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Back to red: allowing specialists to provide primary care would be a step backward for Poland

BMJ 2014; 348 doi: (Published 30 April 2014) Cite this as: BMJ 2014;348:g3030

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Re: Back to red: allowing specialists to provide primary care would be a step backward for Poland

Dear Director
We have read carefully the article written by Dr. Tomasz Tomasik and published in Section
Views and Reviews of your magazine, entitled "Back to red: allowing specialists to provide
primary care would be a step backward for Poland".
Since 1978 the Italian National Health Service (NHS) has provided pediatric primary care to children through the use of Primary Care Pediatricians (PCP). The Italian NHS requires that all children have an identified primary care provider, either a pediatrician or a family practitioner, depending on the patient’s age. Italian NHS pediatricians work in their own private offices, providing primary care for patients from birth to 14 years of age and are compensated under a capitation system. The NHS pediatricians are usually the sole patient entrance to NHS secondary and tertiary care in the 0 to 6 age range, while parents can choose between a pediatrician or a general practitioner for their children’s care between 6 and 14 years of age (italian parents choose pediatrician by 87%; data non published) 1. Acute, chronic, and preventive care, through both office and home visits, are provided by the pediatricians. In addition to acute ambulatory and home care, responsibilities include coordinating the care of chronically ill patients, consulting with subspecialties, performing well baby health checks and all certifications for school activities, parent’s absence from work, indemnities, and social welfare. One The major advantage of this system for the community is that health care is available to all children without any out-of-pocket expenses: health care costs are paid by tax money 1.
As we, in Italy but also elsewhere, use to say “A child IS NOT a small adult”. This is why the field of “Pediatrics” was officially created some 200 years ago.
Systems and organisations of Pediatric Primary Care in Europe are heterogeneous. Pediatric training is heterogeneous too 2,3. The goal of primary care pediatricians all over the world has been to provide preventive care, to treat everyday and chronic illness, and to serve as advocates for their patients without regard to cultural or social status 4
As already mentioned, in BMJ, by Concepción Sánchez Pina et al 5, different studies and one systematic review support that the paediatricians are the most adequate medical professionals in developed countries to provide health care to children in primary care. A recent study conducted in the Italian region of Molise over a 3 year period (2007-2009), compared all of the costs involved in caring for children from 6 to 16 years (divided into two groups: 6-11 years and 11-16 years) between Pediatricians and GP’s 6. The study showed that over the three year period, based on the incurred costs to take care of the children under the GP and under the Pediatrician, if all of the children, in a region where the 6-16 year child population is approximately 35,000, were taken care of by a pediatrician, the Regional government would have saved € 6.5 million. Such results are understandable when one considers that a physician who has not been trained in pediatrics is less confident of his “medical thinking” and “decision making” and in order to be safe, more easily prescribes studies, medicines and refers for hospital admissions. Therefore, even if at first glance it
would look as if the GP would cost less to care for a child, in the long run the expenses incurred by governments (financial) as well as by families and child (emotional and financial) are overwhelmingly unacceptable. The same study looked at “patient satisfaction” through a questionnaire given to those families whose children were or had been under the care of both a pediatrician and a GP. The families were asked to compare the performance of the physicians in a series of situations related to the child’s care and well being. Although these are preliminary results, there is no doubt that families (the voting population with children) overwhelmingly prefer pediatrician related care for their children. Parents want the best for their children; Governments cannot deny this basic fundamental need.
Finally Governmental officials should be reminded that what happens to children during their phases of development from an infant to an adolescent is of critical importance not only to their immediate well-being, but also to their future.

1. del Torso S, Bussi R, DeWitt TG. Primary Care Pediatrics in Italy: Eighteen Years of Clinical Care, Research, and Teaching Under a National Health Service System. Pediatrics 1997;99;e8
2. Katz M, Rubino A, Collier J, Rosen J, Ehrich JHH. Demography of Pediatric Primary Care in Europe: Delivery of Care and Training Pediatrics 2002;109:788-796
3. van Esso D, del Torso S, Hadjipanayis A, Biver A, Jaeger-Roman E, Wettergren B, et al.Paediatric primary care in Europe: variation between countries. Arch Dis Child 2010; 95:791-5.
4. Touraine M. Health inequalities and France's national health strategy The Lancet, 2004; 383(9923); 1101-2
5. Sanchez Pina C, Carrasco A, Villaizán C, Aparacio M, Sanchez L, Begoña D Cite this as: BMJ 2014;348:g3030
6. Jaeger-Roman E, Tenore A, Pettoello-Mantovani M. Letter to Italian Parliament - Jaunuary 2012

Competing interests: No competing interests

03 June 2014
Michele Fiore
Primary Care Pediatrician
Stefano del Torso MD, Primary Care Pediatrician, Vice-President EAP (European Academy of Paediatrics), FIMP iIternational Relations Delegate; Giampietro Chiamenti, MD, Primary Care Pediatrician, President Federazione Italiana Medici Pediatri
Michele Fiore MD, PhD, Primary Care Pediatrician, Federazione Italiana Medici Pediatri (FIMP)
Via Parigi, 11 Scala A int.105 - 00185 Roma (IT)