The role of general practice in the provision of healthcare to children and young adults

Policy declaration

The Royal Australian College of General Practitioners (the RACGP) recognises that comprehensive healthcare for Australian children and young people is a fundamental health priority for Australia, and that GPs play a crucial role in the healthcare and wellbeing of children, young people and their families.

In recognition of the importance of a child’s early years in their physical, cognitive, social and emotional development, the RACGP advocates for the coordination of all resources and services to optimise child health and development. In this policy we outline the role of general practice in promoting the health and wellbeing of children and young people.

Introduction

In recent times, the overall population health status for children has improved. Evidence of improved childhood mortality rates and decreased vaccine preventable illnesses is a testament to improved health service delivery within Australia. General practice has been an integral part of this progress. However, Australia still compares unfavourably with other Organisations for Economic Co-operation and Development (OECD) countries on a number of measures of child health and wellbeing, particularly in relation to outcomes for Aboriginal and Torres Strait Islander children.

The RACGP recognises that improving the health of Aboriginal and Torres Strait Islander people is one of Australia’s highest health priorities and is committed to improving the health of Aboriginal and Torres Strait Islander children and young people through all of its activities, particularly that of the National Faculty of Aboriginal and Torres Strait Islander Health.

There is increasing evidence from social, behavioural and neuroscience that highlights the importance of early childhood development for long term health outcomes. This evidence reinforces that the quality of a child’s early environment, including the care provided to them by parents, carers and health professionals is paramount in determining their life trajectory. In what has been described as the ‘paradox of progress’, social inequalities across many indicators of child development have actually increased, rather than decreased, with increasing wealth in Australia.^1,2 Hence health interventions are now focussing on maintaining developmental wellbeing in addition to preventative health and acute care services. This applies to both well children and children with special needs.

The role of general practice in child health

Australia has a well accepted system of universal health services based on the principles of primary healthcare to meet the needs of pregnant women, children and families at multiple contact points. GPs provide significant primary care services for pregnant women, children and their families.³

GPs are uniquely placed to form an early social relationship with the child and their family. This includes insight into the child’s view of their situation and managing parental concerns in a way that enhances the parents’ understanding, self confidence and capacity to manage. The involvement of young people and their families in decisions about their healthcare is essential to this. Parents report that they value doctors who understand the complexities of family life.⁴

General practice supports optimal healthcare and development of children and young adults by:

• The provision of a ‘medical home’
  General practice provides person centred, continuing, comprehensive and coordinated whole-person healthcare to individuals and families in their communities.⁵ Practices with these characteristics have been shown to improve health outcomes for children.^6,7

• The provision of evidence based preventive health activities
  The provision of preventive care is a key element of the Australian health system. The role of general practice in prevention has been recognised by the Council of Australian Governments (COAG)⁸ and by the Australian Government’s Preventative Health Task Force and Primary Health Care Strategy.^9,10 In addition to preventive activities, the GP also has a role to play in early development and health promotion, parent and carer education.

• Providing access to appropriate medical attention for acute healthcare
  In Australia, GPs are often the first point of contact for patients wishing to access healthcare. GPs see approximately 85% of the Australian population on an annual basis¹¹ and play a significant role in identifying needs and coordinating services for children and young people.

• Delivering systems of care (developmental surveillance) to optimise/support biopsychosocial development of children
  The RACGP recognises there are opportunities for improving the health of Australian children through surveillance of early childhood development. As a sector, general practice, its practice teams and primary healthcare relationships provide the foundations of an effective developmental surveillance and intervention system. Systems are in their infancy, but in line with government policies on child health checks and the recommendations made in the RACGP Guidelines for preventive activities in general practice, 7th edition (the ‘red book’) and the RACGP National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, 2nd edition, increasingly GPs are implementing systems to support children and identify those in need and at risk.

• Providing access to appropriate resources for children and young people who have special health needs
  Children with special needs are those who have, or are at increased risk of, a chronic physical, developmental, behavioural or emotional condition and who also require health and related services of a type or amount beyond that generally required by children. GPs are often the link in the community identifying children at risk and coordinating care across health and social care sectors. GPs are key coordinators and advisors to patients for community based and specialist services for children and youth.
• The coordination of health, social and education sectors with the united purpose to improve health and early childhood development
  GPs cooperate with schools, employment agencies, welfare agencies and law enforcement to enhance the safety, wellbeing and development of children.

The RACGP position

The RACGP believes that general practice is the foundation of the Australian healthcare system. The RACGP recognises and embraces its responsibilities for the health of children, young people and their families in that role. The prenatal, childhood and adolescent phases of development strongly influence an individual’s subsequent health, wellbeing and opportunities in life. Therefore the general practice care of children and young people takes on a special role in creating future opportunities, especially for Aboriginal and Torres Strait Islander people and other communities.

The RACGP believes that all Australian children should have equal access to health and opportunities for optimal childhood development and recognises there are opportunities for improving the health of Australian children through surveillance of early childhood development. As general practice is the only profession with regular contact through the very earliest development stages of the infant – from preconception, antenatal care, infancy, childhood and adolescence – GPs have a crucial role to play in this.

The RACGP’s commitment to better care for children, young people, their families and communities can be seen within its core activities:

• setting the standards for general practice
• setting the curriculum for Australian general practice
• producing clinical guidelines, such as the RACGP red book and the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people
• representing general practice externally, such as in Child Health Researching Universal Services (CHoRUS)
• creation of the National Faculty of Specific Interests – Child and Young Person’s Health Network.

General practice has advanced systems of care, evaluation, and support, from pre-pregnancy to early adulthood. In its role providing person centred, continuing, comprehensive and coordinated whole-person healthcare to individuals and families in their communities, general practice is the only profession that continually supports parents, children and young adults through the very earliest development stages of infancy and on to adolescence. Importantly, general practices also provide care for parents, siblings and extended family and carers involved in a child’s development.

General practice is the only professional body with programmed regular checks (immunisation) in the early development period. The RACGP supports a system of care that offers ongoing surveillance of children’s development and healthcare, and the use of tools to enable early detection and management of biopsychosocial problems.

Whilst the evidence for developmental screening programs in early childhood remains mixed, the RACGP acknowledges the importance of monitoring children’s development over time, and this is articulated in the RACGP red book, the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, 2nd edition, and the Curriculum for Australian general practice 2011.

GPs and their practice teams have training and experience in conducting clinical consultations and evaluations, therefore they have a large capacity to deliver meaningful and balanced health strategies and information. General practice is the first point of call for parents who detect problems or concerns with their children. Aboriginal and Torres Strait Islander health services are often the first point of call for parents or carers of Aboriginal and Torres Strait Islander children.

General practice has quality assurance and clinical governance structures to support continued quality improvement for children and young adults.

The RACGP has developed and implemented a number of mechanisms and systems that embed and support good clinical governance, quality assurance and ongoing quality improvement in general practice.

General practice is the only health professional group that developed its own standards and had these accepted by government for accreditation purposes. The RACGP Standards for general practices, 4th edition, support the development of clinical governance and quality assurance systems. The RACGP is currently revising the existing Interpretative guide for the Standards for general practices in partnership with the National Aboriginal Community Controlled Health Organisation (NACCHO) to assist Aboriginal and Torres Strait Islander health services applying for accreditation against the standards. The RACGP continues to be proactive in addressing issues such as access and equity for Aboriginal and Torres Strait Islander people through the Standards for general practices. This includes active encouragement for Aboriginal and Torres Strait Islander people to identify themselves in general practice.¹² Furthermore, the RACGP has developed a set of voluntary quality indicators that support ongoing quality improvement activities and the development of clinical governance protocols across many areas of practice. In its capacity to set standards and develop program materials for advanced skills training, the RACGP plays a role in improving the delivery of services to children and young adults.

General practice has the appropriate infrastructure in place to support the delivery of early childhood development outcomes. It supports interdisciplinary and integrated approaches and is located to enable ease of access within the community for children and their families. General practices have embraced information and communication technology that has enabled consistent referral and booking procedures across services.

The RACGP acknowledges that there are significant populations within Australia who are disadvantaged, and works toward reducing that disadvantage.

Aboriginal and Torres Strait Islander people have significant capacity to benefit from support to overcome social inequities. Still, disadvantages are evident in a range of social and economic indicators including education, employment, housing and health.¹³ Health indicators continue to show significant disparities between Aboriginal and Torres Strait Islander and nonIndigenous Australian children and young people. The infant mortality rate amongst the Aboriginal and Torres Strait Islander population is three times the rate of non-Indigenous Australians.¹⁴ Aboriginal and Torres Strait Islander people rank the lowest in the OECD in terms of low birth weight.¹⁵

Children and young people living in poverty are also at increased risk of being exposed to unfavourable developmental risk factors. The literature suggests that a child’s capacity to reach their full potential is significantly reduced when being raised in an environ of poverty.¹⁶ Children who live in stressful, social, environments and are exposed to harsh parenting, abuse or neglect, parental substance abuse, mental illness and homelessness, also experience problems with early development.

It is critical that health services provided to children and young people are tailored and designed specifically so that the health needs of that vulnerable patient group are appropriately addressed.

The RACGP recognises Australia’s diversity of communities, which require local health solutions.

Australia is a geographically and culturally diverse country. Local populations have differing levels of need and face different challenges. They also have varying degrees of available resources which should be tailored to address the health needs of a community. For example, in rural areas young people and their families can be disadvantaged by the additional burden of travel and accommodation costs incurred while accessing services.

It is important that general practice continues to work across organisational and professional boundaries to deliver responsive, appropriate and integrated care. The RACGP recognises the contributions of many professionals who contribute to a child’s health and normal development, such as community nurses, Aboriginal and Torres Strait Islander health workers and teachers.

In a truly integrated system, there are pathways from universal services to more targeted and intensive services. Targeted services should be in place to support children and families or communities who have a higher need or higher risk than the general population. Intensive services are individually tailored responses to a particular child and family situation. Examples are parental substance abuse, mental illness and homelessness, and when children are experiencing, or are at risk of, abuse or serious harm. Pathways should also include culturally appropriate programs which build on existing community strengths.