Pediatrics and the organization of child health care in France

The Minister for Health and Solidarity has asked the General Inspectorate for Social Affairs (IGAS) to conduct a mission on pediatrics and the structure of child health care in France ; he has also asked Professor Brigitte Chabrol, President of the French National Professional Council of Pediatrics (CNPP), to provide her expertise to support the mission. The mission would like to sincerely thank her for her commitment throughout the work on the report, which benefited greatly from her expertise and for her independent thinking in an effort to serve the health of children, particularly the most vulnerable ones.
The mission began by establishing an overview of child healthcare professionals, which is cause for concern in itself.
The various components of pediatric outpatient medicine are in crisis. In 2006, Professor Sommelet, in his landmark report on child and adolescent health, underlined the importance of demographic problems in pediatric community care ; things have become even more difficult since then, even though the number of trained pediatricians has significantly increased.
Thus, private practice pediatrics is experiencing a significant demographic decline, which is particularly pronounced for Sector 1 pediatricians. Currently, 8 departments have a density of less than one pediatrician per 100,000 inhabitants, and the average age of private practice pediatricians suggests that the situation will only get worse, as 44% of them are over 60 years old. This situation poses a major issue for access to pediatric care for certain populations. This issue is compounded by the decrease in staff in maternity and child welfare (PMI) and school health services, whose preventive role is essential, particularly for the most vulnerable.
General practitioners also play an increasingly important role in the care of children : they provide more than 85% of community care consultations for children under 16 years of age. Their training in pediatric medicine, even if it has recently been improved, remains mixed and insufficient in relation to this instrumental role.
The declining role played by private pediatrics in the follow-up care of children is a contributing factor to their identity crisis. The duties assumed by community care pediatricians are now similar to those of general practitioners and their respective positions do not appear to complement one another. Pediatricians play an important preventive follow-up role, without specializing in children with special needs, and are hardly involved in referrals, whether for primary care professionals or for hospitals. Their duties thus do not appear to align with their highly specialized training. In addition, the remuneration of private pediatricians is among the lowest compared to other medical specialties, which contributes to the profession’s lack of attractiveness.
Conversely, the demographic evolution of hospital pediatrics and pediatric surgery, two disciplines that are mostly practiced in public hospitals, is more satisfactory. Their rise is driven by the growing specialization of medical disciplines, which responds to key health issues : scientific and technical progress, increase in the incidence of chronic diseases, improvement in the management of rare diseases, and development of research. The growth of pediatrics and pediatric surgery has been substantial for the last few decades, which has brought about an increase in the life expectancy of sick children and an improvement in their health status. Thus, pediatric “subspecialties” have gradually developed (neonatology, pneumopediatrics, neuropediatrics, etc.).
However, the attractiveness of pediatrics is declining among students due to the particularly high workload of after-hours care and continuity of care, especially in pediatric emergencies. This issue of attractiveness is particularly relevant for hospital departments with small teams that sometimes have difficulty recruiting.
In addition, the difficulties faced by pediatric psychiatry affect the activity of pediatrics, as is currently demonstrated by the huge volume of requests from pediatric services to treat, in collaboration with child psychiatrists, the mental health disorders of children and adolescents that have developed as a result of the coronavirus pandemic. The links between the two disciplines are certainly close, particularly for adolescent medicine and neurodevelopmental disorders.
As with pediatrics, the attractiveness of pediatric surgery suffers from the workload of treatment services concentrated on small teams in university hospitals (CHUs), which provide a growing number of care services compared to local institutions. The lack of anesthetists with pediatric skills is also a recurring difficulty for the specialty.
Lastly, paramedical professions for children are given insufficient recognition. The lack of development of the diploma in pediatric nursing since 1983 reflects the lack of recognition of a profession whose position in the hospital is questioned in relation to “generalist” nurses and other specialized nurses. Bizarrely, since 2009, the initial training of “generalist” nurses who also work in pediatric services no longer includes an internship or mandatory training in pediatrics. This loss of skills could have led to greater recognition of pediatric nurses in the hospital, but stakeholders moved in favor of the opposite. The skills of pediatric nurses, particularly in terms of support and prevention, are underused, especially in the outpatient sector, since their practice is limited to PMI, due to the lack of funding for their work in community care.
Like pediatric nurses, childcare assistants report a lack of recognition of their profession and a confusion of their skills with those of nursing assistants.

The mission then prepared a report on the provision of healthcare for children and the links between the various healthcare stakeholders.

There are many monitoring and prevention health measures for children and adolescents, such as compulsory examinations of the child, compulsory vaccinations and, more recently, pediatric primary physicians. However, in most cases these various measures do not manage to cover all children. They do not allow us to address the social and territorial inequalities in health, which remain pronounced : for example, infant mortality is two to three times higher in the French overseas departments and territories than in mainland France, and a working-class child is six times more likely to be obese than a child from a middle-class background.
The child healthcare system also suffers from a lack of clarity for parents, who do not clearly recognize stakeholder roles and are not always aware of the monitoring measures, such as compulsory examinations. In addition, the lack of knowledge of the healthcare services available to children contributes to parents seeking care for their children at hospital emergency departments. This is a particularly common occurrence for children, compared to the adult population, and is increasing (+2% per year) while the child population is decreasing due to the decrease in the birth rate since 2014. This use of emergency departments to access care for children is not always appropriate, especially for children under two years old.
Furthermore, the healthcare system does not always properly address the specific problems of vulnerable children and children suffering from certain conditions. Some health policies are old and relatively well-structured, for example for perinatal care or rare diseases, while others are still being developed (care for autism and neurodevelopmental disorders). Access to treatment for certain groups, such as children and adolescents under child protection or children with disabilities, remains difficult. Furthermore, there is still room for improvement in terms of ensuring that children are admitted to hospital in accordance with their rights throughout the country, and in terms of providing better support for families, in conjunction with patient associations.
Lastly, the coordination of child healthcare providers still falls short, whether between hospitals, community care professionals or between community care and hospital providers. This insufficient coordination is detrimental to both healthcare professionals (inadequate referral level, overcrowding risks in certain institutions, etc.) and families (delays in care, responsibility of coordinating care, difficulties in finding their way through the health system, etc.).

The mission proposes a new care model for children to meet all of their healthcare needs and to enhance and clarify the role of healthcare providers.

(i) This plan clarifies and expands the duties of community care providers.

The practice of pediatric nurses in PMI, as well as the trials examined by the mission (pediatric nurse consultations in a pediatric health center, home visits by pediatric nurses to limit hospitalizations), demonstrate their ability to meet many community care needs.
The mission recommends developing the practice of community care pediatric nurses, beyond PMI, with the provision of independent consultations, in close collaboration with a physician. The duties of pediatric nurses would mainly include consultations with children, the performance of certain developmental examinations, treatment education consultations and follow-up care after hospitalization. The mission thus recommends that specific procedures performed by pediatric nurses be included in the general classification of medical procedures and services (NGAP) so they can be financed by health insurance. It estimates that the practice of 1,000 pediatric nurses in community care would require funding in the region of 50 to 70 million euros. However, this is not a net cost, as the procedures would partly replace medical consultations in community care and in emergency departments.
The pediatric nurses would work in pairs with doctors, preferably in the context of a group practice, under a salaried or private status. Their practice should also be structured in a way that complements that of midwives, who can follow-up with newborns (0 to 28 days), particularly in the context of the PRADO program for supporting patients at home after hospital discharge. The mission recommends that the synergies between pediatric nurses and midwives practicing in the community care be defined locally, in coordination with physicians, for example within the scope of territorial professional healthcare communities (CPTS). One option would be to focus on follow-up by the midwife for newborns and follow-up by the pediatric nurse from the age of one month.
The mission also recommends refocusing the duties of community care pediatricians and better identifying the role of general practitioners in child healthcare, in order to enhance the skills of each specialty and promote complementarity and subsidiarity of interventions. The mission looked into three options to clarify the positions of these two stakeholders. The first option, which consists of consolidating the role of primary care pediatrics in the community by generalizing pediatric follow-up for all children, particularly infants, is neither realistic on a demographical level nor is it desirable, given the role currently played by general practitioners and the specialized skills of pediatricians. The second option involves providing targeted pediatric intervention for all children under community care, reserving it for certain key ages and entrusting general practitioners with the rest of the follow-up, appears to be undesirable, whether for children, pediatricians or general practitioners (sharing of follow-up, lack of diversity in the doctors’ duties, low valuation of skills). The last option preferred by the mission requires a more substantial repositioning of the respective roles of general practitioners and community care pediatricians.
In the proposed system, the community care pediatrician plays a primary and expert role for other healthcare professionals (and more particularly for the general practitioner) and handles the follow-up of certain chronic diseases. Depending on their training, they may also practice a subspecialty within their duties. Their primary care role is repositioned to children with special needs or risk factors, for whom they play a care coordination role. Expanding the specialized duties of community care pediatricians, in line with their training, will require adjustments in the financing of their procedures and in their classifications, which should also aim to increase the income of private pediatricians in order to make community practice more attractive.
The target plan identifies general practitioners trained in child health as the local stakeholder in the medical follow-up of children without chronic conditions or vulnerability factors, thus handling both preventive follow-up and unscheduled care. In addition, support from medical assistants for consultations with general practitioners and pediatricians saves patient contact time and provides a better quality of service. The mission calls for the continuation and expansion of incentives for the development of medical assistants, particularly for pediatricians.
Lastly, the provision of community care for children must be consolidated by improving PMI and school health services, which represent two institutions with an essential social and preventive role. Recent reports on these institutions have called for clarification of their governance and duties, and for financial restructuring of the practice of the physicians working in them.

(ii) In hospitals, the target plan makes it possible to realign hospital pediatrics and pediatric surgery on their referral role and to enhance medical and paramedical practice.

In the proposed system, hospital pediatricians are more focused on their highly specialized referral duties (follow-up of rare diseases and chronic diseases that cannot be managed in community care, neonatology, intensive care, etc.). However, the current shift towards specialization must be reconciled with the continuation of generalist (or multi-disciplinary) pediatrics in hospitals, both in hospitals and university hospitals, which requires better analysis of the need for multi-disciplinary pediatric positions in hospitals. Closer coordination between community care pediatrics and hospital pediatrics is desirable, particularly for the management of chronic diseases. Similarly, there is a need to strengthen the links between child psychiatry and pediatrics to improve the quality of both somatic and psychological care. Areas of cooperation that should be developed include consultative child psychiatry, the presence of child psychiatrists in pediatric emergency departments, as well as joint management of neurodevelopmental disorders and adolescent medicine.
The duties of pediatric nurses must also be better recognized in hospitals in an effort to value their skills and increase their autonomy, particularly through targeted consultations, such as those being developed in pediatric emergency departments. Similarly, the value of childcare assistants should be fostered by reforming their training and skills (currently being finalized), with more delegation of tasks. There is also a need to bolster the presence of pediatric nurses and childcare assistants in hospital pediatric and pediatric surgery departments by drawing on existing regulations which define ratios of specialized personnel in certain departments (pediatric intensive care and neonatology).
Regarding pediatric surgeons, the generalization of structured regional organizations will make it possible to improve their activity in terms of referral and expertise. These organizations, in the same way as the Occitanie network, define referral levels for the different care types, label the institutions and organize the training of those involved (in particular adult surgeons practicing pediatric surgery). In addition, it would be beneficial to set up a care gradation system between hospitals in pediatrics in order to standardize the quality of care and set up patient care pathways using existing organizations such as networks.
Consolidating medical teams, both in pediatric surgery and pediatrics, is necessary given the workload of current treatment services and the attractiveness issues faced by the two disciplines. The introduction of a minimum threshold of practitioners to be on shift in hospital and available on-call in case of emergency should be explored, as recommended in a recent IGAS report on the availability of care in healthcare institutions. Improving the attractiveness of hospital departments also requires larger paramedical teams, particularly for intensive nursing care.
Finally, recognition of pediatric disciplines requires sufficient financial recognition of pediatric medical and surgical procedures. The mission therefore recommends investigating the coverage of the costs of pediatric hospital activity (surgical and non-surgical) by the CCAM (common classification of medical procedures) and PMSI (program for the medicalization of information systems in France) rates. The aim of the study would be to analyze whether the additional costs created by the technical nature and duration of pediatric procedures are covered by the existing rates.

(iii) The implementation of the target plan requires significant changes in the initial and continuing training of professionals.

Regarding doctors, the consolidation and standardization of initial and continuing training for general practitioners in child healthcare are key enablers of their enhanced role with children. The mission therefore recommends creating a Child healthcare option within the post-graduate diploma in general medicine, in order to facilitate an understanding of the skills of general practitioners for both families and professionals. In addition, consolidating the specialized duties of pediatricians requires a major professional training plan as part of continuing professional development.
With regard to pediatric nurses, taking on new duties both in hospitals and in community care settings requires a major reform of pediatric care training. This will have to enable the adaptation of the training framework and the integration of new skills. The training must also be extended, mastered and integrated into university courses. These changes will help significantly improve the diploma and achieve better recognition of this unconventional training in the context of specialized nurses by reconciling the acquisition of technical skills and a generalist and multi-disciplinary field. It complements the training of advanced practice nurses, who are highly specialized and can also work in specialized pediatrics or pediatric surgery.
Lastly, the demand for quality care for children requires consolidation of the pediatric skills of all professionals contributing to the pediatric care environment (nurses, anesthesiologists, radiologists, adult surgeons), in particular by routinely making internships part of initial training. In particular, the mission recommends the reintroduction of a pediatric internship in the training curriculum for nurses, which should be reviewed soon. Regional organizations can also contribute to increasing the skills of healthcare professionals through professional training measures.

(iv) Territorial cooperation must become more widespread in order to coordinate pediatric care pathways, support the management of unscheduled care and ensure the follow-up of all children.

In community care, the existing obstacles to the creation of pediatric health centers must be overcome, and these centers must be given ample support to promote the coordination of community care stakeholders. Territorial professional health communities are also a key lever for developing closer cooperation, establishing care pathways and strengthening prevention and health education measures. It is thus recommended to develop a “child healthcare” focus within the CPTS is by integrating PMI and school health.
Beyond this, more comprehensive cooperation between community care and hospitals is essential for the organization of pediatric care pathways that are clear to families. Developing CPTSs will foster relations between community care and hospitals through the structuring of community care services. The electronic health record, which is set to be rolled out in January 2022 as part of the digital health platform, should promote the sharing of information between all professionals.
Coordinating healthcare stakeholders is also a major challenge for the provision of unscheduled care. The target plan proposed by the mission will allow for increased provision of unscheduled care in the community care by general practitioners, pediatricians and pediatric nurses. Developing group medical practice should also make it easier to organize stakeholders for the provision of unscheduled care. Furthermore, the mission considers that the access to treatment service (SAS) currently being tested is suitable for children, provided that specialized skills in child healthcare are available, both for medical regulation (for the SAS telephone platforms) and for illness (scheduling of community care consultations within 48 hours for non-urgent care). It would also be beneficial to make use of the skills of pediatric nurses.
Lastly, the regional health agencies have a pivotal supporting role to play in encouraging cooperation. In addition, their powers in terms of authorization and programming, particularly through regional health plans, are instrumental for improving the organization of child healthcare in the territories.

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