Improving access to specialists might seem a good idea, but it will undermine the role of the GP and damage continuity of care, says Dr Clare Gerada. But Dr Anthea Lints argues that paediatric GPSIs are intended not to reduce the role of the GP, but to strengthen the ability of primary care to deal with complex problems
The central role of the GP as provider of care for all patients, irrespective of their age, sex or condition, is at risk.
Already the role of the GP in providing antenatal care is considerably reduced. Now there is now an increasing risk of GPs losing responsibility for caring for under-18s, if the ideas being suggested by policymakers of moving the care of all children into children’s centres and networks of polyclinics are implemented.
The GP, together with the health visitor, has been the mainstay of care for families for decades. Children make up a significant part of the GP workload, with around a quarter of all under-18s attending their GP each year.
But under the Heathcare for London proposals, the care of young people will be carried out by a new breed of community paediatrician, supported in a hierarchical manner by GPSIs, health visitors and paediatric nurses.
Initially the generalist GP will refer patients to these community-based children’s services, but in time, as with US and European models, care of all children and young people will take place in these centres and by specially trained clinicians.
The recent publication, Children and Young People’s Health In London (2009) sets out the vision for children’s services in the capital, describing networks of polyclinics, children’s centres, community children’s nursing teams and local hospitals, led by paediatricians (‘generalist paediatric practitioners’) and with GPSIs in paediatrics providing much of the care.
The text notes ‘over the longer term there needs to be a new kind of paediatric primary clinician who plays a heightened role in unplanned and planned care of young people in the community.
The proposed development of ambulatory care services at most hospitals, bringing together the primary and secondary workforce, creates an opportunity for such roles to be developed in future’.
While on paper it might appear in the patient’s best interest to co-locate all those involved in the care of children on a single site staffed by specialty-trained practitioners, in reality removing family doctors from their central role will lead to poorer communication between those involved and fragmentation of care.
We must all be in favour of providing safe, high-quality integrated care delivered by a workforce trained to appropriate standards in a clinically appropriate location, as close to home as possible.
But I believe these principals can only be achieved by the continuing role of the GP at the centre of the child’s care.
The arguments for the generalist are well rehearsed. At population levels general practice improves patient care and reduces over-treatment.
It is especially valuable where intergenerational issues weave into the social context of a patient’s presentation.
Primary care is the point of first contact for families and there is significant evidence GPs and health visitors do a good job, with over 90% of children seen in general practice remaining in general practice.
Children are an integral part of a family and must not be seen as an isolated population. It is vital GPs are able to maintain a holistic, family-centered approach to the care of children and families.
Moreover the change in family structure, with increasing numbers of lone-parent households, mean a single point of access and continuity is more important than ever. This cannot be done where children are seen in a stand-alone service, separated from their social network.
It has been argued the increase in hospital admissions for acute illness is linked to primary care problems being managed by secondary care doctors.
But systems of care must value both the generalist and specialist and foster integration between them. This does not mean a hierarchical relationship between GP, GPSI or consultant paediatrician, or removing the GP from the centre of care for families.
Having specialist practitioners co-located with generalists can help improve care of chronic illness and continuity of care through enhanced communication. Primary care paediatricians and GPSIs in paediatrics can play an important part in the delivery of safe and effective community-based services.
But they should be an adjunct to current services and not replace them.
Dr Clare Gerada is a GP in south London and vice-chair of the RCGP, although these are her personal views and not those of any organisation.
Far from undermining the delivery of paediatric care in general practice, we can strengthen it by shifting the focus of expertise from the hospital to the community.
There are approximately 42,000 GPs and 3,000 paediatricians in the UK. Paediatric consultations constitute 25% of the workload of the average general practice.
Most paediatric consultations in this country are carried out by GPs and it would be neither appropriate nor feasible to change this core component of general practice.
But in the last few years there has been a 15-20% increase in paediatric presentations to A&E Departments. Parents mistakenly assume they will obtain a more immediate paediatric opinion via this route.
There has also been a significant increase in referrals to paediatric outpatients of cases which do not need hospital investigation or treatment, and could be better managed in a community or primary care setting.
The increase in presentations to hospital coincides with a major crisis within the paediatric workforce, with a shortfall in middle-grade paediatricians, inadequate numbers of consultants to cover current numbers of acute hospitals and increasing recruitment problems into the speciality.
General and specialist paediatricians working in hospitals struggle to manage the acute workload generated by children who need inpatient and/or specialist care.
They have no wish to take over or undermine the work currently undertaken by GPs – but rather to support a shift of care back into primary care settings and reverse the public’s perception that ‘hospital is best’.
GPs acquire their paediatric skills through a variety of routes. During training GP specialty trainees (GPSTs) will routinely see children and young people under supervision from more experienced GP trainers.
But in many parts of the country, GP training programmes do not include a hospital paediatric placement.
In 2007, 67% of GPST programmes in London included a hospital paediatric post. In 2009 this figure is 49%. This does not reflect a lack of commitment by paediatricians to train GPs, but a lack of sufficient posts to offer to GPST programmes.
While acute hospital posts may not necessarily be the best way of training GPs, they do offer GPs the opportunity to acquire the competencies relevant to children and young people described in the RCGP curriculum.
It may be possible to raise the capacity and skill base within general practice by allowing some GPSTs to gain more advanced skills in paediatrics and a specialist qualification.
These individuals would still function as GPs with a full workload of adult care, but would also provide advice to their GP colleagues. The limitation here is feasibility.
While there is ‘in principle’ acceptance of the five-year GP training programme that might allow individuals to develop more specialist skills in a range of areas of practice, there are shortfalls in the funding available to support this additional training.
A second option is to provide a modified paediatric training route for paediatricians who could work partly in a community setting – supporting a number of GP practices – and partly in hospital. Such individuals would have enhanced training in primary care paediatrics, and would also have a role in providing training to GP colleagues.
Cases that might be referred to hospital would instead be referred to the paediatrician linked to that practice and ideally be seen either in or close to the practice – allowing direct communication with the GP.
These two options are not necessarily mutually exclusive, but could be developed together to increase the standard of paediatric care in the community.
Today, care is fragmented by the increasing range of urgent care centres and walk-in centres, as well as out-of-hours deputising services. It is now commonplace for children to be seen by a range of clinicians with variable paediatric competencies rather than by their own GP.
But Healthcare for London’s proposal for community paediatric specialists would, I believe, strengthen and unify paediatric care, and bring positives outcomes for children.
Dr Anthea Lints is head of specialty training at the London School of General Practice and a GP in Chelmsford, Essex
Paediatric care: are GPSIs needed? No