Let’s stop children falling through the cracks

30 October 2014

The country's first child and youth NP, PAULA RENOUF, says a decade on, some things have improved but still too many children are falling through the cracks.

Paula RenoufI believe whānau and children should feel that their primary care centre is their place where they are confident to bring their health and whānau concerns, where nothing will get missed, where they learn to manage health, illness, and the health and social service system over time. For this to happen, general practice needs to have qualified paediatric/child and youth staff – especially NPs!

In November 2013, I took a position in a clinic in Gisborne where 40 per cent of the clientele is under 20 years of age, mostly Māori and with high health needs. Our challenges are great and there is a team willingness to look at new models of practice.

Since I first began working as an NP in primary care in the most high-need areas of Auckland a decade ago, I see more parents accepting beneficial vaccines as a matter of course and trust; discussing smoking cessation is now a required norm, parents do not need so much persuading to use antibiotics judiciously; and families are opening up more about family stress and violence. What joy to witness families’ and young people’s sense of accomplishment when they embrace knowledge about health, disease, and treatments, and see their confidence in negotiating the health and social service sectors. Health literacy, one of the cornerstones of NP practice for me since the early 1990s, is now being embraced and promoted by the mainstream.

The problem is “silos of care” still exist, and children literally fall through the cracks! Why am I finding children 8, 10, or even 13 years old with undescended testes? Why did an 18- year-old lose his testicle recently because he was too embarrassed and presented to the clinic after 8 hours of pain? How is it that a 19-year-old with obvious signs of neurofibromatosis has never heard of it despite many clinical encounters over the years? Why did I just diagnose a 12-year-old with Type 2 diabetes? Why are adolescent girls unaware of foetal alcohol syndrome and drinking to oblivion while not contracepting? Today, I saw a 5-year-old who has lost the vision in one eye due to untreated esotropia leading to amblyopia.

In a high-need practice, we know that there are many children and teen girls with iron and other micronutrient deficiencies. We know which ones are on the path to diabetes; we know there are very difficult family and social dynamics often precursors to mental illness, addictions, family violence, and parenting issues. Because we do not see them systematically and holistically in the general practice model, these matters are often not addressed … but primary care is the place where this should happen!

We would benefit from a mandate for ‘joined up’ care of pregnant mothers and infants, such as described by Hoare et al (2012), and then a mandate to case-manage high-need children and families and youth with known risk factors.

It is still presumed by hospital EDs and specialists that GPs hold all the health information for a child and family but this is sometimes far from true. Agpar scores and Hep B status may be all we know about a new 6-week-old. We rarely receive any information at all about social risk factors, bonding/parenting issues, or relevant whanau problems from LMCs or well child nurses. This is not a good way to start the ‘medical home’ for the child.

We receive B4School check results, but how lovely it would be if we knew from well child care which families/children we should pay particular attention to over the ensuing years.

My dream is for the Ministry of Health to fund not just free primary care until age 12. If we cannot offer free care to all children, let’s target funding to:

a)   all children known at the age of 4 (the last time they may ever see the GP) to have significant health (body, mind, family, environment) issues requiring follow up.

b)  Free primary and secondary preventive care for 6–12-year-olds: including maintenance and follow up of chronic conditions (obesity, asthma, eczema, recurrent skin infections, and recurrent respiratory infections included)

c)    A minimum of 4 free primary care consultations in adolescent years (13–18), including a full history, physical exam and HEeADSSs assessment (not to be duplicated if done in schools)

General practices need qualified passionate child and youth health staff to ensure that children enjoy the best health outcomes.


Reference: Hoare, K.J., Fishman, T., Francis, K. & Mills, J (2012). Person–centered maternity services in NZ: a practice development initiative to improve the health of pregnant women and infants. The International Journal of Person Centered Medicine 1(3). Pp 618-626