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Since 1991 there has been talk of abolishing community paediatrics as a specialty.1 At that time, a group of related specialties was proposed: a specialty of child development and rehabilitation (neurodisability); child protection would be subsumed into general paediatrics and there would be child public health doctors. Since then there has been a view among some paediatricians that community paediatricians should become the general paediatricians of the future.2,3 Dr Chambers’ recent article proposes a narrow view of community paediatrics, concentrating on chronic illness and confining its role to diagnosis and medical management.4 He rather misses the point.
The challenge of community paediatrics
Children do not come in neat packages, with diagnostic labels. They and their families need all their needs met. Hospital practice traditionally concentrates on the illness, not the patient, although this is becoming less with time and paediatricians have always been more holistic than adult counterparts. Hospital practice often deals with complex problems by having specialists for each problem. Our adult physician colleagues are beginning to realise that doesn’t work and are reinventing the general physician.
It has been shown that community paediatric patients have significantly more complex problems than those presenting to general paediatricians.5 Many of the conditions we diagnose and treat have no diagnostic tests. Community paediatricians need excellent clinical skills, must be able to manage complexity and uncertainty, and must have the ability to communicate across disciplines and across agencies, creating understanding in those who come from different backgrounds and with different agendas. It is not an easy job.
The National Service Framework
The NSF was constructed by multidisciplinary groups including parents. It is therefore no accident that child health, not illness, is emphasised. Hospital practice has rather less emphasis than crosscutting “out of hospital” issues. Communication, coordination, and early intervention are all key themes. Parents and our sister agencies value medical input that is holistic, available where it is needed (not just in the clinic), and attuned to the needs of the child and family in the community. They demand more of it than we can currently give. Nevertheless, child health outside hospital has moved up the agenda and it will be hard for local authorities to deliver Every Child Matters without focused child health support to education, social, and voluntary services, as well as child health per se. This new agenda requires exactly the skills community paediatricians have. If community paediatricians did not exist, it would be necessary to invent them to deliver the NSF. The challenge is how we tackle it.
Competing interests: Dr Ni Bhrolchain in a Specialty Training Advisor in Community Child Health. These views are her own.
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