Royal College of Paediatrics and Child Health
Submission to the National Assembly for Wales’ Health, Social Care and Sport Committee consultation on Primary Care
Introduction
The RCPCH works to transform child health through knowledge, innovation and expertise. We have over 550 members in Wales and over 17,000 worldwide. The RCPCH is responsible for training and examining paediatricians. We also advocate on behalf of members, represent their views and draw upon their expertise to inform policy development and the maintenance of professional standards. For further information please contact Gethin Jones, External Affairs Manager for Wales: XXXXXXXXXXXXXXX or XXXXXXXXXXXXX.
Meeting future challenges for child health at primary care level
Our response to almost all of the consultation questions focus on four key points:
1. Children and young people are major users of primary care services – their needs must be evaluated and met
2. We must meet the standards set out in the Facing the Future series, specifically Facing the Future Together for Child Health[1] (see Appendix A)
3. Prevention, early intervention and public health are key to managing demand on primary health services and we must prioritise the needs of children and young people. There must be action to meet the recommendations for Wales[2] based on the State of Child Health 2017 report[3] in order to achieve this.
4. Health Education Wales should fund mandatory child health training for all GP trainees.
Further detail on the above can be found in three key documents:
1. State of Child Health report 2017: http://www.rcpch.ac.uk/system/files/protected/page/SOCH-UK-2017.pdf
2. State of Child Health 2017 Recommendations for Wales: http://www.rcpch.ac.uk/system/files/protected/page/SOCH-recommendations-Wales-eng-lang.pdf
3. Facing the Future: Together for Child Health: http://www.rcpch.ac.uk/facing-future-together-child-health
Consultation questions
· How GP cluster networks in Wales can assist in reducing demand on GPs and the extent to which clusters can provide a more accessible route to care (including mental health support in primary care).
· The emerging multi-disciplinary team (how health and care professionals fit into the new cluster model and how their contribution can be measured).
· Local and national leadership supporting the development of the cluster infrastructure; how the actions being taken complement those in the Welsh Government's primary care plan and 2010 vision, Setting the Direction.
We support initiatives to increase links between primary care clusters and lead paediatricians in specified geographical areas. It is easier for paediatricians to support and network with GPs in a cluster and work together to meet the standards set out in Facing the Future.
GPs are the main healthcare providers for children. As parents’ preference for initial advice is their GP, a primary care led model of service delivery should remain the focus but this is hindered by only a third of GP having had an opportunity to undertake paediatric training. GPs should all receive training in child health, but by working with a named paediatrician, they can also draw upon greater expertise. This helps build confidence between GPs and parents, who will know their GP can meet their needs; and between primary and secondary care in the context of child health. It also helps to prevent unnecessary admissions and referrals to hospital.
Various models are being trialled but we do not yet have well evidenced models that can be scaled up that we know will work in all areas of Wales, particularly in remote and rural settings. We need the Welsh Government to work with child health professionals to invest not only in delivering but also evaluating various forms of clustering and relationship building between primary and secondary care to help us better understand what works in all parts of Wales.
The RCPCH has consistently called for greater integration of services for infants, children and young people at a local level, which is particularly important for those with more complex needs (one in seven 11 to 15 year olds now has a long term condition or disability). Compared to adults, children have a greater reliance on the family and education sector and less reliance on social care. Therefore, integrated health services for children must connect to education and youth justice systems as well as to social care. In primary care, this means multidisciplinary teams need to include health visitors and school nurses.
· Workload challenges and the shift to primary prevention in general practice to improve population health outcomes and target health inequalities.
Our recent report, the State of Child Health[4], brings together data from across the UK with Welsh-specific data where possible and sets out a series of recommendations for Wales[5] covering childhood obesity, breastfeeding rates, accident reduction and harmful behaviours such as smoking and drinking.
Meeting these challenges is essential in order for health services at both primary and secondary levels to meet demand and ensure sustainability of services, as well as improve the health of children and young people. It is also essential in order to meet the standards set out in Facing the Future and enable new ways of working to succeed. GPs must receive training in child health and form a key part of delivering solutions to the biggest public health issues facing children and young people.
We welcome the Healthy Child Wales Programme, which will help ensure every child aged 0-7 receives a consistent range of services and could form the basis of a strategy for the whole of childhood that seeks to reduce child deaths, increase the visibility of infants, children and young people in the debates about services that affect their wellbeing and ensure that Wales has the workforce to meet their needs.
GPs also have a huge role to play because of the frequency of contact with children and families. They have significant opportunities to deliver public health priorities. All health care professionals including GPs must see the whole person and be able to deliver public health messages and have conversations about obesity, maternal smoking, mental health issues and other major public health concerns - even when these were not the primary reason for an appointment.
We strongly recommend the following actions:
1. The Welsh Government should develop an evidence-based child health and wellbeing strategy covering the whole of childhood. The strategy should include a clear accountability framework setting out responsibilities for professionals, the public and civil society as well as details about resources and funding to implement it.
2. The Welsh Government should adopt a ‘child health in all policies’ approach to decision making, policy development and service design. This is based on the recognition that challenges facing child health are highly complex and often linked through the social determinants of health. No single government sector will have all the tools, knowledge, capacity or the budget to address this complexity alone.
3. Health Education Wales should fund mandatory child health training for all GP trainees.
4. NHS Wales should ensure that all health care professionals can make every contact count by having difficult conversations with their patients (whatever their age), for example, with those who are overweight or obese.
· The funding allocated directly to clusters to enable GP practices to try out new ways of working; how monies are being used to reduce the pressure on GP practices, improve services and access available to patients.
· Greater detail on the aspects being evaluated, the support being supplied centrally and the criteria in place to determine the success or otherwise of clusters, including how input from local communities is being incorporated into the development and testing being undertaken.
· The current and future workforce challenges.
Children and young people account for about 1 in 5 a typical GP’s patients and about a quarter of a GP’s typical workload in the UK. GP clusters must therefore have an appropriate focus on children and young people with expertise on child health available at each cluster.
Proper evaluation and trials are required in the Welsh context and this must be funded appropriately. Innovative work is happening but we don’t yet have the evaluation necessary to share learning and enable successful models to be scaled up. This testing must include input from families and children and young people themselves given the significant needs of children and young people and the impact on GP workloads.
It is also clear that if GPs themselves are not properly funded and resourced, no model can plug the gaps. There are shortfalls in the number of GPs in parts of Wales and significant problems in recruitment. This must be addressed as a prerequisite to meeting professional standards.
Finally, children and families must be supported to live healthy lifestyles and remain well. The recommendations for Wales drawing on the data from State of Child Health set out the key actions that must be taken by the Welsh Government, Public Health Wales and other agencies in order to achieve this.
Appendix A: Facing the Future Together for Child Health summary of standards:
1. GPs assessing or treating children with unscheduled care needs have access to immediate telephone advice from a consultant paediatrician.
2. Each acute general children’s service provides a consultant paediatrician-led rapid access service so that any child referred for this service can be seen within 24 hours of the referral being made.
3. There is a link consultant paediatrician for each local GP practice or group of GP practices.
4. Each acute general children’s service provides, as a minimum, six-monthly education and knowledge exchange sessions with GPs and other healthcare professionals who work with children with unscheduled care needs.
5. Each acute general children’s service is supported by a community children’s nursing service which operates 24 hours a day, seven days a week, for advice and support, with visits as required depending on the needs of the children using the service.
6. There is a link community children’s nurse for each local GP practice or group of GP practices.
7. When a child presents with unscheduled care needs the discharge summary is sent electronically to their GP and other relevant healthcare professionals within 24 hours and the information is given to the child and their parents and carers.
8. Children presenting with unscheduled care needs and their parents and carers are provided, at the time of their discharge, with both verbal and written safety netting information, in a form that is accessible and that they understand.
9. Healthcare professionals assessing or treating children with unscheduled care needs in any setting have access to the child’s shared electronic healthcare record.
10. Acute general children’s services work together with local primary care and community services to develop care pathways for common acute conditions.
11. There are documented, regular meetings attended by senior healthcare professionals from hospital, community and primary care services and representatives of children and their parents and carers to monitor, review and improve the effectiveness of local unscheduled care services.