Abstract:
EDITOR,-In his article on paediatric inpatient
units, Professor Taylor claims that many
present paediatric units are too small to provide
safe and cost effective care, do not meet
required standards, and should combine into
larger units providing specialist children's
services.' We would disagree with him, at
least with regard to rural communities.
In many small district general hospitals a
very high standard of care is offered, frequently
directly by the consultant and often at
great personal cost. The service shares many
of the better aspects of primary care delivered
by staff who know the families and their backgrounds.
Professor Taylor stresses the value
of a good relationship with the tertiary
centres; where this exists children can be
referred to superspecialists when indicated.
He does, however, make a good case for continuing
update and education for all staff and
the need for clinical commitments to be such
that study and development of appropriate
skills are possible. In a country area almost all acute admissions
are at the request of a general practitioner.
The request to admit is not
undertaken without thought, although the
reason is rarely that the disease is life threatening;
parental anxiety, inexperience, exhaustion,
lack of transport or telephone, or even
inability to carry out instructions may all be
factors. Is it feasible that a visiting service
could overcome these difficulties?
If rural units were to be amalgamated for
financial reasons, children in Cumbria, for
example, could have to travel 40 miles for inpatient
care even if lucky enough to be left with
a day centre. As most acute admissions occur
in the evening and at weekends, few could be
observed locally, even for a few hours. A
massive increase in funding of the ambulance
service, roads, and public transport would be
needed. Sick children would need to travel for
an hour before assessment by a paediatrician
and family disruption would be extreme. It would be a brave obstetrician who considered
offering a service where unforeseen
complications in even 'low risk' deliveries
were the responsibility of obstetric staff
or even nurse practitioners, if the nearest
paediatric support was 40 miles away.
Professor Taylor's sad experience of
district general hospital care for children is
not universal. Even in today's climate of rising
expectations and workload, some units are
proud to provide a local and appropriate
service. The equation should be restated; it is
not 'quality versus access' but 'quality AND
access versus financial expediency'.