GENERALIST AND SPECIALIST

Nearly 30 years ago, Donald Court, whose report drew heavily on the wishes of parents, raised the notion of the “GP paediatrician”.¹ The general practitioner with special clinical interests (GPuSI) has resurfaced in the NHS Plan.² Already as many as 4000 general practitioners (GPs) specialise,³ but rarely in paediatrics. This is not for lack of GPs with expertise or interest in paediatrics; the reason is that Primary Care Trusts have prioritised identifying GPuSIs who are trained and skilled in procedures such as endoscopy, or able to help reduce costs or waiting times in specialities such as ENT, or musculoskeletal medicine. Experience in other specialties has shown that GPuSIs may become valued either by taking formal or informal referrals from less experienced generalist colleagues, or by leading and developing a local service.⁴ Quality assurance,⁵ and the need to certify the necessary competencies⁶ are being addressed. Issues remain around how a paediatric GPuSI may best fit into local contexts;⁷ new appointments should, I believe, only be made to satisfy a case of need in the locality.

FOR RICHER, FOR POORER; IN SICKNESS AND IN HEALTH

Over the past 20 years, GPs have seen enormous changes in parental behaviour, both in respect of the sick child and the well one. The pattern remains one of significantly higher consultation rates in children from socially disadvantaged families for minor to serious illnesses with correspondingly higher home visiting rates. The concern is that these families also have lower rates of child health and preventive consultations.⁸ The trend is for all social classes to call on primary care earlier in the evolution of a child’s illness. Anecdotally at least, there is a domino effect, whereby more risk averse parents, fearing to nurse their feverish child at home, pass their anxiety on to GPs. Their higher call rate results in higher demands on hospitals, many of which have responded by increasing facilities for short term observation rather than inpatient admission. The benefit of early hospital contact is debated. As hospital admission rates for asthma in young children have increased, the mortality rates have declined,⁹ but case fatality rates for meningitis have shown little change.¹⁰ The Commission for Health Improvement (CHI) cites “enhanced primary care” as a factor in reducing emergency admissions to hospital of children with lower respiratory infections, which is an indicator of service quality.¹¹

OUT-OF-HOURS SERVICES

Although nurse triage as part of an on-call service has been shown to be safe, efficient, and effective,¹² NHS Direct has done little to reduce the calls on general practitioner services.^13,14 Many, if not most, GPs will opt out of out-of hours services from April 2004,¹⁵ but there is little indication, as yet, of the nature of the services that Primary Care Trusts will organise to replace doctor’s cooperatives. Commercial deputising may increase, as may the (cheaper) use of nurse led services. Will these involve specialist teams? As the generalist retreats to daytime service, could nighttime calls about sick children be triaged to paediatric trained nurses and doctors? I see another potential role for the GPSCI here, linking closely with hospital colleagues.

LOCUS OF CARE

One thing seems likely: cost pressures will accelerate the trend for fewer home visits. If parents are expected to bring a sick child to a health centre or on-call base, why not to one with child observation facilities? An example of potential benefits is that better detection of urinary tract infections might result from better facilities to collect samples from febrile infants.

In paediatrics, as in other specialties, gatekeeping is cited as part of the role of the general practitioner, but yet when the Americans introduced primary care gatekeeping in the delivery of services for some children with chronic conditions, there was a reduction in visits to specialists, but also, worryingly, less contact with primary care doctors, who were thus unable to provide the care previously supplied by specialists.¹⁶ Other European countries base their systems around primary care paediatricians.¹⁷ It may be best to let parents choose whom to consult!

Community paediatricians, hospital specialists (both medical and nursing), GPuSIs, and community paediatric nurses could between them manage in the community much of the present workload of hospital outpatient clinics. Primary care collaborations are increasing; at the Personal Medical Services (PMS) project where I have been working, the records for 26 000 patients were available on-line at any of three surgeries. It often helps if clinicians, reviewing the child with cystic fibrosis, growth problems, or diabetes, can see and contribute to the primary care records, prescribing on the same database, and making management suggestions that all doctors and nurses will be able to see at future contacts. There is a caveat, as studies of hospital outreach clinics in other specialities have shown that, although popular and effective, they may incur higher NHS costs.¹⁸

PREVENTATIVE CARE

Nowadays, parents of well children, deliberating about immunisation decisions, are perhaps less influenced than former generations by the views of family practitioners and health visitors, and perhaps more influenced by media and net searching. The credibility of health visitors and GPs depends on up-to-date knowledge of the paediatric evidence base, and professionals need to be expert at interpreting the information for the particular parent and child. Modern childcare arrangements have encouraged more parents to work full time, and if we really want to reach parents, we will have to balance reduced out-of-hours responsibilities with increased availability for preventative healthcare at extended practice hours.

NEW WAYS OF LEARNING FOR NEW WAYS OF WORKING

The implications of future gazing are important for learning. As the Children Care Group Workforce Team rethinks training in the light of current changes in NHS planning, they have appropriately prioritised communication skills and leadership.¹⁹ Enhanced skills in evidence based child care, and satisfactory ways of updating about rare but important conditions in primary care²⁰ are other priorities. If clinicians are to become comfortable disrespecting the boundaries between primary and secondary care,²¹ between hospital and community, and between different nursing and medical backgrounds, they need to spend time learning with, from, and about each other. Effective interprofessional learning is crucial. Primary care paediatricians will probably gain more from contextual learning in the community, than from extending time in the hospital setting.