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The basic philosophy must be that will need to be served by ‘‘Tesco Metro’’- Emergency assessment is at the hin- services are built around the needs of style facilities. Perhaps ‘‘Extra’’ terland between primary and secondary the child, not of the professionals. The (24 hours) and ‘‘Metro’’ (8 ‘til late) care. The work perhaps needs to be best possible care must be provided as would be concepts that the public would undertaken by a mixture of those close to a child’s home as possible. understand! currently designated as primary or The ideas set out in Strengthening the Who would staff such a facility? secondary care staff. They could both care of children in the community4 and Nurse practitioners or nurse consultants do the job and enhance local services for ‘‘Paediatrics 2010’’5 suggest we should could be involved as the frontline, with children. be moving towards a model of locally consultant back up either on-site or at Perhaps the time for the court’s GPP delivered services with rapid access when least rapidly available. We know that a has arrived at last? necessary to whatever care is required. third year paediatric registrar can han- Arch Dis Child 2004;89:112–113. I envisage each locality having an dle the majority of acute presentations doi: 10.1136/adc.2003.040642 emergency assessment unit. This is without any back up. The Department of likely to be based in a hospital, within Health’s proposals for shortening the Correspondence to: Dr A Craft, Dept of Child 6 Health, Royal Victoria Infirmary, Newcastle the paediatric department or next to minimum length of training for award upon Tyne, UK; [email protected] A&E (ideally close to both). The hospital of a CCT entry onto the Specialist itself may not have overnight paediatric Register and ability to apply for a inpatients. It will be staffed during consultant post would suggest that we REFERENCES daytime and evening hours by trained might modify our training so that by the 1 Court SDM. Fit for the future. The report of the staff. These may be a combination of end of, say, five years post registrate committee on child health services. London: doctors and nurses. Such a facility training, we could produce ‘‘consultant HMSO, 1976. would be ideal for training but would emergency paediatricians’’. An alter- 2 Department for Education and Skills. Every child matters. London: The Stationery Office, 2003. not rely on trainees to provide the native for staffing these emergency 3 Nuffield Trust. Measuring General Practice. service. When the facility is closed out- assessment units would be to involve Nuffield Trust, 2003. of-hours the local public must be edu- experienced general practitioners. There 4 Royal College of Paediatrics and Child Health. cated to try and adjust their time of are an increasing number of GPs devel- Strengthening the care of children in the community. London: RCPCH, 2002. attendance. There are very few children oping a special interest, known as 5 Royal College of Paediatrics and Child Health. who suddenly become ill out-of-hours. GPuSI.7 With appropriate interest and The next ten years: educating paediatricians for However a mechanism to deal with such training there is no reason why they new roles in the 21st century. London: RCPCH, 2002. sick children needs to be in place. should not be involved as full members 6 Department of Health. Modernising medical The public has been led to expect 24 of such a team looking after the careers: the response of the four UK health hour service, whether it be for super- emergency unit. ministers to the consultation on ‘‘Unfinished Business: Proposals for Reform of the Senior markets or healthcare. These attitudes Primary Care Trusts are ultimately House Officer Grade’’. London: Department of must change if we are to staff the health responsible for out-of-hours primary Health, 2003. service adequately and economically. care, so they might be persuaded to 7 Department of Health and Royal College of General Practitioners. Implementing a scheme for We may be able to provide a ‘‘Tesco divert funds to appropriately staff an general practitioners with special interests. DH, Extra’’ service in some areas, but others emergency assessment unit. 2002.

Primary care paediatrics and child health Primary Care Trusts have prioritised ...... identifying GPuSIs who are trained and skilled in procedures such as endo- scopy, or able to help reduce costs or The future of primary care paediatrics waiting times in specialities such as ENT, or musculoskeletal medicine. and child health Experience in other specialties has shown that GPuSIs may become valued E Peile either by taking formal or informal referrals from less experienced gener- ...... alist colleagues, or by leading and developing a local service.4 Quality Patterns, trends, and influences in child health assurance,5 and the need to certify the necessary competencies6 are being don’t anticipate tomorrow’s children parenting, about societal influences, and addressed. Issues remain around how a will be very different from today’s. about workforce issues. paediatric GPuSI may best fit into local IMore extreme pre-term survivors, contexts;7 new appointments should, I maybe; growing taller perhaps, and GENERALIST AND SPECIALIST believe, only be made to satisfy a case of certainly more likely to be obese, these Nearly 30 years ago, Donald Court, need in the locality. children are likely to be subjected to whose report drew heavily on the ever increasing pressures to perform in wishes of parents, raised the notion of FOR RICHER, FOR POORER; IN their schools and conform in their the ‘‘GP paediatrician’’.1 The general SICKNESS AND IN HEALTH streets. There is something timeless practitioner with special clinical inter- Over the past 20 years, GPs have seen about childhood, but child healthcare ests (GPuSI) has resurfaced in the enormous changes in parental beha- is as subject to the fads and fashions of NHS Plan.2 Already as many as 4000 viour, both in respect of the sick child the era as is the nurturing process. In general practitioners (GPs) specialise,3 and the well one. The pattern remains planning primary care paediatrics, we but rarely in paediatrics. This is not one of significantly higher consultation need to look further than the child. for lack of GPs with expertise or rates in children from socially disadvan- We need to think about parents and interest in paediatrics; the reason is that taged families for minor to serious

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PREVENTATIVE CARE Examples of local cases of need for a paediatric GPuSI appointment Nowadays, parents of well children, deliberating about immunisation deci- N Providing a satellite service for a group of practices in a remote location, sions, are perhaps less influenced than to reduce the need for children to travel to specialist centres former generations by the views of family practitioners and health visitors, N Augmenting a community paediatric service where there are skill and perhaps more influenced by media shortages and net searching. The credibility of N Undertaking practice based follow up of specific chronic conditions to health visitors and GPs depends on up- reduce attendance at hospital clinics to-date knowledge of the paediatric N Initiating new direct access primary paediatric services targeted at certain evidence base, and professionals need population groups (for example, homeless people, travellers, and asylum to be expert at interpreting the informa- seekers) tion for the particular parent and child. Modern childcare arrangements have N Enhancing acute services for minor paediatric conditions (daytime or out- encouraged more parents to work full of-hours) time, and if we really want to reach parents, we will have to balance reduced out-of-hours responsibilities with increased availability for preventative illnesses with correspondingly higher LOCUS OF CARE healthcare at extended practice hours. home visiting rates. The concern is that One thing seems likely: cost pressures these families also have lower rates of will accelerate the trend for fewer home child health and preventive consulta- visits. If parents are expected to bring a NEW WAYS OF LEARNING FOR tions.8 The trend is for all social classes sick child to a health centre or on-call NEW WAYS OF WORKING to call on primary care earlier in the base, why not to one with child obser- The implications of future gazing are important for learning. As the Children evolution of a child’s illness. vation facilities? An example of poten- Care Group Workforce Team rethinks Anecdotally at least, there is a domino tial benefits is that better detection of training in the light of current changes effect, whereby more risk averse par- urinary tract infections might result in NHS planning, they have appropri- ents, fearing to nurse their feverish child from better facilities to collect samples ately prioritised communication skills at home, pass their anxiety on to GPs. from febrile infants. and leadership.19 Enhanced skills in Their higher call rate results in higher In paediatrics, as in other specialties, demands on hospitals, many of which evidence based child care, and satisfac- gatekeeping is cited as part of the role of tory ways of updating about rare but have responded by increasing facilities the general practitioner, but yet when important conditions in primary care20 for short term observation rather than the Americans introduced primary care are other priorities. If clinicians are to inpatient admission. The benefit of early gatekeeping in the delivery of services become comfortable disrespecting the hospital contact is debated. As hospital for some children with chronic condi- boundaries between primary and secon- admission rates for asthma in young tions, there was a reduction in visits to dary care,21 between hospital and com- children have increased, the mortality specialists, but also, worryingly, less munity, and between different nursing rates have declined,9 but case fatality contact with primary care doctors, who and medical backgrounds, they need to rates for meningitis have shown little were thus unable to provide the care spend time learning with, from, and about change.10 The Commission for Health 16 previously supplied by specialists. each other. Effective interprofessional Improvement (CHI) cites ‘‘enhanced Other European countries base their learning is crucial. Primary care paedia- primary care’’ as a factor in reducing systems around primary care paediatri- tricians will probably gain more from con- emergency admissions to hospital of 17 cians. It may be best to let parents textual learning in the community, than children with lower respiratory infec- choose whom to consult! from extending time in the hospital setting. tions, which is an indicator of service Community paediatricians, hospital 11 Arch Dis Child 2004;89:113–115. quality. specialists (both medical and nursing), doi: 10.1136/adc.2003.040741 GPuSIs, and community paediatric OUT-OF-HOURS SERVICES nurses could between them manage in Correspondence to: Professor E Peile, the community much of the present Director of Medical Education, The University of Although nurse triage as part of an on- Warwick, Coventry CV4 7AL, UK; call service has been shown to be safe, workload of hospital outpatient [email protected] efficient, and effective,12 NHS Direct has clinics. Primary care collaborations are done little to reduce the calls on general increasing; at the Personal Medical practitioner services.13 14 Many, if not Services (PMS) project where I have REFERENCES most, GPs will opt out of out-of hours been working, the records for 26 000 1 Court SDM (Chair). Fit for the future: The Report 15 of the Committee on Child Health Services. services from April 2004, but there is patients were available on-line at any of London: HMSO, 1976. little indication, as yet, of the nature of three surgeries. It often helps if clin- 2 Secretary of State for Health. The NHS the services that Primary Care Trusts icians, reviewing the child with cystic Plan: a plan for investment, a plan for reform. London: Stationery Office, 2000. will organise to replace doctor’s co- fibrosis, growth problems, or diabetes, 3 Jones R, Bartholomew J. General practitioners operatives. Commercial deputising may can see and contribute to the primary with special clinical interests: a cross-sectional increase, as may the (cheaper) use of care records, prescribing on the same survey. Br J Gen Pract 2002;52:833–4. 4 Williams S, Ryan D, Price D, et al. General nurse led services. Will these involve database, and making management practitioners with a special clinical interest: a specialist teams? As the generalist suggestions that all doctors and nurses model for improving respiratory disease retreats to daytime service, could night- will be able to see at future contacts. management. Br J Gen Pract 2002;52:838–43. 5 Royal College of General Practitioners. General time calls about sick children be triaged There is a caveat, as studies of hospital practitioners with special clinical interests. to paediatric trained nurses and doc- outreach clinics in other specialities London: RCGP, 2001. tors? I see another potential role for the have shown that, although popular 6 Royal College of Paediatrics and Child Health. Competencies of the primary health paediatrician. GPSCI here, linking closely with hospi- and effective, they may incur higher Reference paper for Diploma of Child Health tal colleagues. NHS costs.18 Examinations Board. London: RCPCH, 2003.

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7 Rosen R, Stevens R, Jones R, General practitioners 12 Lattimer V, George S, Thompson F. Safety and expenditures and utilisation for children. with special clinical interests. BMJ 2003;327:460–2. effectiveness of nurse telephone consultation in Pediatrics 2001;108:283–90. 8 Saxena S, Majeed A, Jones M. Socioeconomic out of hours primary care: randomised controlled 17 Murphy JFA. The role of gatekeeping as a tool in differences in childhood consultation rates in trial. BMJ 1998;317:1054–9. healthcare delivery. Ir Med J 2001;94:292. general practice in England and Wales: 13 Munro J, Nicholl J, O’Cathain A, et al. Impact of 18 Bowling A, Bond M. A national evaluation of prospective cohort study. BMJ 1999;318:642–6. NHS Direct on demand for immediate care: specialists’ clinics in primary care settings. Br J Gen 9 Lung and Asthma Information Agency. Trends in observational study. BMJ 2000;321:150–3. Pract 2001;51:264–9. hospital admissions and deaths from asthma. 14 Chapman R, Smith GE, Warburton F, et al. 19 Children Care Group Workforce Team.A London: St Georges Hospital Medical School, Impact of NHS Direct on general practice general update on workforce planning and 2002. consultations during the winter of 1999–2000: development in relation to children and maternity 10 Goldacre M, Roberts E, Yeates D. Case fatality analysis of routinely collected data. BMJ services. http://www.doh.gov.uk/cgwt. rates for meningococcal disease in an English 2002;325:1397–8. Accessed 18 October 2003. population, 1963–98: database study. BMJ 15 NHS Confederation. Out of hours services under 20 Peile E. Commentary: learning to stay vigilant 2003;327:596–7. the new GP contract. http:// about conditions that are rare but important. BMJ 11 Commission for Health Improvement. Rating the www.nhsconfed.webhoster.co.uk/docs/ 2003;327:919. NHS: 2002/3 NHS performance ratings. http:// 4outofhourse.pdf. Accessed 18 October 2003. 21 Pringle M. Please mind the gap: addressing the www.chi.nhs.uk/eng/ratings/2003/. Accessed 16 Ferris TG, Perrin JM, Manganello JA, et al. divide between primary and secondary care. Clin 18 October 2003. Switching to gatekeeping: changes in Med 2001;1:172–4.

Primary care paediatrics and child health framework of caring for families over ...... time. Artificial separation of children’s health care runs contrary to these principles, and risks the sidelining of The future for child healthcare provision child health care issues from main- stream primary care. A risk that already within general practice exists with the disappointing lack of emphasis on child health within the D Sowden new GMS contract. If we are to accept the premise that ...... there has to be an integral child health Children’s health remains an integral element of general practice care service in GP, then how it will be delivered, and how relevant staff might be trained becomes the area for most n common with other healthcare will the government’s aspirations for a productive debate. services in the United Kingdom, gen- consultant delivered service.23 This article is too short to consider the Ieral practice (GP) is faced with an I would suggest these will prove critical roles of all relevant non-medical ever increasing pace of change which is significant enough challenges without professionals but the future will clearly best highlighted by the implementation expanding the work of paediatricians be multiprofessional and team based. and implications of the new GP (General into the initial presentation of child The structure and leadership of these Medical Services, GMS) contract. illness in primary care. teams will vary across England in line In the light of these changes, the From a GP perspective, there is also with differences in the population and increasing expectations of parents, the the considerable importance of main- the available professional workforce. escalating presentation of disease, ill taining a holistic and family based There will be little future for doctors health, and mental health issues approach. Children remain an integral unable or unwilling to work effectively amongst children, it seems reasonable part of families in the United Kingdom, in such an environment. to ponder the future for child health and cannot be seen as an isolated The following concentrates on a care provision within GP. population. While it will be difficult to future model for training general practi- It seems reasonable to expect there to maintain historic levels of continuity of tioners and how child health services be a comprehensive child health service doctor delivered care, general practice might be delivered in primary care in GP because the frequency of presen- has a long history of innovative team organisations (PCOs). tation of acute illness and the ongoing based approaches to care4 and through While much has been done to refine management of certain key chronic this route current services should be general practice vocational training, since diseases are likely to be beyond the both maintained and refined. The key its formal inception in 1979, the present capacity of any rational existing and role of the general practitioner as NHS arrangements ensure that only one third future secondary care/mental health and gatekeeper and manager of risk needs of training takes place in GP. Therefore, community paediatric service plan. The careful evaluation before major changes both the context and the control of the Wanless report1 highlights the inade- are implemented and these roles poten- educational experience is out with the quacy of the doctor population in the tially lost. control of the discipline of GP and its United Kingdom for the foreseeable Primary care paediatricians could, educators. GP is the only recognised future. It is therefore remarkably unli- however, be seen as a logical extension specialty for which this is the case. kely, even with the Children’s National of the government’s patient choice Unfinished business5 and Modernising Service Framework (NSF), that the agenda. If the evidence base were to medical careers6 provide an opportunity number of paediatricians will expand to support this development there could be to radically change the arrangements for any significant extent at the expense of little objection. However, currently we vocational education for general prac- other medical or surgical disciplines have little or no evidence that paedia- tice. It may allow the implementation of where performance targets remain. tricians based in primary care within UK a three year programme based in GP The implementation of the European health services are even as effective as with planned release to specialist hospi- Working Time Directive (EWTD) will general practitioners. Effective GP is tal and community settings. This will have a major impact on the organisation about the synergy of physical, psycho- allow all future GPs to be trained in rele- and provision of paediatric services, as logical, and social care within the vant child health practice, in particular

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