112 PRIMARY CARE Primary care paediatrics and child health may be potential pitfalls; not least ....................................................................................... whether these concepts fit with cur- rent 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 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 tance of strengthening the care of which force us to rethink how, where, The vast majority of children who are 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. www.archdischild.com PRIMARY CARE 113 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.