The Kennedy report,1 commissioned to look at the cultural barriers to good care for children and young people in the NHS, was recently described in The Back Pages as being ‘prejudiced and ill-informed’.2 Indeed there is scant evidence of consultation with GPs in preparing the report but I would suggest there are other interpretations of Kennedy's conclusions which might be read as a recognition of the ‘extraordinary potential’ of GPs as a catalyst in improving services.
The report is premised on the finding that children and young people are ill-served by the existing structures. It would be hard to deny this given the conclusions drawn from the inquiries into the tragic deaths of children including Victoria Climbie, Tiffany Wright, and more recently ‘baby Peter’; all of whom were known to their local health services. Lord Lamming has consistently called for ‘more joined up services’3 and those of us working in the frontline know only too well of the frustration of working across disciplinary boundaries.
To address this current failing system of ‘silo services’ and to promote better communication between professionals working with children and young people, especially those considered vulnerable, Kennedy advocates a model in which the GP sits at the hub of a network of services. He likens us to navigators rather than the traditional gatekeepers we have long been considered to be.
This idea chimes with the notion of good quality horizontal primary health care which Heath argues is about ‘integrating, prioritising and personalising care’, in her critique of the use of quality indicators which promote vertically-orientated care (focusing on the management of specific diseases from primary to tertiary care) and their more easily measurable outcomes.4 Holistic, integrated, individualised care begins with patients' unique biographical narratives and their complex mix of comorbidities and is, of course, infinitely more difficult to measure.
The report also invites us to consider a radical revision of the way that the NHS is fundamentally structured which might seem both fanciful and tired but which, if it were reality, would transform care pathways and experiences of illness and healing for patients and practitioners alike. The proposal is that the health service be built around the children and young people, and their families, rather than requiring people in need to fit into services provided at the convenience of the care providers.
In these dark times of economic restraint and slashing of public services such a vision may seem utopian but there exist examples of health and social care structures which do just that: start with the individual and their needs and focus on the building of a primary relationship with a ‘key’ worker before calling upon additional services.
One such example is Kids Company, an independent London-based charity offering practical, emotional, and educational support to children and young people living in vulnerable families which I recently visited. Kids Company was founded in 1996 by Camila Batmanghelidjh, a psychotherapist and contemporary social visionary, and is based upon the principles of attachment theory which prioritise positive affirmative one to one relationships. The project is ambitious, reaches up to 14?000 children and has been independently evaluated with impressive results.
Like the Arcadian vision the Kennedy report offers us, the service is built up and around the child who remains at the centre, no matter how traumatic the history or bleak the future. Sceptics and cynics might dispute how feasible it is to deliver such a child-centred and flexible system of care but the charity's trajectory shows us it is both possible and sustainable. Its strength lies in the centrality of the key worker where ‘the power of the relationship’ is harnessed to maximum effect.5
Kids Company's upbeat, ‘can-do’ approach is a timely reminder in these beleaguered times of general practice's extraordinary potential. I would argue, along with others,4 that in this time of an ever-increasing commodification and quantification of health care our central and continuing relationship with patients is our greatest asset. Seeing Kids Company in action reminds me of what we have and what we stand to lose.
- © British Journal of General Practice, January 2011