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OBSERVATIONS: Iona Heath Let’s not widen the gulf in the health care of children BMJ 2008; 336: 1215 [Full text]

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Rapid Responses published:

Primary Care Health Team under Threat

Niall M Cameron   (3 June 2008)

- and think more clearly about what we are doing

Martin W. McNicol   (3 June 2008)

A personal view of the Swedish system

Alison K Godbolt   (4 June 2008)

Bridging the gulf through better integration

Hilary Cass, Ingrid Wolfe, Research Fellow in Public Health, London School of Hygiene and Tropical Medicine & Paediatrician, Whittington Hospital   (9 June 2008)

Primary Care Health Team under Threat 3 June 2008
Niall M Cameron, GP Govan Health Centre Govan, Glasgow G514BJ Send response to journal: Re: Primary Care Health Team under Threat	I read this article with great interest as the provision of Health Visitor services is currently undergoing radical change in the area in which I practice. This will involve Health Visitors no longer being aligned with practices or even based at a practice. This threatens the communication, continuity of care and established relationship which Dr Heath has clearly identified as being of key significance in delivering effective child health particularly in an area of high deprivation and health inequality. Unfortunately the responsible authorities locally appear unwilling to discuss the wealth of evidence that supports the effectiveness of the primary health care team.Further erosion of these services is threatened as midwife led antenatal clinics are also being withdrawn from practices. Whilst I agree that the provision of resources merits review this appears to be a levelling of the playing field downwards rather than as Dr Heath advocates seeking to provide a high quality service in this important area. Competing interests: None declared
- and think more clearly about what we are doing 3 June 2008
Martin W. McNicol, retired none Send response to journal: Re: - and think more clearly about what we are doing	Iona Heath's article stimulated me to read "Healthy Ambitions". We have recently come to live in Beverley and I wanted to understand the local health services. I was dismayed by the document. It gave me a strong sense of de ja vu for it resembled RHA documents of the 1970s. Virtually all of it could have been written for the 30th anniversary of the NHS, not the 60th. It is long on laudable objectives but very short on specifics which the document occasionally hints may have been worked out, but that detail is not revealed and it leaves a strong feeling that, as for paediatrics, the working out was incomplete. It is particularly worrying on its proposals for primary health care where the devil is clearly in the unpublished detail. Its general tone is very curious for it clearly speaks as a health service manager and, despite a few references to commissioning, deals in almost exclusively in managerial approaches. The approach to consultation is similarly vague. Having read it I feel little further forward about the health services where I now live. It would be disturbing if this were the real basis of NHS development in this "Region". Competing interests: Service user in area covered by Humber SHA
A personal view of the Swedish system 4 June 2008
Alison K Godbolt, Specialist trainee in Rehabilitation Medicine Uppsala, Sweden Send response to journal: Re: A personal view of the Swedish system	I would briefly like to endorse, from a personal perspective, the positive comments about the Swedish attitude to children and the family. I am British (trained and worked to early registrar level in the UK), and moved to Sweden a year ago with my (now) 2 and 4 year olds. The societal based emphasis on the value of the family has been particularly apparent in the work place. The attitude is that parents of young children cannot be expected to work full time, and therefore any parent of a child under 7 who applies for a full time job is then entitled to work only 75% of full time. Besides, there is an acceptance (both formally and in interactions with colleagues) that little children become ill on occasion, and there is a formalised system for taking time off work to care for a sick child (and for getting paid during that time). I pay the equivalent of GBP177 a month for high quality full time nursery care for 2 children. There is no problem taking time off for special nursery events. Nursery activities encourage a healthy lifestyle from the age of 12 months - my children spend at least 2 hours outside every day, even in winter, and the nursery provides a healthy diet. Health surveillance for children seems at least as thorough as in the UK. Access to GP services is similar, with the execption that parents pay for drugs, up to a yearly cost limit. Not everything is perfect - anecdotally waiting lists for specialist services can be long. However overall I´m delighted to be in Sweden - oh, and they´re short of doctors, and Swedish isn´t that difficult to learn...... Competing interests: None declared
Bridging the gulf through better integration 9 June 2008
Hilary Cass, Paediatrician, Great Ormond Street Hospital & Head of School of Paediatrics, London Deanery Great Ormond Street Hospital, London WC1 3JH, Ingrid Wolfe, Research Fellow in Public Health, London School of Hygiene and Tropical Medicine & Paediatrician, Whittington Hospital Send response to journal: Re: Bridging the gulf through better integration	Iona Heath’s article on children’s healthcare raises some important points about the need to foster and maintain the skills of the generalist in primary care. There are in excess of 40,000 GPs in the UK (1), and with children’s care constituting at least a quarter of their workload, it is clear that they manage the vast bulk of paediatric consultations. The arguments in favour of developing multi-disciplinary teams for children in community-based settings are cogent; like Dr Heath, we strongly endorse the proposals emerging through the Darzi review teams which highlight the need to strengthen such teams. However despite our best endeavours to augment paediatric care in both primary and secondary care settings, we are failing those children who continue to fall through the gaps between our respective services. Multiple sources demonstrate an increasing usage of emergency departments for self-limiting acute illnesses that might be better managed in primary care (2,3); yet at the same time we have evidence that serious illness is missed by first contact professionals with inadequate training in the recognition of the acutely sick child (4,5). Similar problems underlie the management of long term conditions; for example, the report on the parliamentary hearings on services for disabled children noted that ‘in some cases, a lack of trained staff is driving children from universal to specialist services, regardless of what may be in the best interests of the child’(6). The answer to these problems is not to draw more children and services into the hospital, but rather to break down the unhelpful distinctions between primary and secondary care, and develop more integrated services in the community. Primary care services – like secondary care services – are of variable quality. By developing better integration we will be able to enhance the best of them, whilst supporting those that are struggling. Dr Heath advocates the re-establishment of the tradition of general practices hosting outreach sessions for consultant paediatricians as a means to this end. Whilst we fully support this philosophy, it is wholly impractical in most areas of the country, given the size of the case load within any one practice. Paediatricians are keen to provide better outreach services, but cannot do so within existing staffing levels. There are currently less than 3000 paediatric consultants in the UK, with at least 20% working less than full time (7). Emerging gaps and reduced experience in the middle grade workforce, alongside the changes being driven by the European Working time Directive, mean that they are barely able to cover acute services within the hospital, let alone staff an expansion in community-based care. The RCPCH is arguing strongly for an increase in its consultant workforce to meet these needs. If this message is heard both centrally and by service commissioners, a more practical way to deliver the closer collaboration espoused by Dr Heath would be through the establishment of ‘Paediatric Healthcare Centres’, each serving perhaps 5-8 general practices through a hub and spoke model. Such centres could house a multi- disciplinary team including locality paediatricians (who would also have a rotational commitment to the hospital service), community children’s nurses, children’s trained allied health professionals and other relevant staff. They should not seek to replace any of the excellent care already being delivered within general practice, but instead should provide ‘added value’ through rapid access to paediatric services and opinions delivered closer to the child’s home. Dr Heath reports that all GPs are trained in the recognition of the acutely sick child; however 40% of GP trainees do not gain such experience in a hospital placement, and because of the changes to the GP contract they now have less access to this experience through their registrar posts. Paediatric Healthcare Centres would provide an ideal environment for GP trainees to enhance their paediatric skills. They would also provide a setting in which some GPs might choose to develop a specialist qualification in paediatrics and to work on a part time basis, whilst spending the greater part of their week delivering and enjoying the full breadth of generalist care within their home practice. This would surely be a way of enhancing paediatric expertise in general practice rather than realising Dr Heath’s fears of a threat to its very existence. A DH-supported National Collaborative (8) involving paediatricians, GPs and a wide range of other clinicians and managers is exploring the options for developing such centres, and undertaking modelling work, and would welcome comments from any other interested parties. (1) Key Demographic Statistics from UK General Practice. RCGP, July 2006 (2) Children’s Hospital Use in the East of England. Eastern Regional Public Health Observatory, May 2007 (3) Trends in Children and Young People's Care: Emergency Admission Statistics, 1996/97 – 2006/07, England. DH, March 2008 (4) Why Children Die. Confidential Enquiry into Maternal and Child Health, May 2008 (5) Thompson et al. Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006; 367: 397-403 (6) Parliamentary hearings on services for disabled children. Oct 2006 (7) A Changing Workforce: Workforce Census 2005. RCPCH Aug 2006 (8) http://www.healthcareworkforce.nhs.uk/childrensintegratedhealthcare.html Competing interests: HC is Clinical Lead for the National Collaborative for Children’s Integrated Care. IW is Research Fellow for the Collaborative.