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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 work-force 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:
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:
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):
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:
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 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 in Canada should have timely access to paediatric expertise that meets their needs.
As a population, young Canadians and their families require the following:
Assuring quality care means setting standards for practice, ensuring a continued focus on teaching and research, and fostering a healthy community of care providers.
The following are generally accepted:
Given this reality, and the scope of paediatric expertise, the following recommendations will move provinces and territories toward this model of paediatric practice.
Provinces, territories and district health planners must work with paediatric leadership from provincial associations and, where appropriate, university hospitals and department chairs to create human resource plans that meet the following criteria.
Every child and youth requires a primary health care provider, family physician or nurse practitioner to provide primary care on a regular basis.
The number of paediatricians required to meet the needs of children and youth should be established for each given jurisdiction, and should specify those required:
Evaluating the required number of paediatricians should take into account clinical, teaching, research, government and administrative responsibilities, as well as the role of paediatricians as:
Paediatricians should be encouraged to work in the community as well as in hospital settings. Community paediatricians, as a result of their education and training, have the ability to adapt their practices to meet the needs of the children and youth in a given population. Where possible and appropriate to their needs, children and youth should be able to have paediatric services delivered in their local community hospital setting rather than in a centre farther from their homes.
The number of paediatricians and methods of remuneration should facilitate reasonable call schedules in all areas. In view of limited human resources in paediatrics and the various health needs of children and youth in Canada, paediatricians should consider it their responsibility to participate in on-call activities, including during evenings and on weekends.
A critical mass of all child and youth health professionals, including paediatricians, is necessary to offer continuity of care to children, youth and communities. Governments must work with child and youth health professionals to ensure optimal human resources. Attention must also be given to creating child- and youth-specific electronic health records to facilitate communication between team members and to ensure continuity of care.
All methods of remuneration in provinces/territories should be re-examined to maximize the involvement of paediatricians in the type of care as described in this model as well as teaching, research and administration.
Remuneration models should encourage paediatricians to work with others in the community to meet the needs of children and youth. In addition to providing acute and complex care, paediatricians may need to collaborate with schools, public health, child and youth mental health centres, or child welfare agencies. In some communities, paediatricians may be the primary care provider if that meets the health needs of the children and youth.
Provincial and territorial governments must engage the child and youth health professionals and their leadership to determine how to improve access to care for children, youth and their families. This is especially urgent for mental health and developmental disorders.
Paediatricians should play a leadership role in the coordination of care and in the management of children and youth suffering from serious acute, chronic and/or multisystemic illness. Coordination and continuity of care in these instances is essential to prevent or minimize fragmented of care.
Paediatricians in Canada should participate in the education of medical and health science students, paediatric and family medicine residents and fellows.
Paediatricians in Canada should participate in the continuing medical education of colleagues in nursing, family medicine, paediatric specialties or subspecialties. Paediatricians should also be encouraged and supported to meet their own lifelong learning needs.
To optimize resources, guidelines and standards for the appropriate referral of children and youth to paediatric sub-specialists should be better defined and disseminated. Paediatricians should be involved in assessing health outcomes for children and youth as well as quality improvement projects.
To ensure the smooth transition of youth to adult care, family physicians, paediatricians and adult specialists must develop methods to identify appropriately trained professionals to provide continuing care for young adults with complex medical needs. Professional development and care protocols are needed to support those who take over the care of youth with these complex health care needs.
Using this model to plan health care services for children and youth could result in changes to how paediatrics is practiced. In some communities, paediatric practice will evolve over time. However, this can only be done when certain conditions have been met:
CANADIAN PAEDIATRIC SOCIETY BOARD OF DIRECTORS
President: Dr Joanne Embree, Winnipeg, Manitoba
President-elect: Dr Kenneth J Henderson, St John’s, Newfoundland and Labrador
Vice President: Dr Robert I Hilliard, Toronto, Ontario
Past President: Dr Gary Pekeles, Montreal, Quebec
Directors: Drs Bill Abelson, Prince George (Representing British Columbia and Yukon Territory), Minoli Amit, Antigonish (Representing Nova Scotia), Anthony Ford-Jones, Burlington (Representing Ontario), Marie Gauthier, Montréal (Representing Quebec), Pascale Gervais, Sainte-Foy (Representing Quebec), Janet Grabowski, Winnipeg (Representing Manitoba and Nunavut), Ramaiyer Krishnaswamy, Fredericton (Representing New Brunswick and Prince Edward Island), Heather Onyett, Kingston (Representing Ontario), Theodore A Prince, Calgary (Representing Alberta and Northwest Territories), Élisabeth Rousseau-Harsany, Montréal (Representing Quebec), Koravangattu Sankaran, Saskatoon (Representing Saskatchewan), Susan Tallett, Toronto (Representing Ontario), Christina Templeton, St John’s (Representing Newfoundland and Labrador)
Ex-officios: Drs Ereny Bassilious, Toronto (Representing the CPS Residents Section), Danielle Grenier, Gatineau, Québec (CPS Medical Affairs Director), Robert M Issenman, Hamilton, Ontario (President, Healthy Generations), Noni E MacDonald, Halifax, Nova Scotia (Editor-in-chief, Paediatrics & Child Health), Ms Marie Adèle Davis, Ottawa, Ontario (CPS Executive Director)
Principal authors: Drs Marie Gauthier, Montréal, Québec, Robert M Issenman, Hamilton, Ontario, Ian Wilson, Kitchener, Ontario
The recommendations in this statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.
All Canadian Paediatric Society position statements/notes are reviewed, revised or retired as needed on a regular basis.
For the current version, please consult the “Position Statements” section of the CPS Web site (www.cps.ca/english/publications/StatementsIndex.htm).