Let’s not widen the gulf in the health care of children
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.a170 (Published 29 May 2008) Cite this as: BMJ 2008;336:1215All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests