Five themes were identified in the data analysis, these were: ‘prevention is better than cure’, ‘health promotion: the key messages’, ‘working with families’, ‘working with other health professionals’, and ‘barriers to the delivery of well-child health service’.
Prevention is better than cure
The majority of GPs highlighted the importance of prevention; one stated “prevention is better than cure” (GP18), another prioritised preventative health stating “first of all, we provide preventative medicine for the children…” (GP5) and a third participant described that GPs “…deal with normal GP things like immunisation, preventative medicine, growing and all the usual paediatric things” (GP10). Another participant emphasised that a preventative approach “…also covers not just the child, but the parents” (GP9).
Some reported that they take a proactive approach to health promotion, wanting to “catch things early” (GP6). They achieved this through organising routine health checks to identify problems with development, as well as applying recall systems for immunisation to “…make sure you get them back if they don’t come in time” (GP7).
The majority however, described their role in child health as ‘opportunistic’, with consultations seen as an opportunity to conduct routine health checks and ensure normal development,
"…so I don’t just give them a needle, I also talk about development and what to expect as well (GP1),"
"We see them at four years old for their vaccinations, and then we do the health check then as well (GP20)."
A small number of participants were more focussed on children with an acute illness. When asked about their role in health care for children, they immediately reflected on the sick child rather than the well-child, some responding with, “We normally see unwell children” (GP6) and “With well-children, they hardly come to the surgery. They normally come with a problem” (GP11).
Health promotion: the key messages
While the participants spoke broadly about their role in health promotion, it appeared that this was focused on three areas, namely immunisation, breastfeeding and parent-infant relationships,
"Well, in the well-child, it would basically be, number one to keep them well – that is prevention, meaning immunisation, and preferably full immunisation (GP21)."
"You counsel the mother to see if they are breastfeeding or bottle feeding and how they are going with it, and if they are developmentally consistent (GP2)."
The participants demonstrated some familiarity with anticipatory guidance but provided limited illustrations of putting this into practice other than relating it to the use of the ‘blue book’ (personal health record) in easing parental concerns about their child’s development,
"The parents usually read it and before they reach the age, the parents should know at what age the child should be sitting up and what age they should be talking and how many words they should be talking sentences (GP2)."
Overall the approach to health promotion tended to be reactive, as the GP “…would only see the child opportunistically, when the parent brings the child in…for immunisation” (GP21). In response to conducting routine health checks, one GP answered, “Normally when we do it, a motivated mother asks me, rather than doing it routinely” (GP10). Some GPs agreed that it is “Usually the parents [who] promote the issues to be checked with the children” (GP12) rather than the GPs themselves.
Working with families
Participants were also asked to describe how they worked with families. GPs identified their role as being educators and providers of support, “I think in the early years of parenting it is more important to give them support” (GP2). Providing information in a reassuring way was necessary to ensure that families were not distressed,
"We need to educate, we need to enhance, we need to give more information in a compassionate, empathetic way, but not to scare them (GP5)."
The importance of developing a relationship with parents was also emphasised, with one GP commenting that “…developing a strong rapport and relationship with the family is the most important thing” (GP14). Difficulty in maintaining continuity of care was considered a barrier for working effectively with families. Participants believed that lack of continuity occurred due to both GP and family factors,
"I work 3 days a week in my practice so sometimes I’d like to follow up a child, but it’ll be a day that I’m not there and they end up seeing a different GP so sometimes you tend to lose that follow up (GP3)."
This fragmented care was thought to result from switching doctors frequently,
"Here the family chooses the GP whenever they want, whoever they want. So they can move from GP to GP. So there can be a problem in the continuity of care (GP7)."
Those who were involved in shared antenatal care believed that they had the best opportunity for forming relationships with families from the outset. According to one GP, “It’s easy with shared care, because most of them like it and they are more comfortable with us, because they have known us for a long time” (GP13) and “…the role of this for a GP is absolutely vital because it is the interface between the hospital and primary care” (GP14).
Participants described the educational role of GPs including assisting families to interpret health information, as “providing medical information in lay person terms is of paramount importance” (GP5). They also reported that GPs need to help interpret information available from other sources, “…a lot of the time, parents do their own research and ask us about that service” (GP1). At times, however, this proved to be a challenge,
"The revolution of knowledge through the internet in one way its good but in another way it puts a lot of strain on us, because whenever we make a recommendation, they just Google it or research it and come back with a lot of queries or questions (GP10)."
Working with other health professionals
All participants had some understanding of the services available for the well-child and families. However, only 15 out of the 23 GPs described some form of interaction with other services, which usually only amounted to referrals, “If there is a problem then we’ll refer them to the appropriate services” (GP11). These services included paediatricians, child psychologists and allied health services such as speech therapy, occupational therapy, social work, and audiologists. Some GPs also liaised with non-referral based local government services such as community and childcare groups to support children and families. In the main, GPs would work in collaboration with either a practice nurse or a community-based child and family health nurse in providing care for the well-child, through anticipatory guidance and support as well as health promotion services such as immunisation and information on feeding issues,
"A practice nurse is actually a big help…[they] give vaccinations, weigh the child and take measurements…as well as provide advice to parents (GP20)"
"In our practice, the nurses do the routine health checks. (GP4)"
Of the eight GPs who did not have any involvement with other services, the majority cited the redundancy of these services in well-child care, “If both the child and family are well there isn’t much need to work with other services” (GP14) and commented on logistical issues such as waiting times and poor communication, “Really the problem is the lack of communication between the [specialist] services and the GPs” (GP17).
Barriers to the provision child and family health
The major limitation that GPs identified was finding the time to spend in consultations to provide optimal well-child care. Despite this, one participant added, “In my practice I don’t think time can be an excuse. You can always find the time” (GP11).
Another issue faced by GPs in providing optimal well-child care was the financial status of families, especially in practices that did not bulk bill, “…some people can’t afford to even cover that [Medicare] gap, in the lower socioeconomic groups” (GP8). Furthermore, some GPs identified the lack of knowledge of, and access to, services available for children under their care, “Part of the problem is actually knowing what’s around, you can’t access them” (GP9).
Nonetheless, the GPs recommended possible improvements to facilitate optimal well-child management. Improvements in communication between GPs and other health services were identified as important, both to increase quality of care as well as efficiency, “Better information interflow between hospital and GPs is necessary…awareness of what services are available rather than duplicating some and lacking others” (GP16). Participants also suggested increasing the number of health services in the community, “…more community based services, especially community based nursing. Also easier access to allied health services, like speech pathologists” (GP1).