Introduction by Croakey: Closer relationships between GPs and paediatricians have the potential to improve equity in child healthcare, according to the team behind pilot program, Strengthening Care for Children.
The Victorian and New South Wales-based program – inspired by Connecting Care 4 Children in the UK – is an integrated model of care where participating GPs receive regular visits from a hospital-based paediatrician and they co-consult with families and children.
According to findings from the pilot study, this model of care improves GP confidence in paediatric care which has the potential to reduce referrals to outpatients and emergency departments.
Below, communications and media adviser for North Western Melbourne PHN Andrew Masterson says the program also has the potential to reduce some barriers – financial and geographical – in accessing paediatric care.
Andrew Masterson writes:
Do the children of wealthy parents receive better health care than those in lower income families?
It’s an argument that can be made with solid circumstantial and data-based evidence. Discretionary income can circumvent long waitlists to see paediatricians.
Wealth permits parents to better manage the out-of-pocket costs, time and transport required to travel to the sometimes-distant hospitals in which paediatricians reside.
And these aren’t just casual observations. A UK Nature meta-review published last year identified “positive and significant effects of income on a range of children’s outcomes”.
Strengthening Care for Children
A pilot scheme rolled out across Victoria and New South Wales goes some way to reverse this inequity, by enabling direct patient and GP contact with paediatricians in general practice settings.
Called Strengthening Care for Children (SC4C), the project – which began three years ago as a small test in Melbourne’s western suburbs – has the potential to reduce child presentations to emergency department by about four percent. Nationally, this equates to tens of thousands of hospital visits potentially avoided.
SC4C was originally co-designed by the Murdoch Children’s Research Institute, the Royal Children’s Hospital and North Western Melbourne Primary Health Network (NWMPHN). In its second, larger iteration, additional participants include Sydney Children’s Hospital Network, Central and Eastern Sydney Primary Health Network, the University of NSW, University of Melbourne, and Macquarie University.
It was inspired by a UK model known as Connecting Care 4 Children, but with an added focus on detailed data-gathering and analysis.
This resulted in its designers having not one but two papers published simultaneously in the journal BMJ Open last month.
The premise of SC4C is very simple. Each participating general practice receives regular visits – in person or onscreen – from a hospital-based paediatrician. The paediatrician co-consults with the GP, seeing children and families together.
Multi-faceted benefits
The benefits could be multi-faceted. The pilot suggests that SC4C increases GP knowledge of childhood conditions. The paediatrician receives a better understanding of general practice. Patients and parents are treated within their own geographic community, and receive specialist attention in a timely manner.
Net results all round: increased confidence, reduced stress, improved knowledge, healthier kids.
“The health equity implications of this program are significant,” said the program’s principal architect, Professor Harriet Hiscock, who holds senior research positions at MCRI, the Royal Children’s Hospital and University of Melbourne.
“We are finding that wealthier families often already have a paediatrician who cares for their child whereas less wealthy families miss out. In the SC4C pilot, GPs charge for the consultation with the child according to their standard practice, which in most cases means bulk-billing. The paediatricians are funded by their local hospitals.”
The project represents a much-needed reform and rebalancing of general practice patronage. Currently, children represent a decreasing proportion of GP appointments, but make up the largest share of low urgency emergency department presentations, easily outnumbering adults of all ages.
One of the reasons for this is that many GPs feel inadequately trained for dealing with complex childhood conditions. Others report sometimes patchy communication between hospitals and primary care providers in relation to children discharged from emergency departments or wards.
These factors often result in children being referred back into hospital care. Some parents, too, perhaps as a result of past experience, opt to take their young ones direct to the ED instead of the local general practice.
SC4C research suggests these kinds of hospital presentations often concern common chronic conditions such as asthma and acute illnesses such as tonsilitis, as well as more urgent episodes related to mental health and physical injury.
One of the early adopters of SC4C was the North Coburg Medical Centre in inner-suburban Melbourne.
Having Royal Children’s Hospital paediatrician Dr Victoria McKay visit regularly meant young patients did not have to wait six to twelve months for an appointment.
“The doctors have really embraced the project,” said Karen Hoffman, the centre’s business manager.
“As we know, parents are very anxious when children are sick and reducing that waiting time to get expert advice is beneficial from a patient perspective, a practice perspective and the GPs’ perspective.”
McKay added: “We know there are not enough paediatricians or psychologists to go around, and we know that a lot of this very valuable work can be done with the GPs in their practice. Our aim is to reduce the number of referrals that aren’t needed to the hospital system.”
By boosting the confidence of knowledge of GPs through regular consults with visiting paediatricians – backed up by telephone and email support – more children can be treated at neighbourhood clinics. This not only reduces the number of ED presentations, it also means less disruption and dislocation for patients and families.
Program delivery during the pandemic
Curiously, SC4C turned out to be a project that was undamaged – and perhaps even improved – by the challenges of delivering healthcare over the past two years.
“One of the silver linings of implementing this project during the pandemic was that on occasion, particularly in the depths of Melbourne lockdowns of 2021, it presented opportunities to support telehealth co-consults,” said NWMPHN project manager Stephanie Germano, a co-author on both papers.
“Often we’d have the GP and patient remaining face-to-face in the general practice and the paediatrician joining via telehealth, or the GP and paediatrician remaining face-to-face and dialling in the patient via telehealth. The telehealth mode allowed for an effective, feasible and appropriate way to have GP-paediatrician co-consults.”
As a result of lessons thus learned, clinics in the Wimmera Southern Mallee region of Victoria are currently trialling a fully telehealth-based version of SC4C.
In so doing, they are exploring one of the primary applications of the model in relation to its health equity impacts.
Big picture estimates of the effect of a national roll-out of SC4C posited a significant reduction in ED presentations. However, a range of factors, including workforce size and the need for significant structural practice change, mean that universal access to the model will for the foreseeable future be an aspiration rather than an achievable objective.
“We simply don’t have enough paediatricians in Australia to go to that sort of national scale,” said Hiscock from MCRI.
“However, I think this model is best placed in areas where GPs and families struggle to get timely access to paediatricians. I’m thinking particularly of populations with low socio-economic status, or rural areas.”
*More information about Strengthening Care for Children can be found here and a video on its application in the North Coburg Medical Centre is available here (video credit NWMPHN).
See Croakey’s extensive archive of articles on child health.
