Developing a community child health service for the 21st century

Section 4: Models of care in other countries

USA

Paediatricians in the USA work in a very different healthcare delivery paradigm. However the American Academy of Paediatrics has been forthright in its insistence of the importance of Community Paediatrics ( CP) and defined it in a policy statement in 2005 (reaffirmed in 2010) which emphasises the advocacy role of paediatricians in this aspect of practice as follows ( US spelling retained):

"The American Academy of Pediatrics ( AAP) offers a definition of community pediatrics to remind all pediatricians, generalists and specialists alike, of the profound importance of the community dimension in pediatric practice.

Community pediatrics is all of the following:

• A perspective that enlarges the pediatrician's focus from one child to all children in the community;
• A recognition that family, educational, social, cultural, spiritual, economic, environmental, and political forces act favorably or unfavorably, but always significantly, on the health and functioning of children;
• A synthesis of clinical practice and public health principles directed toward providing health care to a given child and promoting the health of all children within the context of the family, school, and community;
• A commitment to use a community's resources in collaboration with other professionals, agencies, and parents to achieve optimal accessibility, appropriateness, and quality of services for all children and to advocate especially for those who lack access to care because of social, cultural, geographic, or economic conditions or special health care needs; and
• An integral part of the professional role and duty of the paediatrician."

So, in summary, the AAP model emphasises the duty of all paediatricians to consider community aspects of a child's life in a holistic way whether they are generalists or specialists and also highlights the advocacy role of a paediatrician. However, the practice of office-based paediatricians is not directly comparable to our UK set-up.

Canada

In 2009 Ukpeh ⁴² described Canadian community paediatrics as two complementary concepts - the community-based paediatrician and the community paediatrician. He said: "The community-based paediatrician, as the name implies, is a paediatrician based in the community, usually outside a tertiary centre, whose practice is focused on those who visit the clinic, including support for patients accessing needed services within the community. The community paediatrician, on the other hand, sees the community as the patient". These two groups of clinicians therefore appear to combine a clinical practice model with a public health approach.

New Zealand

In New Zealand in 2006 the Paediatric Society of New Zealand issued a paper, "Community Paediatric Service: Notes for Purchasers". They laid out the goals of a community paediatric service with the emphasis on health promotion and improvement as follows:

To develop and/or implement within a defined population for all children:

• a detailed assessment of the health and development needs
• effective health promotion and health protection programs
• a comprehensive co-ordinated system of quality child health services that meet identified needs
• systems for identification, support and reintegration programs for children with "special needs"
• an integrated framework of services linking health and non-health sectors to achieve maximum support and health gain for children and families
• systems for monitoring and evaluation of the efficacy, efficiency and community value of child health programs, and of the service as a whole
• information systems that use evidence to tailor child health services to meet the changing needs and health outcomes of a community
• participation in, and often leading the Child and Youth Mortality Review system.

Europe

In European countries care of children outside hospital is divided between GPs, Primary Care Paediatricians ( PCPs) and community paediatricians ( CPs). In a review of the European approach to paediatric care, Katz et al (2002) ⁴³ defined a CP as "a paediatrician who devotes to the comprehensive recognition and understanding, prevention, and treatment of community-related health problems such as child protection, children in need, behaviour problems, teenager approach, growth and developmental assessment, school medicine, etc."

Katz and colleagues issued questionnaires to 34 country paediatric associations concernng their country's paediatric care and training of paediatricians. They found that 14 out of 34 countries had community paediatricians practising according to their definition above. The UK is praised for its system of community paediatricians, but the point is made that this is an "expensive option". However, there is no economic analysis of the cost of not having CPs.

In 2001 Crouchman et al ⁴⁴ had observed European patterns of community and social paediatric care as showing "wide disparity in overall structure of services, as well as variation in interpretation of what is meant by social/community paediatrics. A comprehensive community paediatric service exists in the UK and Sweden (where 25% of paediatricians work outside hospitals), but elsewhere in Europe secondary paediatric and disability services are still very much hospital based. The concept of child development centres is spreading slowly, and there are isolated initiatives, for example, in Greece and Portugal".

From these references one can gather that the UK has been regarded globally as a leader in providing community and social paediatrics. The absence of primary care paediatricians in the UK (although concept had been successfully piloted, eg in West Lothian during the 1990s), means that a possible gap has developed between primary care and community paediatrics. The future role of GPs in the care of children may need to be re-examined.