more_vert
Upskilling GPs with the support of paediatricians could reduce the number of children referred onto lengthy public hospital waiting lists, a new study has found.
Australian children are struggling to get access to timely specialist care. Some children wait three years or more to be seen in a public specialist outpatient clinic. For families who can afford a private paediatrician, wait times are shorter but the costs are high. A recent Grattan Institute report found that paediatrics was the fourth ranked speciality for “extreme fee-charging” (ie, charging more than triple the Medicare schedule fee), with initial consultations costing families an average of $363 out-of-pocket. If a child needs to see a paediatrician for multiple visits, costs start to add up. This makes accessing private paediatricians unaffordable for those who often need them the most — children with mental health and developmental and behavioural disorders from low-income families.
Whilst general practitioners (GPs) recognise this need to support child health, GP registrars report feeling underprepared to manage chronic conditions in children, especially mental health, behavioural and developmental presentations. Given the pressures of long public hospital waitlists and high out-of-pocket costs for private care, we set out to determine whether upskilling GPs in child health could reduce referrals to hospital services.
An integrated GP-paediatrician model
The Strengthening Care 4 Children (SC4C) trial ran across 21 general practices in Victoria and New South Wales using a stepped wedge randomised controlled trial design, meaning that all practices were randomised to receive the model at different time points. The model included a local paediatrician being co-located in a general practice over a 12-month period — weekly for six months, then fortnightly for another six months — to work alongside general practitioners in joint consultations with their paediatric patients. Co-consultations were scheduled and led by GPs, ensuring they retained primary responsibility for care. Additional support by the paediatrician included monthly case discussions on topics chosen by the GPs, as well as ongoing advice via email and telephone.
The impact of this model
The SC4C model resulted in a reduction in GP referrals to public hospitals, most notably among ‘high referring’ GPs – those who referred 5% or more of children seen during the baseline (control) period of the trial. These GPs reduced their referrals by 4.28%. There was a smaller reduction in referrals to private paediatricians – good news for families who cannot afford out-of-pocket costs. GPs reported an increased in confidence in managing paediatric care, with greater access to reliable resources to guide their decisions, support parents, and expand their scope of practice. Limited time and renumeration were reported by GPs as constraints to practicing integrated GP-paediatric care
One GP said:
“I think it’s great that I can now work up the patient more thoroughly and do a lot of that legwork before they’ve seen a paediatrician, or maybe not even need to. I think it’s great that we can all have more confidence to try and make that decision.”
One parent said:
“It was amazing to get that specialist knowledge on top of your GP and with your GP. I just think it was one of the best experiences of access to quality healthcare, to be honest.”
Following this trial in metropolitan Melbourne and Sydney, SC4C is now being tested in rural settings, with co-consultations delivered in-person and via video telehealth and online group-based case discussions with all participating GPs. It is also being trialled using an online-only platform.
We have shown that an integrated GP-paediatrician model can reduce hospital referrals for high-referring GPs, while increasing scope of practice and confidence in providing paediatric care for all GPs. The Grattan Institute has called for federal and state governments to “set up a system that makes it easy for GPs to get advice from other specialists.” Strengthening Care 4 Children shows how this can work in practice. Paediatricians in the model were funded by their local hospitals (state funding) while GPs were supported in implementing practice changes by their local Primary Health Network (federal funding), Medicare billing, and a one-off practice payment of $7000 (from research project funds). Alongside expanding public paediatric clinics in areas of need, the SC4C model ensures Australian children can access the right care at the right time, closer to home.
Next steps
Given the appropriate funding and implementation support, the SC4C model could be scaled up to strengthen child health care, expand GP scope of practice, and reduce demands on hospitals. The model could be targeted to areas with large numbers of children whose families face barriers to accessing affordable specialist care.
Professor Harriet Hiscock is a paediatrician, the academic lead of the Transforming Healthcare Impact Domain at the University of Melbourne, and co-leader of the Health Services and Economics group at Murdoch Children’s Research Institute.
Professor Lena Sanci is general practitioner and head of the Department of General Practice and Primary Care at the University of Melbourne.
Sonia Khano is Senior Project Officer at the Murdoch Children’s Research Institute and an honorary researcher at the University of Melbourne.
Professor Raghu Lingam is the leader of the Population Child Health and Health Services Research Group at the University of New South Wales, and a consultant paediatrician within the Sydney Children’s Hospital Network.
The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
Subscribe to the free InSight+ weekly newsletter here. It is available to all readers, not just registered medical practitioners.
If you would like to submit an article for consideration, send a Word version to mjainsight-editor@ampco.com.au.