GPs to lose lead role in paediatric care
11 Nov 09
A new breed of specialist GP is set to take on paediatric care from hundreds of practices, in a move the profession’s leaders claim will split responsibility for care of children and adults.
A Londonwide strategy document unveils plans for ‘paediatric primary clinicians’ to lead on the care of children and spearhead a huge shift in the burden of paediatrics from hospitals to primary care.
The Healthcare for London plans, developed under the initial leadership of Lord Darzi, are strikingly similar to those revealed in March by NHS Yorkshire and the Humber, but watered down after protests from GPs. The London strategy could now become a model across the UK, as Healthcare for London’s polyclinic plans did.
It has drawn an angry response from leading GPs, with RCGP vice-chair Dr Clare Gerada branding it a ‘terrible’ idea that would deskill GPs and leave them subservient to community specialists.
But the strategy document, launched on behalf of NHS London last week, makes it clear change was needed because of deficiencies in the current standard of paediatric care – saying 40% of GPs had received no paediatric training.
‘Children’s health in the UK is not as good as it should be. There are complex reasons for this, including changing disease burden and the way medical services are provided.
‘There is a need for a new kind of paediatric primary care-based clinician, who will play a heightened role in unplanned and planned care of children and young people. Primary care paediatricians are the mainstay of paediatric care in many countries,’ the report said.
It added that the role would combine ‘the qualities of a GP with those of a paediatrician, providing breadth as well as depth of skills’.
The new role would work in a team including GPs, who would receive additional paediatric training.
Most hospitals in London have been earmarked for the launch of new child urgent care centres, dealing with a whole range of minor problems such as rashes and constipation, as well as managing long-term conditions such as diabetes and asthma.
Dr Gerada, who was the college’s lead for child services and is a GP in south London, said the proposals would exclude GPs from paediatric care and lead to them becoming unable to recognise signs of serious illness in children.
‘Gradually they muscle in and remove what is basic general practice care – suddenly you have to have specialist training to look in a child’s ear.
‘That is what happened with obstetrics. For 10 years we had midwives, then suddenly they disappeared and we forgot how to do it. This will increase the risk to children and not decrease it.’
Dr Eric Kelly, a GP in Doncaster and senior clinical adviser to NHS Yorkshire and the Humber on its post-Darzi children’s pathway, said its final model had not yet been decided.
‘We initially talked about a children’s GP model, but that didn’t go down well with the profession so we have moved towards teams of appropriately trained professionals – such as specialist nurses.’
Dr Andy Mitchell, medical director for NHS London, said: ‘What we are asking for is that if GPs deal with children they have the experience to deal with them appropriately. They will have more opportunities for training, particularly if we are able to move some expertise out of hospitals into a polysystem.
‘This is an issue for the whole country, but because we have such a high rate of attendance at hospital we have a particular problem in London.’
What children’s GPs will do
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• Be the mainstay for unplanned and planned care of children and young people in the community
• Work as part of the ambulatory care team at local hospitals, instead of inpatient care
• Lead multidisciplinary community teams of GPSIs, specialist and community nurses, and paediatricians
• Take a significant chunk of A&E activity and outpatient appointments for minor problems and the care of children with long-term conditions
Source: Healthcare for London, Meeting the Needs of Children and Young People: Guide for Commissioners, November 2009
Readers' comments
So this is the thin end of the wedge. Next it willl be psychiatry then gynae and then we will be like our GP colleagues in Germany who dont do kids, psych or gynae and the lacunae in care shows up only too clearly when they come over here at weekends and try to do OOH. These proposals will herald the end of FAMILY practice we must resist them and the dumbing down of GP. WE ARE GENERALISTS AND PROUD TO BE SO. If RCPCH have got an employment problem then do your CCT in General Practice! Soon we will be like our hospital colleagues with a left shoulder surgeon and a right shoulder surgeon.
Two difficulties - A) the child is the most important thing in a parents' world so they will always 'want the best' and whilst the NHS behaves in a manner that says 'The (hospital) expert is best' and whilst parents believe the 'GPs are lazy overpaid failed specialists' where are they going to get the best but secondary care? Secondly my own urban PCT has a similar issue and without exception every scheme involving 'expert admission avoidance' fails in terms of reduction in admission numbers. They have increased the quality of the referral information into hospital, they have sometimes reduced the 'in consultation' workload for the hospital on the patients they have see, but none to date have reduced the VOLUME of referrals. I hypothesise some unquantified fundamental process exists which means this initiative also will not address the issue of volume. Perhaps even my own suggestion of 'patients' perception of primary care' could be the issue.
Can I just say I agree completely with Dr Gerada and this is a terrible idea.
If GPs are not good enough for routine care they certainly cannot be good for emergency out of hours care. If this plan goes through GPs doing OOH should refuse to see any paediatric patients.
What an utterly bollocks plan.
Specialist nurses taking full responsibility for diagnosis, implementation of drug therapies and other treatments in the community - what next? How insulting to the GP.
The simple answer is to ensure that every GP has a minimum of 6 months' paediatric training as part of their GP specialist training. I certainly do not believe that the majority of paediatricians would be capable of performing paediatrics in a primary care environment. With regards to specialist care, many paediatricians who are not respiratory-trained are not competent to manage even straightfoward paediatric asthma. So as usual along with Walk in Centres, choose and book, NHS Direct, ISTCs, Surestart...etc etc ad infinitum, this is another potty initiative doomed to fiuther fragnment the NHS and corrupt further what used to be the envy of the world: primary care.
Once again the department extrapolate a plan that may/ may not suit London's particular issues and foist it on the rest of the country with no evidence on its potential effectiveness. How Daft is this plan to further fragment a system of primary care that this week has been lauded as the envy of the world. Andrew Mimnagh's comment on parents wanting the best i.e. a specialist equally applies to politicians in the South who have the same narrow minded, old fashioned view of GP land. We ARE the family care specialists and the general physicians of the NHS. Fragment at your peril.
If '40% of GPs have received no paediatric training' isn't the answer to make sure they all do? This is the most ridiculous idea yet - we look after families, and the issues that affect families as a whole (naughty, difficult children leading to stressed depresed parents etc)- this justfragments everything and we will just become de-skilled (which is perhaps the idea).
This is all going the wrong way. Yes there is an issue about Community Paediatricians - access to them and their availability and resources to help with some complex issues about autism/ADHD and many other - but their specialist skills will be further wasted by attempting to deal with the huge amount of care we already do well. Instead increase their capacity so they can support us more easily in the areas we really need their help and support?!
The down-grading of health visiting together with a large increase in parental concern will swamp any new service that is set up. Having discovered that patients by and large are not impressed by Darzi centres, except in areas of doctor shortage, they are now hunting for ideas to make them seem essential. This will further reduce immunisation rates in the under 5s, unless of course they want to hive that off too.
Hear hear to Nicholas Tresidder - almost exactly what I was going to say!
What a load of rubbish this plan for GPs not to be involved. So short sighted are these moron NHS managers !!!!!!! If London's hospitals are getting overwhelmed with admissions etc then actually supporting primary care practices might help this issue in a much better. If I was a father and my child was ill, I'd want them seen ideally by their own GP and not somebody I'd probably never meet again at hospital !
Without splitting the services there is still possiblity of improving services for children, such as GPwSI in childhealth and community based specialist nurses seeing children with asthma / diabetes /psychological & behavioral problems. Unlike adult general medicine in paediatrics subspecialities are dealt by experts in tertiary centres straight away hence it is possible for primary care to develop services in the community minimising hospital referrals.
Dr Prabhu - NHS is good at duplicating things and wasting money and this is what is likely to happen here. Simple thing is to make sure that all GPs are trained in looking after children. No one should become a GP without being trained in looking after them. I just do not understand why we need experts in looking after children in primary care. Make all GPs experts in what they do and if they have any concerns then children should be referred to the seconday care. What we need is an excellent community service to look after children with disabilities, looked after children, child protection and other works and not secondary care in the community. Of course, we also must have a good working relationship between primary and secondary care.