The epidemiology of general paediatric outpatients referrals: 1988 and 2006.

BACKGROUND: Wirral University Teaching Hospital is a large district general hospital situated on the Wirral peninsula, UK. Because of the district's geographical and demographic characteristics, Wirral is an ideal location for population-based studies. Information on paediatric referrals, case mix and outcomes are scarce. We took advantage of our situation to conduct an epidemiological study of referrals to general paediatrics in Wirral in 1988 and again in 2006. A companion paper examines referrals to community paediatricians in the Department during the same period. METHODS: A prospective observational study of general paediatric outpatient referrals between 1 Feb and 31 May 2006 compared with the same period in 1988, using the same methodology. We included all children under the age of 15 offered a new patient appointment during the study period. RESULTS: The referral rate had increased significantly from 15.5 to 25.7 per thousand children under 15 per annum (P < 0.01; Chi Squared). The most common conditions referred in 2006 were constipation (10.5%) and enuresis (7%) compared with asthma (15%) and heart murmurs (13.8%) in 1988. There were significantly fewer wasted appointments (5% vs. 12%), shorter waiting times (5% vs. 12% waited more than 12 weeks), faster treatment times (25% vs. 14% started treatment after the first appointment) and more discharges (41.2% vs. 30.5%) (all P < 0.01; Chi Squared). CONCLUSIONS: More children were referred to paediatricians in 2006 compares with 1988. Services worked more efficiently, with better attendance, access and time to treatment. We provide information on changes in case mix that is not available elsewhere. This population-based study thus gives a unique insight into changes in referrals to UK general paediatricians.

The epidemiology of community paediatric outpatient referrals 2006.

BACKGROUND: Wirral University Teaching Hospital is a large district general hospital situated on the Wirral Peninsula, UK. Because of the district's geographical and demographic characteristics, Wirral is an ideal location for population-based studies. Information on community paediatric referrals, case mix and outcomes is scarce. We took advantage of our situation to conduct an epidemiological study of referrals to community paediatrics in Wirral. A companion paper examines referrals to general paediatricians during the same period. METHODS: A prospective observational study of community paediatric outpatient referrals between 1 February and 31 May 2006 for all children under the age of 15 offered a new patient appointment during the study period. The study was conducted using the same methodology as a previous population-based study of community paediatric outpatients in Northampton, UK in 1998. We compared our results with this previous study. RESULTS: The referral rate was 10.1 per 1000 children under 15 per annum. School nurses and health visitors made nearly half the referrals, with general practitioners referring most of the remainder. Compared with the Northampton study, more children were seen by consultants. Case mix showed a shift towards behavioural and neurodevelopmental disorders, with less general paediatrics. Attention deficit hyperactivity disorder was the commonest disorder seen (28.2%), a significant increase from the previous study (3.4%) (P < 0.01). Autism spectrum disorder showed little change (8.1% vs. 9.6%; NS). The Wirral study showed significantly more follow-up compared with the Northampton. CONCLUSIONS: This population-based study gives a unique insight into the epidemiology of referrals to community paediatricians in the UK in 2006 and how these differ from those recorded in a different UK district in 1998.

Achieving early surgery for undescended testes: quality improvement through a multifaceted approach to guideline implementation.

BACKGROUND: Surgery for undescended testes is recommended before the age of 2 years. However, boys are still undergoing surgery for undescended testes at a much later age than recommended. METHODS: An initial audit reviewed all orchidopexies performed at Northampton General Hospital between 1992 and 1994. This demonstrated that only 19% of boys had surgery by the age of 2 years, and the key reason for late surgery was late referral. Guidelines for referral of undescended testes were established in which referral to a surgeon was advised following the 8-month child health surveillance check if undescended testis was suspected. This would enable surgery before the age of 2 years. Audit results were disseminated and we implemented a package of measures based on evidence based change management techniques. These included written advice to general practitioners (GPs), a parent information leaflet and an amended personal child health record advising timing of referral. A reminder to the GP to refer following the 8-month check was generated using computer recall from the Child Health System records. Guideline implementation was monitored by annual audit and feedback. RESULTS: The baseline audit for the years 1992-94 found a median age at surgery of 4 years. Implementation of the new policies in 1998 resulted in a reduction in median age at surgery to 2.0 years in the 12 months ending September 2001. CONCLUSIONS: While concern about the age at orchidopexy has been highlighted in many previous studies, this is the first to show that improvement in the age at orchidopexy can be achieved. Implementing locally agreed guidelines with written information to GPs and parents combined with computerized recall from Child Health System records achieved the target within 3 years. Similar systems could be implemented nationally at minimal cost.

Referral patterns to a district Child Development Centre: 25 years experience.

This study describes the changes in referral patterns to a district Child Development Centre over 25 y. Referral information was collected prospectively for all referrals seen at the Child Development Centre at Northampton, UK, from 1974 to 1998 inclusive. This unique data set records CDC usage over 25 y in the same district and was collected, until recently, by the same individual. Professional awareness and identification of complex developmental problems appeared to improve over the study period. The data show a gradual rise in referral rates to reach a plateau of between 5.5 and 7.2 referrals per 1000 children under 5 per annum. This level of referral achieves almost complete ascertainment of childhood disability needing statutory assessment by the age of 6 y. The increases in early referrals followed educational intervention with primary health care teams emphasising the importance of early identification and referral.

Case mix presenting to paediatricians in a UK district (1998).

This observational study analysed paediatric outpatient referrals to a district service in the UK in 1998 and compared results with studies conducted 10 y previously. Data was collected prospectively from the written correspondence on all new outpatient referrals offered appointments by paediatricians at Northampton General Hospital over a 3-month period. Two hundred and ninety-seven (66%) referrals were to general paediatricians, 108 (24%) to 'patch' community paediatricians and 47 (10%) to community paediatrician consultant clinics. The referral rate to general outpatients was 20/1000 per annum, similar to referral rates in 1988. Urogenital and cardiac problems have overtaken asthma as the most commonly referred conditions. Referrals to consultant community paediatricians were predominantly development and behaviour difficulties and were more complex than those referred to other groups. 'Patch' community paediatricians received 87% of their referrals from practitioners other than doctors and played a significant role in co-ordinating care in the community. They referred less than 3% for consultant assessment. The referral rate to general paediatric outpatients has remained stable over the last decade although the case mix has changed. For the first time, we provide population-based case mix and referral rates to community paediatricians. We highlight the important role of non-consultant career grade paediatricians in supporting clinical services in the community. Open access to some investigations for general practitioners (GPs) could be explored as a way of managing demand for general paediatric outpatient appointments.

Direct communication with general practitioners improves management of infants at risk of hepatitis B.

The National Screening Committee has recommended that all women presenting for antenatal care be offered routine screening for hepatitis B by the year 2000. In a low prevalence area a survey of the management of neonates whose mothers were positive for hepatitis B surface antigen showed that management of this group was better among general practitioners who had received advice on treatment.

A new method of evaluating selective school entry medicals.

There is an ongoing debate about the relative value of selective vs routine entrant medicals. This paper describes a districtwide study of entrant medicals using the tracer method to assess the prevalence and detection rates of problems at school entry. Overall 57% of school entrants were selected for a medical but there was a significant difference in selection rates in urban and rural schools. This selection rate is higher than that reported by other authors. There was a trend for tracer conditions to be more prevalent in urban areas although this was not statistically significant. Prevalence rates suggest that the method of selection successfully detected children with problems. The tracer methodology provided useful information for service planning without the collection of large amounts of data and has not, to our knowledge, been used before in community child health. We recommended this methodology to other districts as a simple and effective method of assessing selective entrant medicals.

Will deprived areas still need community paediatricians? An unpopular hypothesis.

Community paediatricians have traditionally provided primary preventive services. The new GP Contract encourages GPs to provide such services within practices but practices in deprived areas may be less able to do so than more affluent practices. This paper attempts to analyse the role of a community paediatrician in a deprived area of South Sefton (Merseyside) HA in providing primary care both before and after the new contract, and the effect the contract had on the involvement of GPs in preventive health care. Only 20% of immunisations and 5% of child health surveillance (CHS) were done within practices in 1989. This rose to 34% and 16% respectively by 1991, but community clinic attendances also rose by 26%. Immunisation uptake improved from DT & Polio 77%, Pertussis 51% and Measles 37% to 98%, 87% and 98% over five years. The identification of problems before school entry was poor, but improved from 31% to 51% over three years. Most problems were identified by professionals during CHS and school health checks rather than being presented by parents. Increased recognition led to an increased need for 'secondary level' support and follow-up of problems. The GPs in this area needed the support of a community paediatrician to provide comprehensive preventive health care. Such areas may need to explore alternative models of care to meet child health needs.

Children with disabilities and the Children Act: who will assess their needs?

The Children Act focuses attention on meeting the assessed needs of children with disabilities. General practitioners (GPs) and Community Child Health (CCH) doctors in one health district were asked by postal questionnaire who it was who currently assessed such needs and who would do so in the future. The involvement of GPs (15) varied from none (1) to regular reassessment (3). Nearly all (14) treated acute illnesses but educational assessments were assigned to CCH doctors. Community doctors (9) had a clearer idea of their role including regular reassessment (9), education assessment (9) and interagency liaison (3). Both groups complained of poor communication with each other and with hospital services. To fulfil the requirements of the Children Act, community child health services, family health services authorities and district health authorities will have to specify how and by whom children with disabilities are identified and assessed. Arrangements will vary according to local service development. These arrangements, and the resulting liaison with other agencies, should be specified in National Health Service contracts, thus improving communication and cooperation.

Routine or selective school entry medicals: a review of current literature.

A review of recent literature on school entry medicals (SEMs) assessed whether selective medicals were as effective and/or cheaper than routine medicals. Data were compared with prospective data from the author's 'patch' on a one-year cohort of routine SEMs. Routine medicals showed that 40-50% of school entrants had health problems but selective systems detected fewer. Districts with high morbidity were less able to detect problems early but effective child health surveillance was not related to the number of new problems at SEM. Selection did not reduce costs and could increase costs in deprived areas. The SEM is an opportunity for health education which is valued by parents. On present evidence, selection for medicals at school entry cannot be recommended.

A district survey of paediatric outpatient referrals.

A prospective analysis of general paediatric outpatient referrals to a district general hospital was conducted over four months. Because of geographical characteristics, this probably represents all referrals within the district during that time. The referral rate referral rate was 15.5 per thousand per annum. Only five children did not see a consultant at their first visit. One hundred and five children were discharged after one consultation. Communication between general practitioners and hospital appeared generally good. Although only 56 referral letters stated the urgency of referral, 351 (94%) stated a reason for referral. One hundred and five children could have been dealt with by the community child health service. The NHS reforms, fund-holding practices and the development of the community child health service may profoundly affect current outpatient workloads and practice.