A landmark Australian study has highlighted the need to strengthen paediatric support in general practice.
While general practitioners manage the majority of children’s healthcare, one in 10 paediatric consultations result in referrals – mostly for mental health and developmental concerns – new Australian research reveals.
The major study analysing nearly 50,000 paediatric consultations across general practices in Victoria and NSW has provided a comprehensive snapshot of paediatric care in Australian general practice.
The researchers found that GPs were managing a broad range of conditions but were significantly more likely to refer children presenting with mental health and developmental–behavioural concerns.
They also advocated for investment in integrated care models that embed paediatric expertise within general practice, alongside upskilling for GPs and expanded public sector capacity to meet rising demand. School-based services and shared-care pathways were also cited as promising solutions.
The research, published this month in the Australian Journal of General Practice, was led by the Murdoch Children’s Research Institute (MCRI) as part of the Strengthening Care for Children trial.
A cross-sectional analysis of paediatric consultations was performed across 22 general practices in Victoria and NSW involving 130 GPs. Electronic medical records were analysed to determine consultation reasons and referrals.
Mental health consultations led to referrals in over a third (33.7%) of cases, while 26.8% of developmental–behavioural visits also resulted in referrals. In contrast, routine medical visits and immunisations, which were the most common reasons for attendance, had far lower referral rates.
During the study period, GPs referred 10% of patients to private specialists (psychologists, psychiatrists, paediatricians, etc), which represented a cost of $1.4 million and a mean cost of just under $300 for each patient.
“GPs mostly refer to private specialists for mental health and developmental–behavioural concerns, particularly with private billing, indicating access disparities,” the authors wrote.
“Increased public sector capacity for these conditions is needed. Strengthening paediatric primary care could yield significant cost savings by reducing referrals.”
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Referrals were significantly more likely in private billing practices (72% higher compared to bulk billing), and among female GPs and those with fewer years of practice.
GPs with 6–15 years of experience were the least likely to refer, suggesting this group may have optimal confidence and skill in managing paediatric issues in primary care settings. Referrals were also more likely when the GP believed a condition could only be managed by a paediatrician.
The study’s findings raise important questions about the distribution of paediatric care within the Australian healthcare system.
Despite mental health and developmental–behavioural concerns being well-recognised priorities in child health, limited public service capacity and long specialist wait times appear to be driving families into the private system, where cost and access barriers are more pronounced.
Lead author and consultant paediatrician Professor Harriet Hiscock told The Medical Republic the research was just the first step in finding ways to better support GPs in paediatric care.
She said another trial had been recently completed, in which a paediatrician had been integrated into a GP practice for half a day each week for six months, followed by fortnightly visits, monthly case discussions and phone/email support.
The trial had showed “promising changes”, but Professor Hiscock, who is also the MCRI’s leader of the Health Services and Economics group, said the paper was currently in submission phase so she could not elaborate further. She hopes the findings to be published sometime this year, however.
Professor Hiscock said these trials were important in laying the foundations to provide evidence and data for solutions that would support GPs, improve education and training, reduce lengthy waiting lists for public and private specialists and provide more equitable access to paediatric services.
As a practicing paediatrician, she said there were certainly patients who could be effectively managed by GPs with the appropriate support. GPs could also play an important role in supporting more complex cases while they waited to be seen by a specialist.
“Certainly with things like bed wetting, constipation, those sorts of things, a GP, if supported, can manage that,” said Professor Hiscock.
“Things like query autism, that’s a little bit harder, I think. But the GP could kick-start things with a referral to a psychologist and speech assessment.
“And certainly with ADHD, what we’ve seen in our trial, was that we can teach the GPs to know what the validated measures for ADHD are, get the parents to fill it out, get the teachers to fill it out, check if there’s any concerns about eyesight etc.
“And then start with some non-medication approaches to supporting ADHD at the home and classroom setting, and getting some of those strategies kick-started. And then by the time the kid gets to see the paediatrician, it’s almost done.”
Professor Hiscock said GPs often knew a family better than a paediatrician meeting them for the first time, and this was a powerful tool for supporting these families where there was a child with mental health or developmental conditions.
“I think the GPs have a huge part to play and support and they can often see the child more frequently and the family more frequently than the specialist can,” she said.
She said GPs undoubtedly needed more support, however – and more than six weeks of paediatric training in their general practice training.
“I think there’s ways to fix this, and it won’t be one, one size fits all,” she said.
“The other thing I would love to see is a Medicare item number for GPs to be able to talk to a specialist without a patient present to get that advice, and that could be to a psychiatrist or a paediatrician, a cardiologist, whoever it might be,” she said.
In the meantime, she urged GPs to take advantage of the opportunities that have arisen in telehealth to improve access to specialists.
“In Victoria we have a virtual GP specialist service, so a GP can book in a 20-minute consult with a specialist of their choice if they’re worried or want to discuss a child,” Professor Hiscock told TMR.
“It’s not just paediatrics, it’s also other adult specialties, but this will be the most relevant one for children.”
