Pragmatism and idealism in community child health

Prior to the Annual Scientific Meeting of the Royal Australasian College of Physicians (RACP) in Wellington 2005, a vigorous debate about the merits or otherwise of establishing special societies within the field of community child health took place on the Child Development Listserv moderated by one of the authors. Essentially the argument was between ‘lumpers’ and ‘splitters’– those who thought being constrained within the ‘broad church’ of community child health was inhibiting subspecialist development in developmental/behavioural paediatrics and child protection/forensic paediatrics; between idealists who restlessly sought perfection and pragmatists who stood back and reminded Listserv members of what has and is being achieved in the maturation of a discipline in a complex, resource-scarce environment where there are many insatiable and conflicting demands on the health care dollar. In this issue, Smith and McDowell helpfully and carefully expand on one side of this debate. See related article by JAS Smith and M McDowell on pp. 297–301. The essential points of their argument are that community paediatrics is still perceived as ‘soft’ (despite the permeation of its concepts into every nook and cranny of paediatrics), that training in community child health lacks quality control, that trainees are inadequately supervised and poorly equipped to understand how to negotiate the systems they work in, that there is a significant deficiency in agreed practice standards and collaborative research, that funding for training, clinical work, research and professional development is poor and that the evidence base for ‘community concepts’ and interventions is suspect and there are no firm foundations in existing structures on which to build the future of community paediatrics. They believe that the Chapter of Community Child Health (CCCH), the three special interest groups (SIGs) and the Specialist Advisory Committee in Community Child Health (SAC-CCH) are insufficient to assure the future of the discipline and advocate the establishment of a ‘special society structure’ which would ensure adequate apprenticeship, leadership and research in community child health. The article focuses mainly on the needs of the profession and ignores not only what parents of children with developmental and behavioural problems require from their medical providers, but also the third leg of the community child health stool – child public health. Is their diagnostic formulation and management plan appropriate? While they highlighted some important deficiencies, I believe there is much to suggest that their formulation has missed some key evidence that would points to a different direction from that they advocate. First, what evidence is there that community paediatrics is soft? The concept of community paediatrics has been around since the early 1950s1 when paediatrician, later US Surgeon General, Julius Richmond referred to it in a paper on medical education and a social paediatrics congress was held in Zurich as part of the IPA meeting.2 The more recent definition of community paediatrics by the American Academy of Pediatrics,3 endorsed recently by the British RCPCH4 highlights the importance of a focus on all children in a community, not just the individual child; a recognition of the pervasive influence of environments on child health; the importance of the synthesis between child public health and the clinical aspects of the discipline; its multidisciplinary nature and focus on service improvement and advocacy and the importance of these perspectives being held by all paediatricians. To this one would add the growing recognition of the life-course implications of childhood experiences.5,6 There is nothing soft about the evidence base that demonstrates the pervasive impact of environments on child health nor more recent work illustrating the role of gene-environment interactions.7 And the evidence base for the effectiveness of strategies that intervene early in the lives of children exposed to environmental disadvantage has been so compelling that governments throughout Australia, Canada and the UK have implemented new policies which incorporate them. Smith and McDowell’s criticisms that training in community child health lacks quality control is not supported by the evidence. While they have very good reason to be concerned about older general paediatricians nominating themselves as ‘developmental paediatricians’, this is undoubtedly a transient phenomenon that will no longer be supportable as those trained under the aegis of the Specialist Advisory Committee in Community Child Health move into practice and are able to provide evidence of quality-assured training. Interestingly, when the Faculty of Community Child Health (FCCH) was established in the former Australian College of Paediatrics, membership criteria were quite strict and required applicants – both paediatricians and community child health medical officers – to demonstrate specified levels of training and experience to be admitted to membership. Most general paediatricians, including some who claimed to be ‘developmental paediatricians’ and general practitioners with a special interest in child health, failed to satisfy these requirements. Inserting a requirement in advertisements for community paediatricians in the public health system that ‘demonstrable eligibility for membership of the FCCH’ was an essential criterion in some jurisdictions and was a guarantee that applicants had reached a defined threshold. When the Faculty became established as a Chapter within the RACP, membership requirements were relaxed in order to ensure the Chapter provided a home within the RACP for anyone interested in community child health. The SAC-CCH was established in 1999, its work underpinned by a very detailed and extensively consulted upon curriculum8– without parallel in any other College training programme at the time – which had been developed by a working party that preceded it. It became a supplement to the Mango book which laid out the statutory criteria for training which requires training in all aspects of community child health. Advanced training requirements stipulate that trainees must spend a total of 12 months in a ‘program of excellence’ that offers high quality training in all domains of community child health, provides good supervision by a recognised community paediatrician and has a broadly based formal didactic training programme. In the past 2 years members of the SAC-CCH have conducted site visits to the majority of training centres where advanced trainees have claimed that a ‘program of excellence’ exists to validate these claims. These visits have acted as a very helpful incentive for improvements to local training programmes. While it is difficult for the College to ensure the availability of adequate training and staff positions in community paediatrics, the establishment of an advanced training programme has already had a positive influence on the establishment of positions. For example, one of the two established 12-month training positions in developmental and behavioural paediatrics in Perth has been converted to a split job between this and child protection to overcome the existing lack of access to child protection training. New staff positions in community child health have also been emerging across the country in the past decade. Often compromises are needed between the ideal and the achievable – at its establishment, the SAC-CCH, given the growing incidence of child maltreatment, would have liked to mandate 6 months’ training in child protection for all community paediatricians, but given the scarcity of training posts this would have created enormous difficulties for trainees, so a pragmatic decision to settle for 3 months was made. With the establishment of a new curriculum in community child health, and the evident growth in importance of ‘high frequency, predominantly ambulatory managed’ conditions that comprise the ‘new morbidity’, the College will be strongly placed to argue for more appropriately focused and located training positions. A balance between satisfying the inexorable service demands of acutely ill infants and children and the need for competence in assessment and management of children, often from toxic and dysfunctional environments, who present with complex developmental, behavioural and social pathology must be achieved. The establishment of a dual 4-year training programme in general and community paediatrics in 2005 is another an important first step that previous experience suggests will increase pressure for more training positions in non-acute settings. I don’t believe there is any evidence to support claims that research funding in community child health is comparatively poor. True, spending is patchy, and poorer in evaluating the assessment and management of clinical problems of development and behaviour than it is in child public health. Research funding is much more likely when multidisciplinary research consortia – either within institutions (such as the Murdoch Children’s Research Institute in Melbourne, or the Institute for Child Health Research in Perth) or across-institutional boundaries (such as the Longitudinal Study of Australian Children auspiced by the Commonwealth Department of Family and Community Services) that address community child health issues – are formed. There are lessons here for the rest of the country. For example, one person in one of these collaborative ventures obtained three community child health NHMRC grants worth A$1.26 million this year. Smith and McDowell do however, make an important point in their assertion that trainees are poorly equipped to understand how to negotiate the systems they work in. Medical training at all levels has largely ignored the systems within which doctors will practise and the skills needed to navigate within them. Historically, most specialists worked in private practice and negotiated what they wanted from the public system with a mixture of guile, threat and brute force. Few of those employed as full-time hospital specialists sought training in management as ‘medical administrators’ were often dismissively regarded as ‘failed clinicians’ or detested along with other perceived ‘obstructive bureaucrats’. Contemporary specialist practice however, clearly requires systems thinking, interdisciplinary teamwork, effective communication and negotiating skills and an attention to continuous practice improvement – all issues which the new generic curriculum will address. Some community paediatricians have found that short periods working in government have provided a career enhancing experience.9 From my reading of the evidence, Smith and McDowell’s conclusion that current structures have either impeded the development of community child health or are likely to constrain its continuing evolution is unjustified. Indeed, I think there are significant dangers with the course they propose. To separate the three arms of community child health into three special societies would inhibit the necessary cross-specialty dialogue that is fostered by the current structure, and would make training in all domains within a reasonable time frame difficult to achieve. Children who have been maltreated often have complex behavioural and developmental problems and dialogue across domains is helpful, especially for a condition where public health approaches to prevention are among the most promising strategies for effective intervention. We have already seen one arm of what, in other systems, has been a traditional arm of community child health separate. Some aspects of the management of neurodevelopmental disability is now primarily the responsibility of specialists within the Faculty of Rehabilitation Medicine, with whom we have little dialogue. The current structure is also well-placed to respond to the emergence of high prevalence, but predominantly ambulatory managed conditions, such as obesity. Epidemiological studies to define its scope and determinants are well advanced, but the development of effective population and clinical interventions – universal, selective and indicated – is proving elusive, just as it has been with our earlier experience in the prevention and management of disruptive behaviour problems. Community child health covers a spectrum – some will want to practise across its full breadth; others will want to focus at a particular point. Our current structures enable both. The relatively new SIGs have a strong and important role in encouraging further development of their domains – only if they failed in this task could the establishment of separate special societies be advanced as a logical alternative strategy.

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