Paediatricians float solutions for deteriorating access problems

Morgan Liotta

31/08/2022 4:00:07 PM

Do solutions for the growing issue lie in integrated GP–paediatrician models and a new Medicare item number?

GP with mother and child
Streamlined, multidisciplinary care, including co-consulting sessions, is being piloted across Australia as a way of easing access issues.

The lack of access to paediatricians – many of whom have closed their books – is a growing problem GPs are increasingly having to navigate.
The issue attracted renewed attention earlier this month when Perth-based GP Dr Andrew Leech, who has a special interest in children’s health, wrote to his state’s Health Minister urging for better support for GPs and the families they care for.
Describing the situation as ‘a crisis’, Dr Leech, backed by other GPs, wants improved referral pathways, support for diagnosing, and a review of rules around prescribing stimulants for children with ADHD – for which childhood presentations are frequent.
But what do those on the other side of the fence have to say?
Professor Harriet Hiscock is a consultant paediatrician who holds research roles at the Murdoch Children’s Research Institute (MCRI), the Centre for Community Child Health at the Royal Children’s Hospital, and the National Health and Medical Research Council (NHMRC).
She agrees with Dr Leech that the situation has ‘absolutely’ reached crisis point.
‘One hundred per cent,’ Professor Hiscock told newsGP.
‘Pre-COVID this was also an issue, but it’s certainly been exacerbated.
‘I try to take on new patients when things are getting close to crisis point or a GP reaches out to me … but I work in a large multi-paediatrician practice in Melbourne and everyone’s closed their books, unless it’s semi-urgent.’
Finding available paediatricians has become so difficult that Professor Hiscock knows of some desperate families trying to secure telehealth appointments for their children in other states or territories – even though the lack of access has been recognised as a nationwide issue.
President of the Paediatrics and Child Health Division of the Royal Australian College of Physicians (RACP), Associate Professor Nitin Kapur, told newsGP the situation is adding to existing pressures in the healthcare system.
‘We are aware of an increase in demand for paediatric services since the COVID-19 pandemic, like many areas of the health system,’ he said.
‘These increases have compounded existing pressures on availability and wait times, similar to the recent increase in wait times for GPs.’
Professor Hiscock is hoping she has some solutions.
She has been focusing on various projects which largely involve GPs – the first being an integrated model of care trial running across Victoria and New South Wales, Strengthening Care for Children, funded by the NHMRC, with the MCRI leading the research.
In the trial, a paediatrician is placed in a general practice once a week for half a day where they see children together with the GP. Monthly case discussions are run so the GPs can upskill and be more confident in their care for children in paediatrics.
‘It doesn’t mean the GP can do everything, but they start to maybe take on and manage things that they didn’t have the competence or skill to do so before,’ Professor Hiscock said.
‘The beauty of the GP is they know the whole family much better – it’s care closer to home. They can provide that continuity when the child is going to multiple specialists.
‘We’ve also found it really streamlines their care. For example, with a kid who might have ADHD, instead of referring them straight to the paediatrician, they’ll now get the parents and teachers to complete a validated questionnaire, then on the basis of those results send it to the paediatrician who then can make a decision with the families in one appointment – not two or three.’
Taking into account GPs’ frustrations over the delays caused by the requirement that only specialist paediatricians or psychiatrists can prescribe stimulants for treating developmental disorders, Professor Hiscock said there should be more cases where GPs can get a special licence to prescribe.
‘Queensland has a model where the GP and the paediatrician [each] see the child once a year, and they share the care of kids who are stable with ADHD and not complicated,’ she said.
‘Again, that just frees up the paediatrician’s time to see new kids … [especially given that] one of the most common reasons children get referred to paediatricians in the community is for ADHD.’
Once the outcomes are measured from the Strengthening Care for Children trial, Professor Hiscock said a fundamental step forward would be the introduction of a Medicare item number for GPs and non-GP specialists to see a patient together as a ‘co-consulting session’.
‘We really need this to make it sustainable,’ she said.
‘At the moment when the paediatrician and the GP sees a kid together only the GP can bill Medicare, not the paediatrician.’

Prof_Harriet-Hiscock-article.jpgProfessor Harriet Hiscock wants to upskill GPs in children’s health to better supported coordinated care models with paediatricians.
The RACP also supports integrated models of care.
‘A fit-for-purpose telehealth MBS system in conjunction with the patient’s GP is also an aspect of integrated care that can improve healthcare access to children and their families,’ Associate Professor Kapur said.
‘This would ideally include a Practice Incentive Payment covering all consultant physicians to promote telehealth models of care and the delivery of integrated multidisciplinary care.’
In response to COVID’s impact on mental health, Professor Hiscock is also running a community of practice program that connects GPs and other healthcare providers in the community, such as psychologists, nurses and paediatricians, with child psychiatry expertise.
Monthly online education sessions are run about topics that GPs are interested in, including case studies and take-home resources.
‘The evaluations from the GPs [in this program] show us that again, they feel more confident to hold some of these children while they’re waiting to get in for mental health appointments and know how to keep them safe,’ Professor Hiscock said.
‘So there are models where we can go to GPs and support them more – and it works.’
Another NHMRC-funded program running in Victoria and New South Wales is also underway, where Professor Hiscock and her team are implementing and evaluating a ‘one-stop shop’ for families of children aged 0–8.
‘This is focusing on better detection and response to adversity in families, which we know leads to mental health problems,’ she said.
‘In the western suburbs [of Victoria and NSW] we’ve put health and social practitioners together … and we’re asking, “How do we all work together and hold kids together and not just refer them off?”.’
Additionally, the RACP has launched a ‘COVID recovery package’ in response to the pandemic’s setbacks, to support children’s mental health, wellbeing and development.
‘Improved access to healthcare for children, young people, and families is important to their development and overall wellbeing,’ Associate Professor Kapur said.
‘Which is why the RACP has advocated strongly through the Kids COVID Catch Up campaign for increased support in this area.’
Through the campaign, the RACP’s lobbying includes the appointment of a national chief paediatrician, increased funding for children with additional needs, and fully funded implementation of the National Children’s Mental Health and Wellbeing Strategy.
‘We’re also advocating for an increase in specialists through the expansion of specialist training programs to strengthen the paediatric workforce,’ Associate Professor Kapur said.
For Professor Hiscock, it all comes down to having multidisciplinary, coordinated care on one site.
‘This is the way we have to go because there’s never going to be enough specialists for the population growth that we have,’ she said.
‘It won’t solve every single referral and child, but we can take some of that pressure off.’
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Dr Manimala Chacko Alexander   1/09/2022 10:16:41 AM

It sure is difficult to get a child to see a Paediatrician particularly in the public system.As for item number for the Paediatrician would it be better a staff specialist Paediatrician to spend some sessions with the GP and get paid from the hospital?

Dr Bethany Reynolds   1/09/2022 11:12:15 AM

If we increased funding/staffing for public developmental clinics (that perhaps include GPs with an interest/seeking more experience) we could not only get more kids/families through, but provide adequate training opportunities for both paediatric and GP trainees. My only experience as a JMO with developmental paeds was incidental - the kid who came in with appendicits who happened to have ADHD etc. The focus on paediatric emergencies in GP is important, but also means many of us are left scrambling trying to help families. As a new fellow I feel only able to recognise patterns and refer....then wait.

Dr Dianne Joy Prior   1/09/2022 11:31:19 AM

So many ‘solutions’ seem to make the false assumption that GPs have spare capacity to do more. ‘ Deteriorating access problems’ are a huge issue in urban and rural general practice too.

Dr Bradley Arthur Olsen   1/09/2022 2:56:08 PM

I will always remember the referral I did to Bundaberg Base Paed dept , for a child with new onset of afebrile recurrent siezures ,I was the only doctor in a town of 2000-2500 people, about 150kms away Of course the referral was rejected by Bundaberg Hospital as there was no EEG with the referral . The nearest EEG service was 150km away-private , expensive , and booked ahead for months. Lesson here- stay in the city!

A.Prof Christopher David Hogan   10/09/2022 11:16:58 PM

There is a lot packed into one article but it stresses shared care of children , colocation of GPs & paediatricians hopefully with regular education sessions.
However when we mention GP education, it is essential that all GP registrars have access to a supervised training term in Paediatrics. This used mean a hospital based term but as a significant proportion of paediatric practice is office based these terms should include hospital & office based experience with access to significant education.