. There are more children with disability, more affected by abuse and neglect, more behaviour problems, more school exclusions, and a growing public demand from parents desperate to see “a specialist”.
WHERE ARE THE DOCTORS WHO WILL CARE FOR CHILDREN OUTSIDE HOSPITALS?
If recruits are the life blood of a service, then community paediatric services are terminally ill. In 2002, the British Association of community Child Health (BACCH) tried to identify the number of specialist registrars in training for community posts. Of approximately 1000 national training numbers (NTNs) in England and Wales, only 88 were identified as training in community. All these doctors were written to twice to try to identity how many actually intended to become community paediatricians. Only 38 specialist registrars responded with firm intentions of pursuing a community career.6
WHY IS COMMUNITY WORK SO UNPOPULAR?
Community paediatrics is in crisis for a number of reasons. There is widespread disparagement of work still considered to be something of a “soft” option. “Married women earning pin money in the community” was a recent description by a senior colleague. Academic and tertiary services are focused largely on organ and system disease and insufficiently interested in the major child health issues affecting UK children. Professional kudos is still reserved for paediatricians treating rare diseases in small numbers of children.
Community activity is rarely recognised in official statistics or waiting lists. Community services rarely have sophisticated monitoring systems, waiting list managers, or even accurate referral data. It is often forgotten that in addition to general practitioners; parents, teachers, therapists, and social workers refer children directly to community paediatricians. This uncounted work, which bypasses the commissioners, counts heavily against community services in an era dominated by resources attached to waiting lists and targets.
Outside child development centres, facilities in the community are generally poor. Children are often seen without nurses, background information, or equipment, in rooms without toys or spaces to play. Problems providing high quality secondary and tertiary community services are often exacerbated by difficulties in accessing hospital facilities, test results, or medical records.
The skills needed to provide good care outside a protected hospital environment are not taught at either medical school or in postgraduate training. The unexpected complexity of the work, particularly when a doctor is unsupported, can lead to isolation and vulnerability. A specialist registrar with outstanding qualifications and clinical skills described running a clinic on a deprived estate as the “most terrifying thing” she had ever done.
THE SOFT OPTION IS NO LONGER SOFT
The first paediatricians were community doctors employed in schools and infant welfare clinics run by local authorities, at the end of the nineteenth century. Adult physicians on adult wards saw acutely ill children. Acute paediatrics as a specialty began with the formation of the British Paediatric Association in 1928, but only really became established after the Second World War.
In 1989, when the first edition of Health for all children7 was published, our team of 16 community doctors saw every child at 6 weeks, 8 months, 24 months, 39 months, 5 years, 7 years, and 11 years. The routine examination of 14 year olds had just stopped despite protests from parents, teachers, and school nurses. Three editions and 14 years later, paediatric work in the community work has changed beyond recognition. The old, defect detecting, universal, medical model of child health no longer exists. Community paediatrics is now secondary or even tertiary level work that is both consultant led and consultant delivered.
This change has accelerated as the political climate has changed. The government committed to reducing inequalities proposes substantial investments in early years, child mental health, and education. The National Service Framework for Children (NSF) and Children’s’ Trusts are on the horizon. Beleaguered, shrinking community services are expected to deliver the bulk of these initiatives. Most consultants now have in-trays several inches high, full of long awaited government directives but no staff to put them into place.
Medical support to social services has increased with the introduction of designated and named doctors for child protection and for looked after children. The statutory Framework for the assessment of children in need8 requires the holistic medical assessment of children with complex social problems. Every district needs a senior doctor responsible for educational medicine and the statutory statementing process for special educational needs. There are increased numbers of health assessments on looked after children and new targets in adoption.
Vaccination rates, especially MMR uptake, are dependent on experienced immunisation coordinators working with primary care teams. New national campaigns like meningitis C and Hib have been implemented, and new vaccinations and new screening programmes are waiting to come on stream.
Every primary care trust must offer a full range of services for children with disability from diagnosis to school leaving age. Mental health resources are scare. In their absence, community paediatricians largely manage the complex emotional and behavioural problems of disabled children, together with attention deficit hyperactivity disorder and the autistic spectrum disorders. Audiology, enuresis, and encopresis clinics, small but invaluable community services, have serious recruitment problems The work is fascinating, challenging, never dull, and can only be delivered by experienced doctors willing to work long hours in a complex multidisciplinary and multi-agency environment.
In 1963, another doctor, Dr Beeching looked at rail services in the United Kingdom. Rarely used branch lines were ruthlessly pruned and only large, cost effective, busy main lines survived. Where branch lines survived, communities flourished; where they no longer existed, communities were condemned to progressive isolation as petrol became more expensive. Forty years later, after global warming, spiralling oil prices, and the development of energy, efficient trains, this short-sighted rationalisation is seen in a new light. Without the basic infrastructure a holistic twenty first century transport policy is difficult to develop.
Sadly, British community child health has undergone a “Dr Beeching” rationalisation. The complex network of community services, the branch lines that would allow new service development, have disappeared and will not be easy to replace. Successive generations of managers saw little point in retaining services not on a priority “must do” list that were perceived as unimportant or could be undertaken in primary care.
Our team of 16 doctors is now reduced to seven and our specialist registrar was withdrawn. Six doctors will retire within five years. We retain our enthusiasm and commitment and continue a campaign of hopeless advertising, but there are vacant community consultant posts in every surrounding local district. Appointment committees mainly interview existing consultants, thus transferring vacancies to other districts.
A recent BACCH document9 estimates that the average district population of 250 000–300 000 requires a minimum of 4.6 whole time equivalent (wte) consultant community paediatricians to provide good enough care and fulfil all the statutory obligations on the service. Disadvantaged populations with higher rates of disability and social need will require more than this minimum. In addition to consultants, all community child health services are still heavily dependent on non-consultant, career grade paediatricians, and workforce estimates also show a rapid decline in the numbers of these doctors. As career grade numbers decline, services will need to be maintained by the creation of new consultant or associate specialist posts, and there are virtually no doctors in training. Urgent action is required.
The distinction between the acute and community paediatrician needs to disappear. Both are consultants delivering secondary care; both need access to facilities that will help them to fulfil their roles. The future must also see hospital paediatricians spending significantly more time in the community.
Training in community child health needs to be systematically increased. Enthusiastic well resourced departments have a much greater success rate in attracting scarce specialist registrars. All undergraduates need basic training in disability, child protection, child mental health, and the impact of deprivation. The time devoted to community training for general practitioner registrars, senior house officers, and specialist registrars needs to increase considerably. Doctors in training need more than knowledge. The competency to manage a problem is gained not in the minimum six month community placement currently recommended but by years of experience. Change must therefore occur while there are sufficient numbers of enthusiastic community paediatricians with the time to teach, mentor, and support young doctors while they develop their skills.
Specialist registrar “ologists” must know how to access educational and social provision for their patients and families. Children will survive and go to school for many years after the initial investigation and diagnosis. A child’s prognosis and quality of life depends as much on social support for their parents and educational provision as on diagnostic acumen or surgical skill.
Most radical of all, perhaps the time has come for national training numbers to be allocated on the basis of what British children need rather than the career aspirations of paediatricians. We are after all spending public money. Practically this would mean at least 40% of NTNs being reserved for paediatricians intending to work largely in the community.
The beginning of the NSF for children states clearly that hospital care is no more important to children than other health services. Indeed for most children, most of the time, hospitals are thankfully irrelevant. Hospitals and presumably paediatricians cannot continue to stand apart from the rest of the health and social care system.10 Our children are much too valuable.