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Knitting with clouds

Our diarist reluctantly steps up to the children's services commissioning plate – but finds it hard just to decipher the menu.

The story so far

Dr Peter Weaving is a GP and locality lead for Cumbria PCT, an area regarded as something of a white paper pioneer for achievements under practice-based commissioning, not least getting in the black from a £50m overspend. But while GPs are up for controlling the county's £850m health budget, there are still areas to get their heads round...

‘I think you should do it, Peter,' said Alan, one of my helpful locality docs.

The ‘it' in question was to take the reins of clinical responsibility for commissioning children's services for the locality. This post has remained vacant for a little while now and, following the detailed presentation we had just listened to at our locality development session, was likely to remain so.

Have you any idea what is included in children's services? I know in detail all the admission and outpatient data and their associated costs; assessing the desirability of commissioning good, experienced paediatric staff in your A&E or emergency floor and, indeed, your out-of-hours service. The data around paediatric admissions correlated to the child's presentation by day of week or hour of day clearly show the experienced staff are working nine to five, Monday to Friday, with peaks of admission outside these periods.

Tackling those issues is bread and butter stuff for GP commissioners. What is a misty nightmare, akin to knitting with clouds, is sorting out community paediatrics – a miasma of important, interconnected but often small services such as occupational, speech and physiotherapies, and dietetics. Then there's commissioning children's centres where we try and teach parenting.

This whole fluffy wraparound is shot through with scary bolts of lightning, such as the four school nurses looking after 68 active child protection cases. Who is going to take responsibility for safeguarding? Who

is going to ensure provision of the children's limb prosthetics service and where are you going to recruit the current consultant's successor? Should health visitors immunise infants when their GPs are paid to do it?

The conclusion of our session was that we had the most enormous collective blind spot about these services. We recognised their importance in an intellectual sense but, by and large, had minimal practical contact with them. Referrals into the service were usually made not by the child's GP but by other clinicians within the cloud – health visitors, community paediatricians, educational psychologists. When, as commissioners, we tried to respond to the simple question ‘What do we want from children's services?' our answer was puerile – ‘Better parents'. This was in recognition of the fact that, after socio-economic factors, it was the psychosocial environment that determined most children's ill health. How on earth do you commission that?

At the end of the session I put it to the assembled GPs that it was essential we had their input into the commissioning of these vital, if ethereal, services – and we needed a volunteer. Even prolonged use of silence failed to elicit a response until Alan batted it back to me. OK, I said, reluctantly, I'll do it.

The next day I receive an invitation to spend some time with the interim Community Infant Feeding Coordinator (East) to address my poor performance in breast-feeding. Thank you, Alan.

Knitting with Clouds