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Arch Dis Child. 2007 August; 92(8): 733.
PMCID: PMC2083897

Is there room for community paediatrics on the Ark?

Professor Stephenson's perspective on the NHS reforms1 is a welcome stimulus for debate about the future of children's health services in the UK. The article touches upon waiting lists for children, the tariff system and the “shifting care closer to home” agenda.

If viewed dispassionately, the NHS reforms make perfect sense. Practice‐based commissioning2 should allow primary care to use knowledge about the needs of local populations to commission appropriate specialist services. Patient choice is built into the process. Payment by results3 was designed to incentivise providers to reduce their costs to the national tariff or below and so retain any surplus. Demand management was introduced to limit perverse incentives for increasing secondary care activity and hence income. The problems we see with these reforms are simply because healthcare is far more complex than any business model and market forces do not sit comfortably with clinicians who often value quality in isolation more than efficiency and cost‐effectiveness.

Where does all this leave children's services?

Specialist inpatient services should be preserved at all costs and 69% tariff top up is the first positive step. Clinicians will have to take clinical coding more seriously to avoid underestimation of the service they provide. Primary care will increasingly demand “real time coding” and prompt discharge summaries to trigger payments.

The paediatric outpatient tariff is set at £217 for first attendance and £114 for follow‐up attendance.4 This provides an opportunity for “shifting care closer to home” without compromising emergency services for children and tertiary services. Strengthening of primary care for common childhood conditions would lead to some reduction in secondary care use over a period of time.

This leaves community child health services in the uncertainty of no‐man's land. There are no tariffs for community services, mental health or learning disability; so far so good. A complex Change for Children agenda conflicts with the principle of an “integrated children's service”. The paediatric outpatient tariff, if strictly applied to community children's services hosted by secondary care, Would ensure its rapid demise. Primary Care Trusts (PCTs) divesting themselves of provider services remains a real threat.

The waters of reform are rising. If our hospital‐based colleagues truly value the contribution of community child health services to the future of children, then they should not forget to help them find a place on the Ark.


Competing interests: None declared.


1. Stephenson T. How can the UK National Health Service be broke? Arch Dis Child 2007. 92189–190.190 [PMC free article] [PubMed]
2. NHS Alliance Practice based commissioning: a primary care led NHS. Retford, Nottinghamshire: NHS Alliance, July, 2006
3. Department of Health Delivering the NHS plan. pp. 19–20.
4. Department of Health Payment by results in 2007–08. (accessed 14 April 2007)

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