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What will the health and health care services that we provide to children and youth look like as we move through the 21st century? As professionals who are committed to the care and well-being of children and youth, we must do our part to answer this question. The present issue of Paediatrics & Child Health is important as we focus on the human resources required for the future.
The 2006 Census (1) shows the absolute number of children gradually increasing, but the proportion of children relative to the population as a whole is dropping as the population ages, with 17.7% of the population being younger than 15 years of age in 2006 compared with 34% in 1961. Within the next 10 years, the proportion of children younger than 15 years of age will be outnumbered by the proportion of individuals older than 65 years of age. For the first time in 2006, there were more census families comprising couples without children (42.7%) than with children (41.4%). Approximately two-thirds (65.7%) of Canada’s 5.6 million children aged 14 years and younger lived with married parents in 2006, a decline from 81.2% in 1986.
These demographic changes must drive our thinking about the 21st century! Children and youth are the future of a nation, and countries that focus on supporting the health and development of their children and youth will benefit enormously from this investment. It is surprising how difficult it is to get the government of Canada to provide leadership in building a national strategy supporting the health and well-being of children and youth. The United Nations International Children’s Emergency Fund Canada (2) has recommended that the government create a Commissioner for Children and Youth, and many organizations including the Canadian Paediatric Society (3) have advocated for this. The Leitch report (4), commissioned by the federal government, recommends the creation of a National Office of Child and Youth Health.
Contrast our commitment with that of England, where a Commissioner for Children and Young People was established and where there has been a major focus on rebuilding a social, education and health infrastructure that better supports the needs of children and young people with the goal of making England ‘the best place for children to grow up’. A recent policy document, “Healthy lives, brighter futures – the strategy for children and young people’s health” (5), extends this United Kingdom commitment.
Many provinces are increasing their commitment to children and youth, and building cross-ministry policies and strategies that improve support for children and youth. But this is not sufficient. There is an important role for the federal government in building a common vision, in advancing knowledge, in supporting dissemination of best practice and in planning of human resources. As well, the role of the federal government is to make sure that our policies and practices are consistent with our endorsement of the United Nations Convention on the Rights of the Child.
The challenge is complex because we must examine the whole fabric that supports the health and development of a child. The family is central to success and, as Urie Bronfenbrenner notes (6), we must recognize and take advantage of the “irrational attachment” that families have to their children and that “every kid needs at least one adult who is crazy about him”. However, families alone cannot succeed. They are dependent on the community through which the child experiences the world and the social structures – early child care, education, social services and health care – that are critical to success. There are an array of ‘human resources’ that in various ways, in various quantities and at various times are important to the future of a child. As we examine health human resources, we must not lose sight of the breadth and depth of these broader human resource needs. Indeed, the greatest risk to success may well be the opportunity cost of society paying for an increasingly expensive health care system at the expense of the social and educational infrastructure that supports children and youth.
If we assume for the moment that we have a national vision and commitment, are aware of the dramatic demographic changes, and recognize the breadth of human resources involved in supporting children and youth, what are the issues for health and health care services?
The discipline of paediatrics came to life in the 1950s with services focused on the acutely ill child needing hospitalization. Public health initiatives were important but were largely divorced from acute care. In subsequent years, sub-specialty expertise developed and we have a service system that is a mixture of primary care by family doctors and, in some areas, paediatricians and a ‘primary-secondary-tertiary referral-consultant’ model that is structured more around episodic care and compensation mechanisms than a quality service system.
The system that evolved was successful in dramatically reducing child mortality and morbidity. However, children and youth are very different today. Episodic care is not going to meet their needs, and a continuum of services across the trajectory of a child’s development is required (7). In a recent commentary in Pediatrics, Paul Wise argued for the rebirth of paediatrics, that we must “craft strategies that protect what remains essential in paediatric practice and yet embrace an historic opportunity to craft requisite reforms” (8).
Our models of health care are still largely stuck in the 1970s and 1980s. The federal and provincial governments of Canada have focused on models of care over the past 10 years, but children and youth have not been part of the discussion. Models of care must recognize the geography and demographics of our country and must address issues of access to the right services in the right place at the right time and seeing the right health care professionals. Transforming the models of care and aligning these models with child and youth health human resource planning is critical.
We must maximize the role of primary care practitioners (nurse practitioners, family physicians), provide continuity of expertise for those with chronic illnesses or special health care needs, and protect the core of highly specialized services that children and youth may need. This will require changes in the way we train health professionals, in the way we deliver care, the location of care and how we fund the services.
We need a specific focus on improving public health services so that children and youth are central to the public health mandate. There is a rebirth of public health in Canada following events such as the SARS epidemic and threats to food safety and the environment. It is important in this rebirth that we incorporate children and youth specifically in the mandate of public health services. For example, the British Columbia government has identified child development as one of 21 core public health functions that health authorities are responsible for and must report on annually (9).
Yet, where are the public health professionals who have expertise and commitment to children and youth? Do we have training programs that are preparing our paediatricians, nurses and other health professionals for leadership roles in public health? While there are some important leaders in the field, the current expertise is nowhere near the level that is required.
We must also focus on the cross-discipline human resources that are required to advance knowledge in child and youth health across the spectrum of basic, clinical, health services and health policy/population health research. There has been some success such as the creation of the Institute for Human Development, Child and Youth Health within the Canadian Institutes of Health Research, the Canadian Child Health Clinician Scientist Program that provides a national training program across disciplines and pillars (10), and the early beginnings of a national collaboration in clinical and health services research focused on maternal, infant, child and youth health (11). However, a much greater investment is needed if Canada is to meet the challenges facing the health of children and youth.
Children and youth have common needs across the geographic boundaries of provinces and territories. Their numbers are proportionately small but they are all of the future. We need a national health human resource strategy that is linked to innovative transformations in care and an increased investment in collaborative research that translates to best practice.
We must move from the concept of hospital and specialty care to a focus on populations and coordinated care across the continuum, respecting the trajectory that individual children are moving along. We have the capacity to achieve this in Canada. This would be greatly facilitated by federal leadership and provincial and territorial commitment to collaborate across their boundaries. However, we do not need to wait for the government. Significant progress can be made by mobilizing the leadership of national and provincial organizations committed to children and youth, perhaps bringing along governments in the process. The Canadian Coalition for Child and Youth Health is one example of this commitment (12). We clearly need to work together if, as a country, we are committed to our children and youth.