THE PAEDIATRIC SOCIETY
OF NEW ZEALAND
Secretariat:
Email:
Denise Tringham
P O Box 22 234
Wellington
Tel:
(04) 938 4827
Fax: (04) 976 4827
psnz@paradise.net.nz
Community Paediatric Service
Notes for purchasers January 2006
Executive summary
This short paper will define Community Paediatrics and give four examples of local community
paediatric services in New Zealand. The core skills of community paediatricians are defined by
the guidelines for training of the Royal Australasian College of Physicians Specialist Advisory
Committee in Community Child Health1. However local services will develop according to local
need and opportunity.
This paper assumes the reader has a detailed knowledge of the epidemiology of child
morbidity and mortality in New Zealand and therefore understands the issues for child health. If
not, we recommend you read the following publications from the Ministry of Health:
 MOH 1998. Our Children’s Health: Key Findings on the Health of New Zealand Children
 MOH 1998. Child Health Program Review
 MOH 1998. Child Health Strategy
 MOH 1998. Through the Eyes of a Child: A National Review of Paediatric Specialty
Services.
 MOH 2005. Child Health Toolkit www.moh.govt.nz
The paper was originally compiled by Dr Russell Wills, Community Paediatrician in Hawke’s
Bay and previous Chair of the Community Child and Youth Health Special Interest Group of
the Paediatric Society of New Zealand, and has been updated by Dr Alison Vogel, current
Chair, with input from Dr Wills, Dr Nick Baker and Dr Giles Bates, Community Paediatricians in
Nelson and Palmerston North.
Skills of the Community Paediatrician
The Royal Australasian College of Physicians defines Community Child Health as involving “an
understanding of how the interplay between physical and social environmental factors and
human biology affects the growth and development of all young people whether well, ill,
impaired or disabled. The social environment includes family and school as well as broader
social influences, such as the regard given to the rights of children and the policies and laws
that affect the life of children and the services provided within a society to promote their
developmental health and well being”.1
The training guidelines of the Royal Australasian College of Physicians SAC Community
Paediatrics requires specialist Community Paediatricians to receive training and demonstrate
competence in the following domains:
 clinical practice: including general hospital and outpatient paediatrics, assessment and
management of children and young people with developmental, learning and behavioural
1
Royal Australasian College of Physicians 1998. Requirements for Physician Training. Sydney, RACP.
“Health of our children: Wealth of our nation”
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problems and disabilities, child abuse and neglect, paediatric rehabilitation, child and
adolescent psychiatry
population medicine: encompassing needs assessment, including the needs of child and
adolescent populations with specific needs, community diagnosis, screening and
surveillance, infectious disease control, injury control, health program planning, evaluation,
and research including the quantitative and qualitative measurement of health outcomes
effective health service provision and utilisation: management, communication, team
leadership, liaison and referral skills within and across disciplines and relevant government,
non-government and private agencies
child and adolescent health promotion: through education, information provision, effective
use of medicine and other preventive programs and advocacy
academic leadership: through participation in teaching, training and research
individual professional development through an ability to critically appraise literature,
undertake research, demonstrable keyboard and computing skills, and continuing medical
and other professionally relevant education
knowledge: of government policies, programs and services and their philosophical
underpinnings which affect the health of children, particularly those with additional needs.
Goals of a community paediatric service2
To develop and/or implement within a defined population for all children: a detailed assessment of the health and development needs
 effective health promotion and health protection programs
 a comprehensive co-ordinated system of quality child health services that meet identified
needs
 systems for identification, support and reintegration programs for children with "special
needs"
 an integrated framework of services linking health and non-health sectors to achieve
maximum support and health gain for children and families
 systems for monitoring and evaluation of the efficacy, efficiency and community value of
child health programs, and of the service as a whole.

information systems that use evidence to tailor child health services to meet the
changing needs and health outcomes of a community.
 Participation in, and often leading the Child and Youth Mortality Review system for the
DHB. This requires participation in the National Framework for Mortality Review and being
appointed as an agent of the national CYMRC. The local group of agents of the CYMRC
act as a multi-disciplinary, multi-agency point of contact to examine both local and
national systems that surround children, making recommendations for improvements to
both the local DHB and the Minister of Health through the National CYMRC. See
www.newhealth.govt.nz/cymrc
"One model of the population health role of community paediatrics sits within a conceptual
model of Health Promotion. That model considers three overlapping elements: Health
Education, Health Protection, and Disease Prevention. Community Paediatricians are placed
2
Paediatric Society of New Zealand 1998. Community paediatrics: Tertiary Services Review. Wellington,
PSNZ.
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within the disease prevention sphere, and using the intertwined knowledge, skills and
resources and knowledge of health education and health protection, to achieve their goals.
Disease prevention includes primary prevention (expressed as prevention of child and youth
morbidity and mortality), secondary prevention (which encompasses elements of both
screening and surveillance, and the function of early detection of child and youth morbidity and
mortality, or potential for this) and finally tertiary prevention (which covers the scope of systems
for management of existing morbidity, at both the individual and group level.
As a case example, one of the roles of the Community Paediatrician is in relation to childhood
obesity. Operationally, the community paediatrician's role is first to undertake a needs
assessment (identifying whether there is a problem and it's order of magnitude), and to
evaluate the risks and benefits of developing and implementing a response. Prevention and
treatment programmes may then be developed, implemented and evaluated. This requires
multi-agency, intersectorial and multidisciplinary work, utilising a skill-set that includes Health
Education and Health Protection. Much of the required work cannot be done by the
Community Paediatrician in isolation, but they may act as a catalyst and/or leader, maximising
the potential contribution of others with appropriate skill sets."
The Paediatric Society of New Zealand submission to the Tertiary Services Review
recommended that, based on UK standards for Community Paediatric Services, “Each district
should have a designated person or group that provides local community paediatric services.
As a guide 1 FTE (excluding registrar posts) should initially be employed for every 66,000
population age 0 - 19 years. (Approx. 1 FTE per 200,000 population depending on age
structure.)”2. Currently (December 2005) we are aware of dedicated paediatric tenths for
community paediatrics in Northland, West and South Auckland, Waikato, Hawke’s Bay, Bay of
Plenty, Palmerston North, Tairawhiti, Nelson Marlborough and Christchurch.
Examples of Community Paediatric services in New Zealand
Nelson – Marlborough
Nelson-Marlborough employs a community paediatrician, Dr Nick Baker, who has
approximately 0.4 for local community paediatrics (population child health work). Dr Baker is
also employed as a general paediatrician for the region. Over the years it has proved very
important to have clearly defined time for the community paediatric work. There is a constant
trend for clinical work involved in personal health care to grow to fill all employed hours. By
having days with no clinical responsibility this trend has been reduced. The general paediatric
and community roles complement each other. Direct involvement in personal health care
allows much greater understanding of current issues and problems that require population
based interventions.
The overall goals of the community paediatric service in the region are included as Appendix 1.
There are three major arms to the community paediatric work in Nelson-Marlborough:
1.
Basic work within the community to improve local service delivery for children by
training, planning, care pathway development, and participation in and development of
multidisciplinary teams. Public Health, the PHO, Funding and Planning and Mäori
providers also do this type of work. It has been very important to work closely with
these groups.
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The work is done by all paediatricians although the bulk is done by the community
paediatrician.
Current activities include work with several community agencies including:
 Early Intervention Team
 Strengthening families steering group
 Child and Adolescent Mental Health Services
 General Practitioners/ Primary health organisations
 Plunket
 Public health nurses
 Local Territorial Authorities
 Health promoters
 Health Protection Officers
 Midwives
 Support for community hospitals
 Group Special Education
 Schools
 Iwi Providers
 The Media
2. Project work to address specific causes of childhood mortality and morbidity.
Specific project work aims to provide a catalyst and a framework for child health activities
across all levels of the community. For instance although dental caries was the commonest
disease in children in the region and many people were working to address the problem they
were not working together. By developing a specific project team it has been possible share
knowledge, concentrate expertise and plan future interventions together. Extensive community
paediatrician time is needed in the early phases of each project and then less specialised
workers are needed to sustain each project.
An information system has also been developed to target the projects and study their impact.
The newly developed Child and Youth Epidemiology Service has this year provided a detailed
report to guide local strategic planning and funding.
Current projects (2005)
1) DHB Child and Youth Advocacy and Expert Advisory
http://www.nmdhb.govt.nz/publisheddocs/index.shtml#child
2) Meningococcal programme and NIR
3) Dental project Team
4) Breastfeeding Network
5) Smoke-free Project Team
6) Well Child Steering Group
7) Physical activity and Nutrition team
8) Green prescription pilot
9) Carer support group
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Reference
Group
10) Special Nelson Asthma Project
11) Child Abuse Family Violence DHB Working Group
12) Strengthening Families Management Group
13) General Practitioner Guidelines Work
14) Youth matters committee NCC
15) Injury prevention- Kidsafe coalitions
16) Youth Suicide Groups
17) Obstetric audit committee
18) Policy and planning secondary care
19) Development of Child and Youth Mortality Review
3. Liaison with National and International Groups.
Community paediatrics cannot be practised in isolation from national bodies, as many of the
factors influencing local child health are determined nationally. In addition much can be learnt
from the impact of programs in other communities. Much of the work in Nelson has been
innovative creating considerable national interest with requests for involvement in meetings,
committees and publications outside of the region.
Counties Manukau DHB
CMDHB/ South Auckland Health has employed community paediatricians since 1999. A
number of clinicians have shared components of community paediatric work. Community
paediatricians have combined clinical work with dedicated population health time. Since 2003
there has been a community fellow position providing training in population child health,
comprising half time clinical workload and half time academic study/ research project work.
Multidisciplinary support functions include support for
 Home care nursing service
 Public health nursing
 Child development service
 Family options
There is a significant education and training function for the community fellow, ambulatory
registrars and medical officer.
Project work of various people includes involvement and liaison with
1. DHB child strategic plan
2. School health stocktake
3. Special Schools disability project
4. Well child steering group
5. Meningococcal implementation
6. Kidslink/NIR
7. Child Oral Health project
8. Let’s Beat Diabetes
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9. Kids in Action obesity interventionAIMHI schools NEW (Nutrition, Education Weight)
Project
10. AIMHI schools NEW (Nutrition, Education Weight) Project
11. Healthy Housing Project
12. Paediatric epidemiology service
13. Hospital Child Mortality review
14. Guidelines development and implementation across primary and secondary care
15. B4 Baby breastfeeding support project
16. Child Disability allowance access project
National roles include
 Chair CCYH SIG
 Baby Friendly community Initiative working party
Midcentral DHB
Midcentral DHB has identified Community Child Health as a priority area and have guaranteed
funding for a stand alone Community Paediatric Service. The project has a full-time Project
Manager and the service started functioning in January 2006, initially with:
 0.3 FTE Community Paediatrician
 0.5 FTE Social Work
 0.5FTE Health promotion
There is the potential for expansion and the Community Paediatric time should be at least
0.5FTE by the end of 2006.
The Community Paediatric Service has a focus on working collaboratively with agencies/
health providers. The areas for development are:
 Population Health
 Child Health advocacy through the Child Health Portfolio Manager (appointed May
2006) and the establishment of Child and Youth Health Reference and Advocacy
Group
 Co-ordination of Community Services and improved linkages
 Education of Primary Health Care Providers
 Development of a community wide project in a high needs area
 Some paediatrician clinic workload
 Paediatric Nursing projects e.g. Enuresis
 Establishment of the Child Mortality Review
 A pilot health assessment of Children in Care, run in conjunction with Child, Youth and
Family
 Development of community Child Abuse and Child Sexual Abuse guidelines and
clinics.
Hawke’s Bay District Health Board
HBDHB has employed a general and community paediatrician with approximately 0.5FTE for
community child health since 2002. Of this, 0.2 FTE is spent in specialist developmental and
behavioural and child protection clinical work, particularly assessing children with the
developmental and behavioural effects of abuse and neglect. Population child health projects
occupy 0.3 FTE. The community paediatrician is supported by
 0.5 FTE Family Violence Intervention Programme Coordinator
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0.6FTE Child Protection Programme Coordinator
Developmental Assessment Programme (multidisciplinary assessment service for
children suspected of ADHD or Autistic Disorders)
Analyst support as required.
The HBDHB Public Health Physicians and Public Health Nurses have a strong interest in child
health and work in close collaboration, e.g., in Health Promoting Schools and Child Injury
Prevention. Senior management support has also been critical in the achievements of the
community child health programmes to date.
Community Child Health achievements at HBDHB to date include:
 Reduction of admissions to the Children’s Ward of 20%
 Successful implementation of MeNZB and National Immunisation Register
 Over 900 staff trained in dual assessment of child abuse and domestic violence
 Increased referrals to Child, Youth and Family of seven times and identification of
domestic violence increased by three times
 Reduced mean age at diagnosis for children with autistic disorders
 Workforce development programme for Resource Teachers Behaviour and Learning,
with improved referrals and Individual Education Plans
 Closer working relationships with CYFS, Special Education, Police and NGO sector
 Child Health Service Strategic Plan in place for three years
 Annual Child and Youth Health Status Report, which guides all purchasing and service
planning
 Reduced child injury admissions.
Current projects include
 Joint research programme with Otago University aiming to reduce preschool injuries in
the home
 Hawke’s Bay Family Violence Prevention Strategy, an intersectoral, multi-agency
approach to prevention of family violence
 The Journey to 2015, a major planning exercise across HBDHB
 Community Asthma Project, implementing the New Zealand Asthma and Wheezy Baby
Guidelines in the hospital and general practice
 Screening for Congenital Sensorineural Hearing Loss
 Publication of the various evaluations of the above programmes.
What helps to make regional community paediatrics effective?
In our experience the following are helpful ingredients for success in regional community
paediatrics:
1.
Supportive infrastructure: The Community Paediatrician needs a supportive
infrastructure of staff, with designated individuals to take on the role of sustaining and
implementing projects as well as clerical support. Clear support at senior management
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2.
3.
4.
5.
6.
7.
level is frequently necessary to sponsor projects requiring significant organisational
change. Sub contracts for IT, conference organising and evaluation need to occur at
times.
Clinical role: a clinical component is very helpful to give credibility to the role. In New
Zealand most community paediatricians are also general paediatricians, with a
commitment to the acute roster. However a clear division of clinical from community
paediatric time is vital to prevent community work from being disrupted by clinical
pressures.
Relationship with DHB strategic planning and funding teams. Joint working with DHB
public health physicians is very useful.
Accountability: It is appropriate to set key performance indicators (KPIs) for the
Community Paediatrician, but these deserve careful thought. A “settling in period” is
critical to allow the community paediatrician to form local networks. The first few months
may appear non-productive as relationships are established and joint plans formed;
however without this time plans will be unlikely to be supported by groups in the
community. We suggest a monthly narrative report initially, describing the broad goals,
what has been achieved and the work plan for the coming month. In time specific
projects with measurable objectives will become clear and can be included in the
Community Paediatrician’s KPIs.
National projects: Work at national level has been instrumental in achieving funding for
local community paediatric services, however a balance has to be retained between
national and local project work. In the future these national links may lead to new
opportunities for funding.
Professional supervision: The work can be stressful and, at times, progress can appear
to be slow and frustrating. It is helpful for the community paediatrician to have ready
access to senior colleagues for support and guidance, both locally and nationally.
Regular meetings with others working in population child health are helpful to share
knowledge and ideas. Opportunities for this are available through the Child and Youth
Health Special interest Group of the Paediatric Society NZ.
Teaching: Teaching and provision of training opportunities can be time consuming but
also allow for reflection on ways to improve service provision.
Alison Vogel Chair
Community Child and Youth Health Special Interest Group
Paediatric Society of New Zealand
ALVogel@middlemore.co.nz
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THE PAEDIATRIC SOCIETY
OF NEW ZEALAND
Secretariat:
Email:
Denise Tringham
P O Box 22 234
Wellington
Tel:
(04) 938 4827
Fax: (04) 976 4827
psnz@paradise.net.nz
Appendix 1
Functions of Community Child and Youth Health Services. (NMDHB)
Aim
TO:
Improve the health status of children and young persons within the Nelson
Marlborough region.
Strategic Planning
TO:
Undertake population-based strategic planning for improving child and youth health
status.
TO:
Obtain detailed assessment of the health and development needs.
TO:
Use information systems to produce evidence to tailor child health services to meet the
changing needs and health outcomes of our community.
Integration Process
TO:
Promote, facilitate co-ordinate and manage the process of integrating health service
delivery including effective health promotion and health protection programs
throughout the region and beyond.
TO:
Undertake any activity or function, which is consistent with management of the
integration process.
TO:
Develop an integrated framework of services linking health and non-health sectors to
achieve maximum support and health gain for children and families
Relationships
TO:
Foster and facilitate effective relationships between child and youth service providers,
voluntary organisations, iwi and consumer groups from all sectors.
Integration Initiatives (e.g. projects, programmes, pathway development, guidelines,
multidisciplinary teams etc)
TO:
Encourage, facilitate and assist the development and implementation of integration
initiatives.
TO:
Advise the DHB on funding and other resources to assist integration initiatives.
TO:
Ensure that any systems created are jointly developed and simple to use.
“Health of our children: Wealth of our nation”
Resource Utilisation
TO:
Promote, encourage, facilitate and assist initiatives which seek to:
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improve the efficiency and effectiveness of resource utilisation and service delivery
eliminate service duplication
encourage best practice and/or evidence based practice
achieve health gain targets
Contracting Strategies
TO:
Collaborate with the District Health Board to ensure that:
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contracting strategies are appropriately targeted to achieve population health gain
targets
incentives are aligned
perverse incentives are eliminated
Publicity & Public Relations
TO:
Create an appropriate local and national profile for the integration process
TO:
Promote, publicise, raise public awareness and keep people informed of the
integration process
TO:
Ensure that people who should know do know
Research & Analysis
TO:
Promote, facilitate and where appropriate manage the development and analysis of
child health data to provide accurate information, evidence of need, influence funding
decisions, establish health gain priorities and monitor outcomes of initiatives taken
Monitoring & Evaluation
TO:
Ensure that:
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integration initiatives properly planned, executed, monitored and evaluated.
action is taken on information arising from monitoring, evaluation and research
Intersectoral Collaboration
TO:
Promote and facilitate:
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intersectoral collaboration
opportunities for the non-health sector to contribute to health gain
the elimination of unnecessary service duplication of health-related services in the
non-health sector
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THE PAEDIATRIC SOCIETY
OF NEW ZEALAND
Secretariat:
Email:
Denise Tringham
P O Box 22 234
Wellington
Tel:
(04) 938 4827
Fax: (04) 976 4827
psnz@paradise.net.nz
Workforce Development and Standards
TO:
Provide resources and expertise to support organizations in professional development
and in-service training.
TO:
Advise on development and implementation of standards of care.
“Health of our children: Wealth of our nation”