A proposal by Matthew Thompson, MBChB
40%
of children in hospital A&E departments don’t need to be there
15%
of paediatricians leave during training, for reasons including burnout
18.4%
lower treatment costs when GPs managed non-urgent paediatric attendances
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Contents
03
Why Paediatricians in Primary Care?
04
How would it work?
05
Three primary care systems
06
What do the studies say?
07
Keeping our paediatricians
08
I need your help
01
Too many children are waiting in our hospital emergency departments, and as many as 40% may not need to be there.
Primary care is overstretched, and too many GPs are left managing children with four months or less of clinical paediatric experience behind them. The result is predictable: babies, children, teenagers & their parents turning to accident & emergency, waiting hours, worrying, sharing infections in a corridor. What they usually need is a simple medication and a clear explanation of what to watch for.
Paediatricians, meanwhile, live in hospitals. General practice sees patients of every age, and in an ageing population most of that work is adult work. Children change quickly, present atypically, and carry conditions that behave nothing like their adult equivalents, so the safe move is often a referral into a second-care service that is already overwhelmed. Up to 15% of paediatric trainees leave during training.
None of that is a failure of individual clinicians. It is a structural gap. We have no doctor whose entire job is children in the community.
We need Paediatricians in Primary Care.
02
I’m proposing a new specialist role: Paediatrician in Primary Care.
These ‘GPs for children’ would join or advise existing primary care practices, keeping the majority of children’s care in the community rather than referring it onwards.
Training would last three years before a Certificate of Completion of Training, in the same way a GP trains. It would sit entirely within paediatrics, covering senior house officer ward and on-call work, but weighted towards paediatric emergency medicine, child and adolescent mental health services, and clinic referrals arriving from primary care under consultant supervision.
The role would be overseen by the Royal College of Paediatrics & Child Health or the Royal College of General Practitioners. Progress demonstrated locally is the next step.
03 WHY PAEDIATRICIANS IN PRIMARY CARE?
Greater
Social equality
Better access to childhood expertise produces better health outcomes, and better outcomes in childhood compound across a life.
Expert care
Chronic conditions in children behave differently to their adult forms, and would be managed by someone who sees them constantly.
Continuity
A child would be more likely to see the same paediatrician through childhood than to rely on GP availability.
Community care
Children would attend settings built for them, rather than a busy emergency department.
Retention
We would keep paediatricians who currently leave because of hospital hours and on-call patterns.
Fewer
Hospital attendances
Fewer children would need advice that only exists inside a hospital.
Waiting times
Fewer non-urgent children would be queueing ahead of urgent ones.
Consultant workload
Fewer children would reach senior hospital doctors, leaving them for complex cases.
Burnout
Fewer doctors would be overwhelmed by volume or by a lack of viable career options.
Cost
Through fewer hospital visits and a workforce we stop losing.
04
Paediatricians in Primary Care would act as specialist contacts for children and families in the community, complementing GP expertise rather than replacing it.
Paediatric hub and spoke centres could provide expertise and services to practices across a local area. A GP could refer a child to the hub, or call the duty paediatrician for advice on a case they would otherwise send to hospital. Larger practices and primary care networks could support a permanently embedded specialist as part of the team.
Most non-urgent conditions could be managed locally. Urgent and acute presentations would be escalated swiftly to secondary care, as now. Chronic conditions would gain community-based oversight.
Services could include non-urgent consultations, congenital and chronic condition care, school support, safeguarding, newborn examinations, post-surgical reviews, and child and adolescent mental health.
05
In a 2010 European survey, 12 countries used general practitioners to assess children in the community, seven used paediatricians, and 10 used both. The UK sits in the GP-led group. I’m proposing we move to a combined system, already used in a third of Europe.
Paediatrician led (24%)
Cyprus, Czechia, Greece, Israel, Slovakia, Slovenia, Spain.
GP led (41%)
Bulgaria, Denmark, Estonia, Finland, Ireland, Latvia, Netherlands, Norway, Poland, Portugal, Sweden, United Kingdom.
Combined (35%)
Austria, Belgium, France, Germany, Hungary, Iceland, Italy, Lithuania, Luxembourg, Switzerland.
06
The idea is not new. Writing in the London Journal of Primary Care in 2010, Clare Gerada noted that the 1976 Court Report had already introduced the GP Paediatrician, a GP with additional training providing services to children. Fifty years after Court, we have not done it.
The demand side has moved in one direction throughout. Children’s use of hospital urgent and outpatient care rose across every age group, with the sharpest rise in infants. The conclusion is a need for better access to specialist and community-based support for families with young children.
The RCPCH’s contribution to Right Place, Right Care put paediatric attendances likely to be non-urgent at approximately 40%, with difficulty accessing primary care identified as a key driver. Children under five were the group for whom targeted care outside usual community opening hours would be most beneficial.
A 2020 study of paediatric emergency attendances found that children managed by GPs were less likely to be admitted and less likely to wait over four hours. Treatment costs were 18.4% lower in the GP-managed group.
Staff salaries
82.81
46.00
+36.81
Observation / inpatient
28.86
89.28
-60.42
Investigations
0.43
2.77
-2.34
Total
134.88
188.21
-53.33
Including societal costs, the total was 28% lower in primary care. The saving comes from what stops happening afterwards: observation, admission, investigation, and the hours a parent spends not at work.
Leigh S, Mehta B, Dummer L, et al. Management of non-urgent paediatric emergency department attendances by GPs. Br J Gen Pract. 2020;71(702):e22–e30.
Sources
01 van Esso D, del Torso S, Hadjipanayis A, et al. Paediatric primary care in Europe. Archives of Disease in Childhood, 2010.
02 Ruzangi J, et al. Trends in children’s primary and hospital care use in England, 2007–2017. BMJ Open.
03 Royal College of Paediatrics and Child Health. Right Place, Right Care, 2022.
DR NEWMON · CONSULTANT PAEDIATRICIAN
07
We are losing too many paediatricians. A 2015 study found attrition of 15% between the first and third year of paediatric training. Of those still training after the third year, only 5.4% intended to become community paediatricians.
Doctors leave for reasons that are not mysterious: hours, nights, on-calls, and a shortage of paths that fit a life. A community-based paediatric career would offer an alternative to leaving. Children in the community would gain specialist care in settings built for them, hospital paediatricians would carry lighter loads, and the doctors taking that path would have a career that suits them.
Shortland G, et al. Paediatric training and intended career destinations. Archives of Disease in Childhood. 2015.
This is not a small project, and different people can help with different parts of it.
I’m looking for supervision, a research home, a route to a local pilot, and the honest objections that would make the proposal stronger.
Please get in touch if you can help, or if you simply want to follow the work. Thank you.
GET IN TOUCH
If you are an academic or a funder
I’m looking for supervision and a research home for this work.
If you are at RCPCH or RCGP
I’d like to understand whether a local pilot could inform a national position.
If you are a GP or a paediatrician
Tell me where this is wrong. I’d rather argue it out properly than quietly decide the outcome.
If you are a parent
You already know what four hours in an emergency department with a feverish toddler is worth.