Primary care for children in the 21st century

The British model of general practice is rightly admired.¹,² Explicit responsibility for a defined population facilitates a public health dimension to health care. The training emphasises teamwork, consultation skills, management of undifferentiated symptoms, and the integration of psychosocial and biological aspects of health and illness in the context of the family and community. These skills are crucial for working with children and young people and the recently published national service framework for children has a whole section on primary care.^{3 w1} Therefore, to question the future of children's health care in general practice may seem perverse, but there are several causes for concern.

Although serious acute childhood illness has become less common, both professionals and parents worry about overlooking potentially life threatening conditions. When a child is ill outside surgery hours, parents accept that they are unlikely to see their usual doctor and the new contract permits general practitioners to opt out of 24 hour responsibilities.^{w2 w3} Out of hours services, such as NHS Direct, often direct parents to a primary care assessment facility or a hospital emergency department. Even if primary care organisations can sustain 24 hour cover, more parents may well decide to bypass primary care and seek emergency care in hospitals, accelerating the move towards centralised emergency services and more short stay admissions.^{w4 w5}

Rare complex paediatric conditions need specialised management, but chronic neurological, psychosocial, and mental health problems (in particular conduct and behavioural disorders) make up a large part of modern paediatrics,⁴ yet their care remains fragmented and the resources allocated inadequate.⁵ General practitioners have yet to take on a major role in managing chronic disorders, many of which persist into adult life,⁶ although children's trusts could in the future facilitate cooperation between health services and the education and social services provided by local government.

The 1990 contract encouraged general practitioners to provide child health surveillance programmes. They are well placed to understand how individual social circumstances might influence each child's health and development.^w6 The growing evidence for child health screening and promotion in preschool facilities and schools underlies government support for a child health promotion programme.^{3 w7 w8}

Although some doctors enjoy preventive care and caring for well children, many believe that this is best delivered by other professional staff such as health visitors. The latter, however, work increasingly on a geographical basis separate from general practices. Physical examination, once the preserve of doctors, can be undertaken by appropriately trained nurses and midwives, at least where the newborn is concerned and non-medical staff are increasingly functioning as independent practitioners.^w9 Health promotion for teenagers is also problematic; they often prefer clinics near their school or college for sensitive issues like sexual health because of concerns about the privacy and confidentiality offered by their local general practice, despite many practices having sought to reassure young people by establishing special teenage clinics.⁷

In other European Union countries and the United States,⁸,⁹ office based paediatricians provide most care, referring complex cases to specialist colleagues. In mixed systems, paediatricians work in larger population centres, and general practitioners provide care in small communities. Which is best? Evidence is scanty. In Europe, a system of primary care paediatricians was claimed to be associated with better health indicators than one based on general practitioners, when other variables were controlled.²,⁸ The United Kingdom performs as well as other European Union states in treating acute leukaemia and lymphoma, but relatively poorly for solid tumours, which present more insidiously,¹⁰ a finding that might be due to delayed referral by primary care services in the United Kingdom. International comparisons show, however, that primary care in the United Kingdom may be more cost effective than systems based on specialists.²

Tomorrow's parents and young people will expect their doctor to have confirmed competences in acute and non-urgent children's care, particularly psychological disorders and chronic disease. But the new contract does not encourage general practitioners to undertake formal training in these areas. It offers additional remuneration based on a points system for high quality care programmes but child health surveillance (a term made obsolete by the national service framework) gets just six points. In contrast, cervical screening can get 22 points, mental health work 41 points, diabetes 99, and heart disease 121. This structure may encourage general practitioners to focus on and develop special interests in adult health and chronic disease.

General practice is at a crossroads, and we need to contemplate the implications of either nurturing or abandoning the concept of the whole family doctor.^w10 To maintain their place as the main providers of health care for children and young people, general practitioners will need appropriate training and remuneration for providing a practice based quality child health service for the 21st century and opportunities to develop special interests in various aspects of child and adolescent health.^w11 The alternative is that children's health care will increasingly be offered outside general practice by a range of other disciplines and providers,^w12 supported by a new generation of general paediatricians for whom traditional barriers between hospital and community will seem irrelevant.^w5