Second Opinion: We must get our free GP care right from the start

The new scheme to provide free GP care for children under six years of age is very good news. Service providers, who must be either doctors or practice nurses, will be required to carry out periodic “wellness assessments”.

Obesity in children is a public health problem, so initially wellness checks will involve monitoring and recording of height and weight under the age of two, and measuring body mass index (BMI) between the ages of two and six. The GP and practice nurse must take follow-up action with the parent or guardians if necessary.

Service providers must also record whether a child lives in a smoke-free household or not, with a view to helping with smoking cessation.

Extra time
The draft contract does not specify how much extra consultation time a wellness check might take, which could theoretically vary from five to 30 minutes.

Consider the following scenarios. Mrs Jones attends with her overweight, three-year-old son Seán. His height and weight are measured and his BMI calculated.

Scenario 1, GP: “Seán is too fat for his age. He needs to lose weight. Here’s a diet sheet.” Mrs Jones (thinks): “Is he saying I’m a bad mother?” Says: “Thanks, doctor.” Extra consultation time is five minutes. The success rate of this approach is either zero or negative. Mrs Jones takes Seán for some fast food on the way home to rid herself of guilt and boost Seán’s self-esteem.

Scenario 2, GP: “It’s not easy keeping children a healthy weight these days. Seán needs to lose some weight and we can offer some help with that. What do you think?” Mrs Jones: “I’d like that. I’ve been a bit worried about it. He starts pre-school next week and I’m afraid he’ll be bullied.”

GP: “Mary, our practice nurse, can support you with planning a healthy eating programme for the whole family. It will take about 15 minutes.” Mrs Jones: “Thanks, I’ll talk to her on the way out.”

Extra consultation time is 25 minutes. This approach is more likely to be effective, especially when repeated at every wellness check.

Wellness checks can add between five and 30 minutes to every GP visit. Weighing, measuring, and calculating BMI takes five minutes. A further 15 minutes with the practice nurse is needed if a child is overweight or obese.

These children are not ill so do not need referrals or further diagnosis. Practice nurses are sufficiently qualified to be able to discuss healthy eating and physical activity with parents.

However, practice nurses may need intensive training in brief intervention techniques which are more effective than advice-giving in helping people change health habits. These interventions involve asking a series of questions to help parents devise their own workable plan.

Advice-giving does not work and can be counterproductive.

Parents can interpret advice as criticism of their parenting skills. They may begin to avoid future wellness checks.

Intervention
Wellness checks for children under six make total sense. They are one of the strategies listed in Healthy Ireland: A framework for improved health and wellbeing 2013-2025 (Hi).

Early intervention before birth and early childhood works better than later intervention. By the age of five, children already show signs of having wellbeing problems related to diet, physical activity and social health.

The latest Growing Up in Ireland study, on wellbeing, play and diet among five year olds (November, 2013), found that 20 per cent of five year olds are overweight or obese. Childhood obesity is linked to the development of type 2 diabetes and cardiovascular diseases.

Although the new GP scheme is a fantastic idea, changes must be made to the contract. It needs to include mental health which develops between birth and two years of age.

Overweight and obesity are inextricably linked to mental health. Childhood obesity is associated with emotional and behavioural problems from a very young age, with boys at particular risk.

The impact of overweight on self-competence can start as young as five years of age. Wellness checks take time and must include physical and mental health aspects of health or they are worse than useless.

Brief intervention techniques instead of advice-giving must be used. Free GP care and wellness checks for children under six years of age is one of the best things to happen in Irish health services in recent years.

The Department of Health and Children and the HSE must get it right from the start or it will cost taxpayers a fortune with little to show for it.

Dr Jacky Jones is a former HSE regional manager of health promotion

drjackyjones@gmail.com