Paediatrics in Primary Care out of Hours Care

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Primary care paediatrics and child health may be potential pitfalls; not least Arch Dis Child: first published as 10.1136/adc.2003.040642 on 21 January 2004. Downloaded from ...... whether these concepts fit with current ideas of service planning by general practitioners and health service Paediatrics in primary care managers. Hence we have asked a range of T Waterston, N Mann experts with specific expertise to describe their perspective on the future ...... of paediatric primary care and the interface with secondary care, as well A new series as seeking the perspective of the RCPCH. These issues are for debate and we encourage readers to contribute ncreasingly the future organisation of Whilst the Court Report in 1976 (‘‘Fit their views through a rapid response. paediatrics at secondary level, the for the Future’’) introduced the concept Arch Dis Child 2004;89:112. Iplace of first referral, depends greatly of the GP paediatrician, this was doi: 10.1136/adc.2003.046235 on the organisation and quality of care intended to be a GP with additional at primary level. The ability of paedia- training rather than a trained paedia- ...... tricians to influence primary child trician, as we know it today. Authors’ affiliations health care is limited at present to Clearly there are many potential T Waterston, Guest editor advocacy and training, but recently benefits of paediatricians working in N Mann, Commissioning editor, ADC some have been expressing the view primary care to provide specialist care that we in the UK should follow US and and manage chronic conditions. Some Correspondence to: Dr N Mann, Dept of Paediatrics, Royal Berkshire Hospital, London European practice in developing the also argue the case for management of Road, Reading RG1 5AN, UK; concept of primary care paediatricians. acute illness at this level. However there [email protected]

Primary care paediatrics and child health cooperatives that are staffed by GPs ...... working shifts of six to eight hours. This makes it difficult for a GP to see a potentially sick child and to review them Out of hours care again within the same shift. There is an understandable reluctance to hand on to A Craft the next shift so that the safest thing to do is to send the child up to hospital ...... where a short period of observation will A personal view be possible. The new GP contract which will allow them to opt out of night-time

cover is likely to increase the flow of http://adc.bmj.com/ t is now just over 25 years since changing and child protection is just one such patients. We must accept that this Donald Court reviewed paediatric of the driving forces. The implementa- change in pattern of referral is inevitable services in the UK. The only major tion of the European Working Time I and unlikely to be reversed, at least in recommendation that was not even- Directive for trainee doctors in 2004, the medium term. Services must be tually implemented was the concept of changes in morbidity, greater public designed and staffed to cope with this a general practitioner paediatrician expectation from parents, and the fall- workload. (GPP).1 Court recognised the impor- ing birth rate are just some of the issues The vast majority of children who are tance of strengthening the care of which force us to rethink how, where, on October 2, 2021 by guest. Protected copyright. children wherever they might be: in and by whom paediatric services should perceived to be ill have always been seen the hospital, community, or in general be delivered. in general practice. They form a sub- practice. Recent years have seen an The most obvious change in recent stantial part of any GP’s workload. integration of hospital and community years has been the vastly increased Indeed general practice is a fundamen- paediatric services which has resulted in numbers of children who attend hospi- tally important part of the NHS in the better care, especially for vulnerable and tal for emergency assessment when they UK. Over 99% of the population are disabled children. The government’s are perceived by their parents to be ill. registered with a family doctor. Ninety new Green Paper,2 which puts an Many can be seen and immediately five per cent of consultations in the NHS emphasis on integration of education, reassured that there is nothing seriously are conducted in primary care, and 80% social care, and aspects of health, does amiss, while the majority of the rest can are dealt with by primary care teams potentially threaten to destabilise the be sent home after a short period of with no involvement of hospital specia- 3 integration of paediatric services. We observation. There appears to have been lists. During the day, sick children will must be aware of the danger and find a a substantial shift of work from general continue to be cared for by GPs and this way of working across boundaries. The practice to hospital, although this is is to be encouraged and supported. green paper was driven by the horror of difficult to quantify. The greater number However, out-of-hours the situation is the murder of Victoria Climbie´ and we of children attending hospital could different. Although general practice will must all try to ensure that in a further genuinely be due to greater parental have a role, the number who are 25 years we are still saying that we have anxiety. But it is also fuelled by diffi- proposing to opt out of night-time cover not learned the lessons that date back to culty in access to out-of-hours general makes it likely that a different and the tragedy of Maria Colwell in the practice care and by NHS Direct. Most appropriately funded situation needs to 1970s. Paediatric services are inevitably such care is now provided through be found.

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The basic philosophy must be that will need to be served by ‘‘Tesco Metro’’- Emergency assessment is at the hin- Arch Dis Child: first published as 10.1136/adc.2003.040642 on 21 January 2004. Downloaded from 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 http://adc.bmj.com/ ...... 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 on October 2, 2021 by guest. Protected copyright. 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 Arch Dis Child: first published as 10.1136/adc.2003.040642 on 21 January 2004. Downloaded from 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 10 16

change. The Commission for Health http://adc.bmj.com/ 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 on October 2, 2021 by guest. Protected copyright. 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. Arch Dis Child: first published as 10.1136/adc.2003.040642 on 21 January 2004. Downloaded from 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. http://adc.bmj.com/ 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 on October 2, 2021 by guest. Protected copyright. 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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the recognition of acute illness, and that such units can provide safe assess- Arch Dis Child 2004;89:115–116. Arch Dis Child: first published as 10.1136/adc.2003.040642 on 21 January 2004. Downloaded from experience of working in extended ment and care of acutely ill children. To doi: 10.1136/adc.2003.040691 teams managing children with complex that end such units will need to be Correspondence to: Dr D Sowden, Nottingham and special needs. It will allow some staffed at all times by general practi- Postgraduate Dean; david.sowden@ GPs to develop special interests in child tioners with relevant child health train- nottingham.ac.uk health who will provide specialist ser- ing and most critically of all must have vices within PCOs. Such services must facilities for observation, perhaps by form part of a comprehensive and trained nurses for an hour or so, in REFERENCES collaborative local arrangement with order that the trajectory of illness can be 1 Wanless D. Securing our future health: community and hospital sectors. To this adequately assessed. In fact secondary taking a long term view. Final report. London: HM Treasury, 2002. end care must be taken in defining the care paediatric services probably have a 2 Department of Health. The NHS plan. A plan for roles and responsibilities of community right to expect this level of service to investment. A plan for reform. London: Stationery and secondary care paediatricians, and limit the rising tide of admissions that Office, 2001. 3 Department of Health. Delivering the NHS plan. how these interface with primary care. has arisen, at least in part, for want of Next steps on investment. Next steps on reform. This leaves the problem of out of appropriate opportunities for assess- London: Stationery Office, 2002. hours care. After the implementation of ment over time in the community. 4 Marsh G, Kaim-Candle P. Team care in general practice. London: Croom Helm, 1976. the GMS contract the move to out of The future is clear; it remains a 5 Department of Health. Unfinished business. hours centres to which parents and general practice based service but with Proposals for reform of the SHO grade. London: children travel will become more pre- better and more formalised relation- Stationery Office, 2002. 6 Department of Health. Modernising valent as more general practitioners opt ships with both community and hospital medical careers. London: Stationery Office, out of out of hours care. It is essential paediatric services. 2003.

Primary care paediatrics and child health small children may also generate anxi- ...... ety, fuelled by regular headlines about deaths from meningitis. Solutions might include GPs in A&E Who should provide primary care for to manage primary care problems, training in primary care for specialist trainees, children? and redesigning services in ways that avoid admission, for example, hospital at C M Ni Bhrolchain home schemes run by nurses.67 ...... Community paediatricians have ‘‘Primary health care is essential health care … made universally until recently provided primary accessible to individuals and families in the community … It is the care services and may not be too keen to go back to it first level of contact of individuals … with the national health Community paediatricians have spent system bringing health care as close as possible to where people the past decade extracting themselves live and work, and constitutes the first element of a continuing from providing primary care. We have 1 redesigned services to meet the increas- health care process’’. http://adc.bmj.com/ ing need for specialist care for children with non-acute conditions. We have raditionally, UK general practi- paediatricians often cite poor primary been forerunners in supporting clinical tioners (GPs) have provided pri- care as the reason. nurse specialists (we call them health Tmary care for all age groups. The evidence challenges this theory. visitors and school nurses), improving However, the Royal College of Boyle et al showed that referrals from access by referral protocols from screen- Paediatrics and Child Health (RCPCH) primary care to Derbyshire Children’s ing and surveillance to manage demand

has recently proposed that paediatri- Hospital showed no increase between and delegating to our specialists nurses on October 2, 2021 by guest. Protected copyright. cians should take on primary care for 1994 and 1998.3 MacFaul et al found those tasks that do not need medical children. This article assumes that this that admission in Yorkshire was more training. With our primary care collea- proposal includes all the elements of likely after self-referral to A&E.4 gues we have reduced or all but elimi- primary care paediatrics as seen in those Admission was also related to social nated a number of fatal conditions countries where primary care paediatri- disadvantage and presentation at night. through preventive programmes, and cians already practice: assessment and In 1996, Dale et al showed that GPs were have ensured that all GP registrars have management of acute illness, ongoing significantly more cost effective in deal- access to protected training in child management of chronic conditions ing with primary care presentations health and development through the including disability, and primary pre- to a London A&E, when compared child health surveillance courses run for vention including immunisation and with senior house officers (SHOs) and GP registrars. ‘‘well child’’ visits. Does this proposal registrars.5 The committed paediatricians who withstand scrutiny? The problem here therefore seems to provided primary care in preceding be one of access on the one hand and decades had few career opportunities. The increase in hospital admissions secondary care doctors who are less They belonged neither to the paediatric for acute illness appears to be due skilled in managing primary care pro- ‘‘club’’ nor to general practice and lived to primary care problems managed blems on the other. Inappropriate use of largely in no man’s land. Much of what by secondary care doctors secondary care services is likely to be they did has now been delegated to There has been a significant increase in worse in city areas and where there is a primary care nurses and allied health the number of children admitted to children’s hospital with a reputation for professionals (AHPs) or remains a hospital for acute illness.2 Those who knowing about children. Parents’ lack of secondary service within community promote the concept of primary care experience in managing acute illness in paediatrics.

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Table 1 Training needs for each level of child health practitioner Arch Dis Child: first published as 10.1136/adc.2003.040642 on 21 January 2004. Downloaded from

Training level Training needs Summative assessment

Undergraduate An understanding of child health in the community, child development, the care pyramid, MB managing common conditions, both in primary and secondary care SHO Consolidating knowledge of child health, managing common conditions, and exposure to DCH rare conditions under supervision MRCPCH (Part 1) GP registrar/career Consolidating above, managing rare and long term conditions under supervision, DCH paediatric SHO understanding the referral process, understanding preventive services for children, MRCPCH understanding the role of specialist nurses and AHPs MRCGP Specialist registrar Consolidating above, taking increasing responsibility for seeing unselected referrals CCST and managing complex conditions, understanding how to manage services MD GPwSI Consolidating knowledge of paediatrics in primary care, understanding the interface between DCH primary and secondary, taking a strategic role in children’s services within the PCT, perhaps MSc contributing to non-acute paediatric services in hospital and/or community settings Consultant in the early Consolidating clinical knowledge, practising independently but with a senior colleague as MSc years mentor, taking increasing responsibility for managing services, strategic role in area of special Management qualification interest Teaching qualification Established consultant Consolidating knowledge and expertise in management, clinical manager role, training role, external roles in college or wider NHS

Demand management techniques possible to home or school. Primary care Arch Dis Child 2004;89:116–117. such as protocol driven is the point of first access and the doi: 10.1136/adc.2003.040667 investigation could significantly evidence suggests that primary care reduce outpatient referrals nurses and doctors do a good job: they The author is an FRCPCH and MRCGP. She is About 2% of children are referred to manage about 90% of children present- currently developing training materials for primary care on child development topics with general paediatricians in any year and ing to them without referral, and GPs the RCGP but these are equally applicable to this rate has not changed for the past are consistent about what they wish to any group delivering primary care to children 8–10 decade. The commonest conditions manage and what should go to second- in the community. referred are heart murmurs, urinary ary care (Mindlin M et al, unpublished tract infections, and constipation.10 data) for non-acute presentations at Correspondence to: Dr C M Ni Bhrolchain, Huntingdonshire PCT, Primrose Lane, Asthma—the single commonest condi- least. The pressure on secondary care Huntingdon PE29 1WG, UK; tion referred in the 1988 study8—no services comes from patient demand, a [email protected] longer features in the top five. This need to control working hours and, in suggests that GPs can successfully man- my view, a need to redesign and REFERENCES age childhood conditions when sup- modernise services. I do not believe that ported to do so by clear guidelines. GP 1 First International Conference on Primary Health paediatricians should take on the 90% of Care. Alma Ata 1978. access to echocardiograms, renal ultra- patient contacts now seen in primary 2 Royal College of Paediatrics and Child Health. sound, and management protocols for care. I think we do need to consider The next ten years. Educating paediatricians for constipation could reduce outpatient new roles in the 21st century. London: RCPCH, which patients need secondary care 2002. http://adc.bmj.com/ demand by 30%, releasing paediatric services and which can be seen safely 3 Boyle R, Smith C, McIntyre J. The changing time for other things. Progress on and more effectively in primary care. utilization of a children’s emergency department. improving GP access to such investiga- Ambulatory Child Health 2000;6:39–43. This may require us to challenge exist- 4 MacFaul R, Stewart M, Werneke U, et al. Parental tions has been slow, with a tendency to ing beliefs about how, where, and by and professional perception of need for expand secondary care services to meet whom services should be provided. emergency admission to hospital: prospective demand rather than redesigning ser- questionnaire based study. Arch Dis Child The training needs I perceive for each 1998;79:213–18. vices. Yet, the yield from investigations level of child health practitioner are 5 Dale J, Lang H, Roberts JA, et al. Cost requested by GPs has consistently been effectiveness of treating primary care patients in outlined in Table 1. I have not presumed on October 2, 2021 by guest. Protected copyright. shown to be as good as the yield from to comment on nurse or AHP training. accident and emergency: a comparison between those requested by specialists.11 general practitioners, senior house officers, and The concept of GPs with a special registrars. BMJ 1996;312:1340–4. There is some evidence that commu- interest (GPwSI) could foster links 6 Royal College of Paediatrics and Child Health. nity paediatricians are experiencing between primary and secondary care, Old problems, new solutions. 21st century increased demand and see more com- children’s healthcare. London: RCPCH, 2002. as will community paediatricians’ move Sartain SA 10 7 , Maxwell MJ, Todd PJ, et al. plex children. There may also be less into Primary Care Trusts (PCTs) along- Randomised controlled trial comparing an acute opportunity to transfer care to GPs. side GPs. Hospital based paediatricians paediatric hospital at home scheme with While GPs are confident in managing conventional hospital care. Arch Dis Child need to strengthen ties with primary 2002;87:371–5. some issues such as immunisation with care based on mutual respect for their 8 Ni Bhrolchain CM. A district survey of paediatric advice, they are not confident in mana- different talents. It is unlikely that many outpatient referrals. Public Health ging children with special needs without 1992;106:429–36. GPwSIs could maintain their skills to 9 MacFaul R, Long R. Paediatric outpatient secondary care support (Mindlin M et al, contribute to acute hospital rotas. utilisation in a district general hospital. Arch Dis 12 unpublished data). Community paediatricians are already Child 1992;67:1068–72. 10 Holmes NR, Ni Bhrolchain CM. Case mix finding this difficult and withdrawing presenting to paediatricians in a UK district We need to train the next from them, concerned about clinical (1998). Public Health 2002;116:179–83. generation of primary and governance issues. 11 White PM, Halliday-Pegg JC, Collie DA. Open access neuroimaging for general practitioners— secondary care practitioners to Hospital paediatricians will need to diagnostic yield and influence on patient meet the needs of children and find other solutions to maintain essen- management. Br J Gen Pract 2002;52:33–5. families first tial acute services for ill children who 12 Ni Bhrolchain CM, Klein LE, Smith MJ. Children with disabilities and the Children Act: who will Children and families need good access need them. Primary care paediatricians, assess their needs? Public Health to appropriate services as close as in my view, are not it. 1993;107:101–6.

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Primary care paediatrics and child health analgesics (11%), antibiotics (11%), and Arch Dis Child: first published as 10.1136/adc.2003.040642 on 21 January 2004. Downloaded from ...... emollients (4%). Further analysis of the 0–5 year olds data reveals that between May 2001 and Nurse practitioners May 2002, 59% of children, after clinical assessment, were offered S Hall, C Lawson ‘‘advice only’’. A further 39% received treatment; 1% were referred to their ...... own GP and a further 1% to paediatric Role in acute paediatric care secondary care. The data show nurse practitioners can be seen as key care providers for children presenting with acute condi- his paper proposes that community package and ongoing education based tions in a primary care setting, as most based nurse practitioners are well on clinical/nursing competencies. This conditions are self limiting and do not Tplaced to provide care to acutely ill they propose will enable them to be require any medical intervention. What children. The data provided from a competent, autonomous, and ultimately the data do not illustrate is that as nurse led primary care service in safe practitioners.4 primary care nurse practitioners we also Newcastle upon Tyne illustrate that So can the nurse practitioner provide possess considerable knowledge of the 98% of children presenting with every- safe, effective care to acutely ill chil- determinants of health within our local day complaints are effectively treated by dren? Our evidence confirms that, in the community. This makes it possible for a nurse practitioner. majority of cases, the answer is yes. us to support the child and family The role of the nurse practitioner in We have developed an entirely nurse beyond issues related entirely to the primary care, although innovative, can led primary care service to a deprived treatment of their presenting com- present challenges to historical practices inner city population in Newcastle upon plaints. in the National Health Service. Tyne (approx 10 000) which has been To illustrate, one example from our Nevertheless the movement away from open to the public since May 2002 and practice was the many children who conventional roles and service delivery offers an appointment/walk-in service presented to our service with impetigo. is a strategy that is recommended by on a daily basis. It transpired that many of the affected current health service reform and This generic service has evolved with children attended the same school policy.1 the support of the local community, nearby and there were no overt hand One such reform is the notion that Newcastle Primary Care Trust, and local washing/hygiene practices in place. experienced nursing staff can relieve general practitioners. Our aim is to Having regular contact with local par- doctors of certain tasks, which accord- provide a holistic service to the local ents enabled us to discuss infection ing to Pearce,2 are tasks the medical population by offering a range of ser- pathways and possible solutions with profession have been doing for many vices, which include, for example, those concerned in a sensitive way to years, that other suitably trained staff undertaking cervical smears, blood tests, resolve the situation. could undertake, for example, clinically childhood immunisations, and advice Comprehensive audit trails reveal that assessing patients and requesting x ray and support for people who want to stop we are providing an effective, safe, examinations. smoking. primary care service while adhering to http://adc.bmj.com/ 5 Step forward the nurse practitioner! It is our experience that this holistic our Scope of Professional Practice. We Nurse practitioners are experienced approach is realised; for example, the have also sought the views of service nurses who, after extensive training, father who attends with his asthmatic users and the data confirm that nurse are proficient in certain competencies child is encouraged to share any con- practitioners can provide a range of such as consultation skills, physical cerns he may have about his own health care services for children that examination skills, and clinical diagno- health. These can then be addressed are acceptable to their parents/carers sis. Equipped with these skills they are within this contact or he will be and that parents/carers attach high on October 2, 2021 by guest. Protected copyright. able to accept responsibility and actively encouraged to access the service value to the fact that the service is an accountability for the assessment, diag- again. easily accessible point of contact. nosis, and implementation of a range of Although this nurse practitioner ser- Parents/carers inform us that they do care interventions for patients who vice is available to children, parents, not want unnecessary contact with their present to them with undifferentiated individuals, and their extended families, GP or lengthy waits in accident and medical conditions.3 paediatric consultations form the vast emergency departments—services which Most nurse practitioners have an majority of our work, accounting for can be miles away from their homes— Extended Nurse Prescribing qualifica- almost two thirds of all contacts (954 of for their children to receive treatment tion, which permits them to prescribe 1515, May 2002–03). for minor ailments and minor injuries drugs and therapeutics for specific The statistics relating to acute paedia- that often require advice only or simple conditions. They are also able, with tric consultations illustrate that the total treatments. Nurse practitioners can pro- the consent of the patient/carer, to number of 0–16 year olds seen between vide this level of care and can, after negotiate care packages, which may May 2002 and May 2003 was 954; of clinical assessment of the child, deter- include commencement of investiga- these, 744 were 0–5 year olds. The mine when a more specialised paediatric tions, liaison with multiple agencies, commonest paediatric presentations opinion is required. and onward referral to different care were for skin conditions (23%), vaccina- There are many good reasons for providers. tions (16%), ear nose and throat (14%), introducing the nurse practitioner role To sustain them in this challenging and respiratory conditions (10%). A in different settings and each must role the Royal College of Nursing advo- total of 291 drugs were dispensed/pre- identify its own. The value of our nurse cates that nurse practitioners should scribed within these 744 consultations practitioner service is that it is a have access to a comprehensive training (39%). These were predominantly for convenient, safe, effective health care

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provision for children presenting with Correspondence to: S Hall, Nurse Practitioner, 2 Pearce L. Handing over. Nursing Standard Arch Dis Child: first published as 10.1136/adc.2003.040642 on 21 January 2004. Downloaded from acute illnesses. Newcastle Primary Care Trust, UK; 2003;17(22):14. [email protected] 3 United Kingdom Central Council for Nursing, Arch Dis Child 2004;89:118–119. Midwifery and Health Visiting. Standards for education and practice. London: UKCC, 1994. doi: 10.1136/adc.2003.043216 4 Royal College of Nursing. Statement on the role ...... and scope of nurse practitioner practice. London: REFERENCES Royal College of Nursing, 1996. Authors’ affiliations 5 National Midwifery Council. Scope of S Hall, C Lawson, Newcastle Primary Care 1 Coulter A. Shifting the balance from secondary to professional practice. National Midwifery Trust, UK primary care. BMJ 1995;311:1447. Council, 2002.

Primary care paediatrics and child health N Initial diagnosis and investigation of ...... children with developmental delay N Recognition and management of child protection (CP) The future of paediatric primary care N Initial management of acute illness and uncomplicated chronic illness. and child health N Management of growth problems S Court N Responsibility for looked after children and adoption medical service ...... N School health.

Child care teams are well placed to deliver needs led primary care Of necessity the service will be deliv- paediatrics ered in different sites (home, school, CDCC) by members of ‘‘functional teams’’ drawn from the above list of he central objective of paediatric localities these primary care paediatri- professionals. Examples of locality func- primary care (PPC) should be the cians (PCPs) should be part of multi- tional teams might include: Tintegration of preventative and disciplinary Locality Child Care Teams. curative health services. Delivering this Team members should include. N Behaviour/mental health (ADHD, objective will not be simple or the same autism, truancy, bullying) in different health districts, but it would N PCPs N Child protection (parenting, sleep achieve a level of primacy if manage- N Clinical medical officer/staff grade/ and crying management, social rially it was the responsibility of the associate specialist exclusion/LAC/adoption) Primary Care Trust (PCT). In my opinion N SHO(s) N Disability there should no longer be any distinc- N Registrar(s) N Nutrition tion between the community paediatri- N Illness (acute, chronic). cian and the conventional DGH based N The consultant(s) http://adc.bmj.com/ generalist. Both need to be confident N Dietician Co-location of core staff within func- working in hospital and community; in N Paediatric nurse practitioner (PNP) tional teams is important, perhaps par- order to understand chronic illness N Community paediatric nurse (CpaedN) ticularly for child protection (teams will clinicians need to have a familiarity N School health advisers (SHA) include SW, police, EWO, and named CP with home, community, and school. health professionals). Extending the We need evidence based pathways of N Health visitor(s) (HV) model of community based manage- care so that a child’s need is met by the N Physiotherapists, speech therapists, ment of growth faltering,4 the ‘‘func- most appropriate health professional in and occupational therapists tional nutrition team’’ would include on October 2, 2021 by guest. Protected copyright. a convenient child friendly environment N Education welfare officer (EWO) consultant plus trainee, dietician, HV, and where the outcome reflects the N Social worker (SW) CpaedN, PCP, SHA, SW, and behaviour- quality of decision making at each stage. alist. This would allow the team to N Police Much ‘‘secondary’’ care previously encompass breast feeding, weaning, undertaken in hospitals is now under- N Named child protection personnel healthy eating, healthy schools, height taken by general practitioners, specialist N Psychologist screening, constipation prevention, eat- nurses, and consultants in the commu- N Pharmacists. ing disorders, obesity prevention, and nity. The boundaries of ambulatory gastrostomy care. A constipation service, primary/secondary care are becoming Any service has to be needs driven for example, requires an initial ‘‘medi- increasingly blurred. and delivered by a team with compli- cal’’ review; with frequent contact by In 1976 the role of a general practi- mentary skills. Each locality has its CpaedNs providing necessary support. tioner paediatrician was described but particular mix of social and clinical Attendance at a consultant or PCP clinic found little favour.2 Even so in many challenges. If practical, teams should can be minimised by scheduled notes practices now, certain partners are work from children’s day care centres review of the locality case load by all assuming a greater responsibility for (CDCCs)3 or polyclinic within the local- involved practitioners, identifying children, and are recognised by parents ity. The following would be the respon- patients needing an appointment. This as the children’s doctor. Within sibility of locality child care teams: model of empowered nursing plus joint Newcastle upon Tyne (with 40 practices medical review could be applied to other distributed between three localities), N Public health of all children in the loca- chronic illness, reducing clinic review in there are practitioners who have a lity (to include health promotion/ hospital for children who remain well, declared paediatric interest. Within accident prevention/immunisation) for example, asthmatics or epileptics.

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Members of the ‘‘functional illness Until recently children were not seen only in a small percentage of cases are Arch Dis Child: first published as 10.1136/adc.2003.040642 on 21 January 2004. Downloaded from team’’, particularly community based as politically important; the climate is hospitals the necessary forum for care. generalist trainees together with their now changing. The government, in the Most childhood illness is or should be consultants, could ‘‘in reach’’ into local recent green paper,7 identifies account- dealt with outside hospital. The essence hospitals by rotation. Much acute ability as a priority. If health profes- of this proposal has been reviewed in work is/could be dealt with by junior sionals are to be accountable, they need Strengthening the care of children in the paediatric staff5 and PNPs. The day to appropriate training to meet defined community.1 day running of the acute unit (A&E, day responsibilities; outcomes should be Arch Dis Child 2004;89:119–120. ward, short stay unit) would be under- audited and training updated. doi: 10.1136/adc.2003.040659 taken by PNPs,6 together with registrar/ We know that a sizable minority of staff grade doctors, overseen by the Correspondence to: Dr S Court, Community GPs receive little further postgraduate Paediatric Department, Newcastle General consultants who would have both hos- training. If the generalists of tomorrow Hospital, Westgate Road, Newcastle upon Tyne pital and community responsibilities. are to work in managed networks and NE4 6BE, UK; [email protected] The ‘‘acute’’ pathway of care starts with multiple small focused teams, trainees parents, some using NHS Direct, and need to be exposed to this model from REFERENCES ends with a consultant; triage remains the start. 1 Royal College of Paediatrics and Child Health. an essential element undertaken by Strengthening the care of children in the Child care teams that include general community: a review of community child health in PCPs or PNPs. In the community, paediatricians, paediatric nurse practi- 2001. London: Royal College of Paediatrics and consultants would work alongside tioners, primary care paediatricians, as Child Health, 2001. PCPs and other members of the illness 2 Court SDM. Fit for the future. Report of the well as other disciplines are well placed Committee on Child Health Services. London: team (PNPs, CpaedNs) undertaking to deliver needs led primary care paedia- HMSO, 1976. clinics within a locality CDCC, cover- trics working from a locality base. Some 3 Taylor B. How many in patient paediatric units do we need? Arch Dis Child 1994;71:360–4. ing general referrals (for example, members will ‘‘in reach’’ into the local 4 Wright CM. Identification and management of headache, abdominal pain, growth pro- hospital unit undertaking secondary failure to thrive: a community perspective. Arch blems, enuresis, constipation, asthma, care. Training should be largely com- Dis Child 2000;82:5–9. 5 Armon K, Stephenson T, Gabriel V, et al. behaviour and development problems, munity based. Pathways of care should Determining the common medical presenting fits and ‘‘funny turns’’, or possi- be followed, with referral to tertiary problems to an accident and emergency ble congenital anomalies). In progres- services only when accepted thresholds department. Arch Dis Child 2001;84:390–2. 6 Royal College of Nursing. Nurse sing along the care pathway it should have been reached. practitioners: a draft RCN guide to the nurse only be necessary to see a tertiary Despite our best efforts hospitals practitioners role, competencies and programme specialist once accepted thresholds remain frightening, unfamiliar, and at of accreditation. London: Royal College of Nursing, 2003. for onward referral have been times dangerous places for children. In 7 Green paper. Every child matters. London: The reached. the broad context of childhood illness, Stationery Office, September 2003. http://adc.bmj.com/ on October 2, 2021 by guest. Protected copyright.