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Why we need social paediatrics
The past 20 years have produced dramatic changes in the configuration of Europe and the health of our children. While important progress has been made in areas such as neonatal and intensive care, treatment of malignancy, and transplant surgery, paediatricians enter the new millennium knowing that many children are increasingly disadvantaged by the social and political climate of their countries.
In the early 1980s when community paediatrics became a sub-specialty in the UK and the World Health Organisation drew up its policy document “Targets for health for all”, Europe consisted of 32 member states. Today we are divided into 51 countries with very different history, culture, economy, and health needs.1 The multiple armed conflicts of central and eastern Europe have resulted in massive migration, separation of families, disruption of even the most basic health services, and regression of child health indicators to levels far below those targets set 20 years ago.2-4 Although the incidence of most communicable diseases has fallen radically throughout Europe, in the eastern states the numbers infected with HIV continue to rise and old enemies such as diphtheria and tuberculosis are re-emerging.
Even in those states untouched by conflict, poverty remains a resilient enemy. The most recent figures from the UK (which has the third largest child population) show an increasing gap between rich and poor, with 3.4 million children now living below the poverty line. Morbidity is increasingly sociogenic rather than biogenic but the patterns have altered. While under-nutrition remains a reality,5 obesity poses a much greater overall threat to children's health; changes in the structure of society and raised expectations are associated with increasing mental health problems in adolescence.6Increasing identification of abuse and neglect and of special needs has contributed to this “new morbidity”.7-9 Ironically, advances in public health, medical, and surgical techniques have probably been responsible for much of the increase in chronic childhood illness and disability.
It is very difficult to obtain useful information about relevant paediatric services in Europe. This is largely a result of the wide disparity in overall structure of services, as well as variation in interpretation of what is meant by social/community paediatrics. The presence of private insurance, which is largely confined to urban areas, is another confounding factor (60% of children in Catalonia are treated privately compared with 15% in Portugal, 10% in Greece, and less than 1% in Bulgaria and Poland). A comprehensive community paediatric service exists in the UK and Sweden (where 25% of paediatricians work outside hospitals), but elsewhere in Europe secondary paediatric and disability services are still very much hospital based. The concept of child development centres is spreading slowly, and there are isolated initiatives, for example, in Greece and Portugal. In Croatia, many children with cerebral palsy attend “sports clinics”. These developments tend to be driven by individuals or local communities rather than cohesive government programmes.
Primary paediatric care is provided by “generalists” in the UK, Sweden, Norway, and the Netherlands, by paediatricians in Greece, Portugal, Spain, Italy, France, and Luxembourg, and by a mixture of both in Germany. Within Europe as a whole, social paediatrics falls within the remit of general practitioners who are unlikely to have had paediatric training. Ambulatory paediatrics, on the other hand, is a vigorous and expanding service in southern Europe (particularly Spain) and is probably the closest model to the “GP paediatrician” of the Court Report, providing primary paediatrics from a base in the community.
Community and Social Paediatrics is not officially recognised as an integral part of paediatric training and practice outside the UK and the Nordic countries. For example, the French Society of Paediatrics was recently unable to identify a sufficient number of doctors working in this field to form a sub-group, and so they have been amalgamated with ambulatory paediatricians. The paediatrician working outside the hospital or private consulting room is an unfamiliar concept, teaching students in the community is virtually unknown, and even the concept of trainees rotating to non-university hospitals is a relatively new one. The Association for Paediatric Education in Europe has included the required knowledge and skills in the document Paediatric education for all physicians providing primary paediatric care,10 and has also recommended community experience as part of basic training of all paediatricians.11 However, community experience is regrettably absent from the European paediatric common trunk12 (the approximate equivalent of the UK paediatric senior house officer training), but Child Public Health is increasingly recognised as the basis of service provision and hence training. In the UK, Community Paediatrics has always included elements of public health, but in most other countries the epidemiology of childhood disease and disability remains the remit of adult public health services who still have responsibility for teaching the subject in the undergraduate curriculum.
In the Netherlands, where there has been an increasing divergence of preventive child health and hospital based services, the University of Maastricht has attempted to close the gap by appointing a community paediatrician and has introduced the subject at postgraduate level as a series of lectures.
The mechanisms for change
There is light at the end of the tunnel. Paediatricians all over Europe, not just those whose countries have been affected by the massive shifts in population caused by war, share concerns about the change in children's health needs and want this to be reflected in training at all levels. The responsibility for paediatric training lies with the Confederation of European Specialists in Paediatrics (CESP), which is the paediatric sub-section of the European Union of Medical Specialties (UEMS), through which it advises the European Commission (fig 1). Its first two objectives are: (a) to study, promote, and guarantee a comparably high quality of paediatric care; and (b) to ensure a high standard of paediatric training in the member countries. CESP is made up of representatives from all EU countries with observers from non-member states. At a meeting in Graz in 1996 the subject of social and community paediatrics was raised. Representatives from most countries freely acknowledged their lack of familiarity with this area of paediatrics but recognised both its importance and its absence from the training curriculum.
The Bordeaux meeting
To enable and expand the discussion following this meeting, the Association for Paediatric Education in Europe (APEE) invited the European Society for Social Paediatrics (ESSOP) to a joint conference. Prior to the meeting, which was held in Bordeaux in 1998, Macfarlaneet al carried out a Delphi project in which 23 perceived experts in 11 European countries defined priorities for undergraduate, postgraduate, and specialist training.13The results were presented and discussed and the meeting went on to address the question of whether child public health and social and community paediatrics (CPH/SCP) should become a European specialty.
The overall consensus of the Bordeaux meeting was that in an ideal world many of the elements of SCP would be assimilated into general and ambulatory paediatrics as part of everyday practice, but this cannot happen until the subject is taught at undergraduate level and as part of the common trunk training of all paediatricians. Every medical student and paediatric trainee should have the opportunity to experience paediatric practice in a community setting and a multidisciplinary approach is essential to the subject. Europe has a long way to travel to reach these goals. The lack of expertise in SCP in most countries (and of most paediatricians) makes a very strong case for a recognised specialty to develop and promote the subject, and to provide the necessary academic base. It was agreed that CPH was an essential component and driving force.
When specialty status was discussed there was an important minority point of view that in spite of the fact that more and more paediatricians in all specialties now take into account the influences of developmental, environmental, and family factors, currently trainees have neither the experience of the subject nor the financial incentives to stimulate interest in this field, and that many of the best social paediatricians come to the subject at a later stage from a different career path. A move towards specialty status was perceived as premature and possibly counter productive.14
Achieving specialty status
There is already a will in Europe to increase collaboration in the field of CPH. The first step must be to create a European paediatric specialty which combines CPH and SCP, but allows for the development of two main pathways through the curriculum. There are a number of tasks to complete if CPH/SCP is to achieve specialty recognition. The broad consensus on the content of training has to be developed into a core curriculum which allows individual countries to add modules according to their population profiles and health needs. We then need to identify university departments throughout east and west Europe which can deliver the core curriculum and/or the optional modules (some of which may appropriately be taught by specialists in adult public health). When this has been completed, application can be made via CESP to UEMS for specialty status. This process is both rigorous and arduous. (To date there are only five recognised paediatric specialties: endocrinology and diabetes; hepatology, gastroenterology, and nutrition; nephrology; rheumatology; and respiratory medicine.)
At a later stage the specialty could consider a non-compulsory exit examination in the form of a Certificate from the European Board (the training committee of the CESP). This already exists in a small number of adult specialties (including rehabilitation medicine). Although most junior doctors are highly resistant to yet more examinations, the current disparities in training, the inevitable movement of doctors throughout Europe, and the worrying levels of medical unemployment in some member states, may encourage them to seek objective evidence of a satisfactory specialist training. The process of seeking recognition takes a minimum of two years in even a small, well organised specialty, but nevertheless a start has to be made. ESSOP would be expected to take the lead and they and APEE have the basis of the necessary working groups to draw up recommendations for the undergraduate curriculum and common trunk as well as specialist training. They will need help from others in the field. The machinery of Europe moves frustratingly slowly, but it carries the weight of millions of children. Community paediatricians in the UK, who are already a long way ahead down the road, are invited to pause and put their shoulders to the wheel.
The conflicts and population movements of the last few years have further increased social morbidity and the disparities in children's health needs and service provision between the countries of Europe. Paediatricians from east and west Europe have shared concerns and recognise that changes are needed in the way paediatrics is taught and practised at all levels. Although there is a European consensus that many of the elements of SCP should be assimilated into general and ambulatory paediatrics as part of everyday knowledge and practice, Europe has a long road to travel to reach this goal. As yet these subjects are absent from the postgraduate common trunk curriculum, and inadequately taught to most medical students. A strong academic base is essential to promote and develop SCP in Europe, and this can probably only succeed if it remains allied to CPH as a single specialty. There are a number of steps that must be taken before specialty status can be achieved, and these will require hard work and cooperation.
Our thanks to Stevie Beljung for preparing the manuscript.