Estudio de la localización de la ruptura a lo largo del canal

The findings in this study highlighted a range of organisational, operational and wider service challenges that could also impact on the decision making process of GPs regarding support to children who are obese.

5.2.4.1. The ‘lost child’ in General Practice.

As Chapter 4 has indicated most of the GP practices in this study had childhood obesity prevalence rates close or above the national average rate, (NOO, 2013). However, the GPs were unable to provide any reliable estimates of the number of children on their registered list who were obese. This is likely to be related to the fact that it is not routine practice for the GPs to record height, weight, and BMI for children, and not part of the General Practice QOF, (DoH, 2004b). In addition the NCMP data which records the BMI for children in reception and Year 6 children is currently not fed back, in the area of this study, to the child’s GP, which again seems a missed opportunity for GPs to ask about weight, diet, and exercise when consultations are taking place for other reasons. It is recommended that GP practices develop more active recording on their clinical systems which would enable the production of individual registers of obese children. This would provide opportunities both to store and monitor such data and act as a trigger for GPs to consider raising the issue of weight and offering advice or referral.

5.2.4.2. Other health professional staff.

The findings in this study identified that GPs were reluctant to acknowledge or develop the support that Practice Nurses could provide to children who are obese. They indicated that Practice Nurses lacked key areas of knowledge, particularly around advice on food and portion size for childhood weight management and were generally unwilling to be involved in areas where there were few protocols or pathways. This is contrary to Walker et al., (2007) who found that Practice Nurses felt that their role centred upon raising the issue of a child's weight, and providing basic diet and exercise. However, other research (Hoppe and Ogden 1997; Nolan et al., 2012) found Practice Nurses had particular anxieties and fears about raising the topic of weight with children, young people and parents.

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In light of the concerns of the GPs that there was no support available to them in the practice, it is interesting to consider why they did not encourage Practice Nurses to take a role in childhood obesity, particularly as they had acquired considerable expertise in health promotion programmes including those related to adult obesity. For example Ross et al’s., (2008) evaluation of the Practice Nurse led Counterweight programme for obese adult patients, reported that this intervention successfully supported patients in achieving and maintaining “clinically valuable weight loss within routine primary care,” (2008 p.548). The reluctance of the GPs to use Practice Nurses may reflect the lower priority that the GPs afforded to childhood obesity as opposed to the other QOF targets, such as Coronary Heart Disease, that the Practice Nurses were heavily involved in. It does, however, seem that a valuable resource to the practice was not being utilised, and it is disappointing that the scope for a multidisciplinary team based approach in the practice was not considered. Furthermore, given the previous discussions about GPs staying within their preferred clinical domain there is the scope to consider whether GPs with a special interest (GPwSI) in childhood weight management should be developed. This could possibly be linked to those GPs in a practice who have specialist expertise in child health or to those GPs with an interest in obesity.

5.2.4.3. Time and competing priorities.

The current findings also identified a wide range of practical challenges that GPs experienced when raising childhood obesity in their consultations, often presented through concepts such as workload and conflicting and competing priorities. This is a consistent theme in the literature (Gerner et al., 2006; King et al., 2007; Turner et al., 2009). The GPs in this study were Senior Partners with time consuming responsibility for many managerial, organisational and financial decisions aligned to the General Practice contract (DoH, 2004b) and its associated QOF national targets (Doran et al., 2006; Roland, 2007). Some research (Walker et al., 2007) has suggested that because there were no childhood obesity QOF targets and therefore no financial gains to be secured from this work, GPs tended to give it a lower priority. The findings in this study also indicated that by excluding childhood obesity as a QOF target there was no access to all the other associated developments, such as staff training or the development of registers which were available for the adult obesity QOF targets. The significant prominence given by the GPs to time factors is consistent with other research which documents that time restrictions could be a hindrance to engagement and deeper involvement with families during routine consultations (Walker et al., 2007; Lachal et al.,

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2013). The fact that GP workload in primary care is often extensive (Lester et al., 2009) is rarely contested and it is acknowledged that many clinical decisions are taken in a context of pressure and time constraints, (Sayal et al., 2010; Illiffe et al., 2012). It is interesting that Turner et al., (2011) found that parents also picked up on the time constraints of some GPs questioning whether the GPs had the time and resources to effectively manage childhood obesity. Edmunds (2005) however found that parents spoke positively about their relationship with the GPs if they were given time to discuss the issues related to their children’s weight. There is little doubt that GPs, by conveying the impression of having time for obese children and their families, would express a powerful message about their interest and legitimate parents’ concerns. Moreover, having a series of short consultations over a period of time could benefit the family by promoting a trusting relationship where problems could be addressed gradually, and at a steady pace, in order to achieve long term behaviour change.

5.2.4.4. Services for children who are obese outside of primary care.

The lack of services outside of primary care for children who are obese was a key concern for the GPs in this study. At times this resulted in an unwillingness to raise the issue of a child’s weight when they perceived the health care system was not currently structured to deal with this issue effectively. As a consequence they admitted that they were reluctant to uncover issues in the family that they themselves were powerless to help with. This view has also been expressed by other GPs, (Walker et al., 2007, Turner et al., 2009) and also in relation to where GPs felt there was no local support to access (Story et al., 2002). The GPs in this study expressed disappointment about the lack of clinical pathways, the paucity of available local specialist service or treatments to refer families to, which is consistent with Gerner at al., (2006) and Hearn et al., (2008). Locally the fact that provision of the children weight management service was only delivered at one site in the Borough was also of concern for some GPs, who felt this limited access for many families. Despite this the GPs displayed no intentions to address these gaps by campaigning for further sites or advocating on behalf of their parents for additional investment in such services. This finding has clearly supported the need for investment in extended weight management services for children (NICE, 2013) with accompanying seamless pathways for signposting families and children who are obese to such services and other community based exercise programmes. However, some of the GPs did acknowledge that environmental and social policy changes were needed if any substantial difference is to be made to current childhood obesity trends. This element of professional support for such changes is an important consideration for future policy makers.

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