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. 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 www.archdischild.com 114 PRIMARY CARE 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