Paediatrics at a crossroads: what next?

Please note that views expressed in guest articles on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.

Paediatrics in the 21^st century stands at a crossroads. Despite advances in genomics, theranostics and other high-technology medicine, many child health outcomes have worsened over the past decade, and in many cases inequalities have widened.

Given that truth, and following the launch of the Commission on the Future Paediatrician and the focus on children and young people within the Long Term Plan, now is an opportunity to rethink how we do child health. Through initiatives such as Rethinking Medicine, the medical profession more generally is being challenged to transcend the dominance of the biomedical model as a universal solution to population health problems.

But what might it mean for the ordinary child health clinician, like me, who already often feels that they lack the time (among other things) to do anything about it?

Reimagining paediatrics

If we want to reimagine paediatrics, paying attention to the social determinants of health is a good place to start. 20% of paediatric presentations stem from social problems, and paediatric care is frequently the first point of contact between health services and children and young people with health and social problems. Given that adverse early life environments affect outcomes later in life, paediatricians like me are ideally placed to identify those most at risk and to facilitate interventions for prevention and support.

Despite the strong case for its existence, the practice of ‘social paediatrics’ is yet to be fully realised. A global, holistic and multidisciplinary approach to child health, social paediatrics considers the health of the child within the context of their society, environment, school, and family – integrating the physical, mental, and social dimensions of child health and development as well as care, prevention and promotion of health and quality of life.

On the shop floor, there is very little guidance delimiting what role a ‘social paediatrician’ might take, let alone the kinds of tasks such a role would entail. What’s worse, other than rhetorical support from medical institutions, health systems themselves do not currently support such an approach, and as health professionals up and down the country are telling me, may even actively prevent efforts to do so.

Social paediatrics: can we bring it home?

What can we learn from elsewhere in the world? Canada has long been leading the way under the vision of Gilles Julien’s Social Paediatrics Centre in Montreal, where specific training and career tracks have been cultivated over the years. Sweden, a leader in achieving excellent child health outcomes, can in part thank its focus on prevention and health promotion, while the Netherlands and Turkey have granted social paediatrics the status of its own specialty.

But here in the UK, clinicians are flying solo with no instructional manual. Yet rather than despair, we should take inspiration from the social determinants thesis and exploit this gap. Pockets of innovation around the country, such as the Children and Young People’s Improvement Collaborative in Scotland and the Children and Young People’s Health Partnership in London, show how a social lens presents opportunities for alternative avenues for socially conscious paediatric professionalism. They open up action both at the level of the presenting patient and at the level of the wider community and population at large.

So what could more ‘social paediatrics’ look like?

By no means exhaustive, opportunities for rethinking roles within child health could lie at three broad levels.

1. At the level of the individual and interpersonal

Understanding social history

Obtaining a more appropriate and comprehensive social history enables proper assessment of a child or young person’s social environment, enabling understanding and empathy and more effective signposting to relevant services.

Refocusing research and quality improvement

While lip service to the social determinants and health inequalities is paid at policy and guideline level, how far does this translate into individual practitioner behaviour? A social lens might help doctors themselves to engage in service improvement projects that explicitly attend to these issues, such as highlighting gaps in service provision and inequities of access to care for certain social groups.

Social prescribing

Social prescribing is a way of linking patients with sources of support within the community. While social prescribing is in its infancy (the evidence for effectiveness and efficacy is by no means established), by opening up non-medical interventions to deprived families, it can potentially help to address child health inequalities.

2. At the level of local service provision

A social lens encourages the removal of barriers to care, greater respect for the autonomy of patients, and the development of more collaborative ways of working for child health professionals. These might include locally integrated care models where the boundaries between primary and secondary care are blurred; community empowerment and engagement through the co-creation of health systems; and the reframing of inter-professional relations, such as shifting traditional tasks and responsibilities from doctors to nurses.

3. At the level of national policy and advocacy

For social paediatrics to become the norm, a broadening of medical education is needed, drawing on knowledge of political economy, public health, and humanities and social sciences. Armed with this knowledge, paediatricians will be in a better position to advocate for children and their families both locally and nationally.

The future

While social paediatrics presents opportunities, it will undoubtedly present new political and ethical challenges. We simply don’t have enough evidence to know how changing health care models and new ways of working will impact on professional roles or on outcomes. When the potential of adequately addressing the social determinants of health is so large, the need for such research is urgent. It’s time to work together to develop the clinical, professional and public health responses this demands.

Dr Guddi Singh is an integrated child health quality improvement fellow and a paediatric registrar at East London NHS Foundation Trust.