A model of paediatrics: Rethinking health care for children and youth

Children and youth represent 25% of the Canadian popula­tion and 100% of the country's future. Supporting their health from birth is a responsibility and a tremendous opportunity to foster generations of healthy Canadians. To do this, we must not only care for them when they are sick, but do everything possible to keep them healthy and safe. Health starts outside the medical system – supportive families and communities, education, employment, proper nutrition, hygiene, and adequate housing and income are, of course, among the key determinants of health. Most chronic conditions affecting adults develop during child­hood. When children and youth come in contact with the health care system, they need timely access to trained pro­fessionals who support their growth and development, pro­mote health and safety, and provide quality care for acute and chronic problems. Ensuring that our health care system better meets the needs of children and youth is not only a moral obligation, but also a wise economic investment. Paediatricians are integral to child and youth health care in Canada. (Throughout this document, ‘paediatrician' is used to refer to all paediatricians, regardless of the location [eg, hospital-, university- or community-based] or the nature [eg, generalist or specialized] of their practice.) While some believe that fewer paediatricians will be required as the population ages, there is already a shortage of paediatric specialists and subspecialists. Overall, the paediatric work­force is aging, and there are not enough trainees to replace those leaving practice. This shortage is expected to worsen at a time when the needs of children and youth are, in fact, increasing. Increasingly, effective health care requires a coordin­ated team approach, and paediatricians working with other professionals are critical to such teams. In November 2006, the Paediatric Chairs of Canada and the Canadian Association of Paediatric Health Centres brought together a range of experts to determine how to best plan paediatric resources [1]. The consensus was that the health needs of children and youth are unique and complex, and that no single health care professional can meet all of these needs. A commitment to a coordinated team approach – with family physicians, paediatricians, child and adolescent psychiatrists, nurses, psychologists, speech language path­ologists, dieticians, physiotherapists, occupational ther­apists and many others – was one of the major outcomes of the meeting. The purpose this document is twofold: It aims to clearly set out the broad health needs of children and youth (meeting those needs requires a coordinated approach across disciplines and sectors) It describes the specific role of paediatricians to meet those needs. Like physicians who care for adults, paediatricians are a diverse group. They differ in the nature, scope and setting of their practice. Depending on the needs of their com­munity, a paediatrician may fulfill any one or more of the roles listed below: provide emergency and critical care to acutely ill children and youth; work in tertiary care hospitals and clinics; provide consulting care in their offices or in regional and community hospitals, treating patients referred from diverse sources such as family physicians, nurses and school authorities; provide comprehensive care to children and youth living with complex chronic conditions or developmental challenges; provide primary and preventive care in the community; work in community organizations such as children's mental health centres; work in academic settings, providing patient care while teaching medical students and residents, and/or doing research; work in administrative roles within hospitals and universities; work in public health departments and other areas of government; and work in child protective services, assessing and treating children and youth who have suffered abuse or neglect. In 2001, the Canadian Paediatric Society (CPS) published the results of a comprehensive survey of paediatricians con­ducted in 1999 and 2000 [2]. The survey found an aging paediatric work force, with not enough trainees in the sys­tem to replace retiring physicians. Smaller and remote com­munities were identified as particularly vulnerable. In 2005, approximately 11% of paediatricians surveyed said that they will retire by 2010, while another 36% planned to reduce their work hours. Smaller and remote communities were again noted to be particularly vulnerable: more than 80% of Canadian paediatricians work in towns or cities with populations of more than 100,000 (unpub­lished data). The retirement of even a single practitioner can leave a community in a crisis. Despite advocacy by the CPS and other organizations, no progress has been made to meet the health needs of chil­dren and youth. Of particular note are some of the findings of the most recent National Physician Survey (2007) [3]: Paediatricians work longer work weeks than most physicians, reporting an average of 52.5 h per week (not including on-call services), which includes patient care, teaching, administration and research. Paediatricians have one of the highest on-call rates among physicians. Nearly 70% report that they provide on-call services, with 40% of those doing more than 30 h per week (on average 34 h per week). Nearly one-third of paediatricians said that they plan to reduce their workload (excluding on-call) in the next two years. When asked about factors that impede patient care, paediatricians cited the lack of available services to support their work, including other physicians and professional services, and the increasing demands on their time. When asked what accounts for the increasing demands on their time, paediatricians reported the following top three factors: increasing complexity of patient caseload, management of patients with chronic diseases or conditions, and increasing patient expectations. There is an urgency involved in the care of children and youth, which paediatricians respond to. They report one of the lowest waiting times for urgent referrals: nearly 60% of paediatricians said that patients with urgent needs are seen within one day, despite the fact that 28% reported that their practices are partially closed to new patients. Another 3.9% said that their practices are completely closed. A 2007 CPS report [4] identified that no province or territory has a paediatric human resource plan. A recent Canadian Medical Association report on the future of spe­ciality care found a critical need for general specialists in areas such as internal medicine, psychiatry and paediatrics. Comprehensive national processes, including A Canada Fit for Children [5] and Canada's Child and Youth Health Charter [6], continue to assert that young people have a right to the best specialized medical professionals, working collaboratively with others in health, to meet their acute and chronic health needs and to optimize their physical, emotional, behavioural and cognitive development. To effectively plan paediatric services, it is critical to under­stand why the health needs of children and youth are increasing and/or changing. Consider the following: Many children now survive extreme prematurity. The number of children and youth with chronic health conditions is steadily rising. The rate of obesity continues to rise. More children and youth experience mental health problems. Many children with malignancies, chronic cardiac problems, diabetes and severe behavioural challenges receive their ongoing medical care in the community. Many conditions that once required treatment in a paediatric teaching hospital are now being handled closer to home, coordinated by a community paediatrician. As the health status of children and youth changes, paediatrics must adapt to best serve young Canadians. An extensive review of the literature revealed that Canada lacks a robust body of research on child and youth health care delivery. There is minimal literature describing the specific roles of various professionals in improving the health of children and youth. In light of the available evi­dence, the CPS has thoroughly deliberated how paediatri­cians can contribute to meet the particular health needs of children and youth in Canada. The conclusions reached form the basis of the recommendations in this document and were used to develop a ‘model of paediatrics' for the evolving Canadian health care environment. The model of paediatrics that follows describes the opti­mal role of paediatricians within the current and future health care environment, working collaboratively with other health professionals. This flexible model allows com­munities, regions, provinces and territories to use it to meet the unique needs of the children and youth in their juris­dictions. Some of the central features of the model are as follows: The priority for paediatricians should be the delivery of comprehensive consulting care, regardless of the location (hospital-, university- or community-based) or the nature (eg, generalist or specialized) of their practice. Paediatricians should be available to provide ongoing comprehensive care to children and youth with complex medical needs, both in the community and when hospitalization is needed. Paediatricians should, where possible, give preference to collaborative medical practice, including working with other professionals such as family physicians, psychologists, social workers and nurses. Governments should ensure there are appropriate numbers of all child and youth health professionals to meet the needs and to participate in teams. The foundation of this model of paediatrics is the health needs of children and youth. Some of the key assumptions are as follows: All children and youth must have a primary care provider. Family physicians, nurse practitioners and physician assistants should receive adequate training, in collaboration with paediatricians. Timely access to care and services, including early intervention, is critical to promote health and prevent problems. Evidence shows that the long-term prognosis for children with developmental and mental health conditions, for example, is significantly improved when diagnosis and treatment are not delayed. Continuity of care is essential. When needed, children and youth must have regular access to a paediatrician who knows their history and can work with their family and other professionals to provide ongoing comprehensive care. A strong collaborative relationship with the primary care provider will ensure adequate follow-up care. There are many ways to ensure access to paediatricians, depending on health needs, population and geography. Among the various models are: paediatricians practicing in the community and working in groups (ie, outside the hospital setting) – they are critical to the effective delivery of health care for young Canadians; paediatricians working in community hospitals, either full time or through on-call; paediatricians working in university teaching hospitals; and paediatricians visiting rural and remote areas on a regular basis, or supporting them through telemedicine. Access to care can be improved through better distribution and support of community paediatricians, who must be adequately resourced to provide comprehensive care. Access to care can also be improved through teamwork, collaboration with other health professionals, and flexibility among support staff to ensure that the majority of paediatricians' time is spent on those activities requiring their expertise. Paediatric subspecialists must be appropriately distributed and accessible. Further investment and enough protected time are required to allow paediatricians to participate in the teaching of other child and youth health professionals and in research. All children and youth in Canada should have timely access to paediatric expertise that meets their needs. As a population, young Canadians and their families require the following: Appropriate hospital care: Children and youth who are hospitalized should have access to quality, specialized paediatric expertise that meets their needs. Smaller, remote and northern communities should have adequately resourced visitation or telemedicine programs to ensure access to this paediatric expertise. Newborn care: Newborns with serious illness (eg, significant prematurity, respiratory distress, malformation) should have access to specialized neonatal or paediatric expertise that meets their needs. All newborns should have access to a neonatal intensive care unit, designated as such by government authorities, as required. These units should meet Canadian standards for human resources (medical specialists, nursing personnel), training and physical resources (space, equipment). All newborns requiring transportation should have access to an appropriate transport system/team to a neonatal intensive care unit designated as such by government authorities. Critical care: All children and youth who require emergency transportation should have access to an appropriate transport system and, as needed, a hospital with paediatric expertise. Paediatricians must actively participate in the implementation of appropriate transport teams. When required because of the state of their physical health, all children and youth should have access to a paediatric intensive care unit, designated as such by government authorities. These units should meet Canadian standards for human resources (paediatric intensivists and nursing personnel), training and physical resources (space, equipment). Child/youth protection services: Children and youth who have suffered abuse – whether physical, sexual, psychological or neglect – should have timely access to a specialized age-appropriate health assessment by a properly trained and resourced team that meets their needs. All paediatricians should receive training to recognize and treat cases of child/youth maltreatment. Palliative care services: Children and youth with a terminal illness should have access to paediatricians with specific training in palliative care and pain control. First Nations, Inuit and Métis children and youth: All First Nations, Inuit and Métis children in Canada should have timely access to culturally appropriate paediatric expertise, regardless of their geographic location. Vulnerable populations: Children and youth at risk of health problems (eg, new Canadians, children from disadvantaged socioeconomic groups) should receive paediatric care that considers their environment and, in conjunction with professionals from various disciplines, minimizes the potential for poor health outcomes. Children with developmental problems: Children and youth with developmental problems should have timely access to specialized assessment, diagnosis, treatment, and/or follow-up by a paediatrician or, when needed, a developmental paediatrician in addition to the other health professionals such as dietitians, speech language pathologists, occupational therapists and physiotherapists. With preventive and anticipatory care, children and youth have a better chance of meeting their developmental milestones. A collaborative relationship with the primary care physician may be required to provide follow-up care. Children and youth with mental illness: Children and youth with mental illness should have timely access to a specialized assessment by a paediatrician, in addition to a mental health assessment by a psychiatrist, psychologist, social worker, nurse or another subspecialist trained in child/youth mental health. As needed, paediatricians should be part of the team and, where appropriate, the care coordinator. When necessary, paediatricians may provide ongoing mental health care. Children and youth with serious acute or chronic illness: Children and youth with serious acute or chronic disease should, regardless of where they live, have a paediatrician involved in their care, whether in a community or hospital setting or through telemedicine. As appropriate, the paediatrician will manage the illness alone or in cooperation with family physicians and subspecialists, and/or with a multidisciplinary team. Youth: All adolescents should have access to expertise that meets their specific needs, based on their age group, as required. When needed, adolescents should have access to appropriately trained paediatric expertise. When youth with serious chronic diseases reach adulthood, after having been cared for up to that point by paediatric specialists or subspecialists, there should be a properly planned transition to the appropriate primary care family physician and adult medical specialist or subspecialist, to ensure of care. quality care setting standards for practice, a on teaching and and a healthy community of care that meets standards of Paediatric should at all times Canadian standards or, such standards do not those for care: Paediatricians must develop and on the physical, emotional, cognitive and mental health of children and youth. These must and which health and must be by professionals with expertise. These must be to all health professionals who care for children and youth. It is also that public be to health professionals to the practice. Paediatricians must develop and in key areas for child and youth advocacy for use at the or regional Centres of To ensure the highest quality care for children and youth who require specialized of must be and to ensure that a critical of expertise is and example, already for complex cardiac and on child and youth health must be at the and in all medical and for trainees in other health disciplines (eg, medicine, Paediatricians should have a key role in the teaching of child and youth health. and adequately research programs – on the needs of youth and families – must be and and programs must be to ensure that child and youth health outcomes. should the of both and paediatricians. 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