Finally guarantee the same specialised care for children as for adults
Signed by Jean-Michel Hougardy, Nicolas Deconinck, Pierre Smeesters, Virginie De Wilde, Jean-Christophe Beghin, Sylvie Tenoutasse, Anna Groswasser et Renaud Witmeur
The way our healthcare system is structured causes overspecialisation
We can be proud of our healthcare system. Its quality and accessibility are recognised and at times it is more a victim of its success than of its failings. In Belgium we are able to deliver excellent care within highly specialised infrastructures. Yet this is certainly not the first time that an alarm has been sounded. (,2,3)
The paediatrician is a key player in preventive medicine for the child and is also a hospital specialist who, in line with developments in care and medical progress, hyperspecialises so as to be able to respond to the healthcare needs of children and the way modern healthcare is structured.
In Belgium, despite this reality and the evident need for increasingly specialised hospital care for children, the recognition of particular medical competences in paediatrics (cardiology, nephrology, endocrinology, gastroenterology, pneumology, dermatology, rheumatology, rehabilitation, etc.) is not yet a reality. Yet this recognition is essential to offer children and adolescents medical care that concentrates all the required skills and expertise. In marked contrast to the situation in medicine for adults, since 2016 just four specialities have been recognised for children and adolescents: paediatric haemato-oncology, neonatology, neuropaediatrics and paediatric infectiology. Why not the others?
The hyperspecialisation of paediatricians: not so much a need, more an inevitability
It would be naïve at best to believe that "general" paediatricians treat complex or rare diseases of the organs within a reference hospital such as the HUDERF or within specific paediatric units as found at university hospitals for example.
Who could believe that installing and monitoring an insulin pump on a four-year-old child with diabetes is something that can be done without specialist skills? Or that heart surgery or an organ transplant on an infant is possible without in-depth specialised training? Or that anybody other than a paediatric pneumonologist can treat an adolescent with a severe lung infection linked to COVID? Or that a rare family metabolic illness can be treated without a multidisciplinary team and an efficient laboratory? Also, would our readers agree to their children being cared for staff without knowledge of their precise particularities in environments such as paediatric intensive care? Inevitably, as knowledge and technologies have developed, paediatricians (usually hospital paediatricians) have become hyperspecialised to meet this legitimate need, but unfortunately without recognition by the INAMI/RIZIV [National Institute for Health and Disability Insurance] or specific financing. Hence the need to structure and recognise specialisations in paediatrics while also ensuring that being a paediatrician in a hospital environment remains an attractive career option.
Striking examples with a serious impact
For an equivalent pathology such as diabetes or heart disease, care for children is less well financed. For example, a consultation in paediatrics is under-financed by 32% compared to an adult consultation for the same pathology. A reimbursement that is all the more incoherent when you consider that a paediatric consultation takes longer structurally than an adult consultation. While the priority at the time of a paediatric consultation is of course the child, who needs a holistic, gentle approach and specific explanations if an examination is going to be possible, paediatricians must also concern themselves with one or more parents as part of an essential integrated approach. The longer and more complex interventions by anaesthetists or surgeons are also not taken specifically into account when the patient is a child.
This non-recognition of paediatric specialities has persisted for too many years and is having major consequences in the field. The lack of attractiveness of paediatric disciplines combined with the lack of appropriate financing is giving rise to a shortage of care staff (doctors, nurses, paramedics, etc.) that can result in the closure of highly specialised hospitalisation services and excessive waiting times. The unfavourable reimbursements also greatly complicate the development of hospitals centred on medicine for children and adolescents in a spirit of integration and innovation with a strong technological focus. The economic crisis, inflation, energy costs, non-recognition and the structural under-financing are pushing to breaking point hospitals seeking to maintain highly developed paediatric care.
Overspecialisation in paediatrics is essential and virtuous
The absence of official recognition brings the risk, for financial reasons alone, that the care administered may not be in keeping with the expertise required by the highest quality standards. It can contribute to a less rational prescribing of additional investigations or treatment by the less specialised physician. In no way is specialisation detrimental to general paediatrics that clearly has its place in the healthcare landscape for children and adolescents as well as in prevention. Furthermore, the good news for our political decision-makers is that this investment in childhood is also profitable in strictly financial terms through the long-term impact it has on engendering a better physical and mental health among our young people as participants in the economy and, even more importantly, in the society of the future.
To conclude, our appeal is based on the desperate need for highly specialised hospital care for children and adolescents in Belgium. Despite the slight progress made since 2016, the recognition of particular medical skills in paediatrics remains greatly insufficient. Paediatricians are both key players in preventive medicine and hospital specialists who hyperspecialise to meet the health needs of children and adolescents. Their well-being in the current context is an essential value that must be defended. Among the means to respond to this need, the development of a children's hospital is based on the concentration of rare and vital expertise within an infrastructure adapted to a continuous service. To pursue our mission as carers it is therefore necessary to recognise and finance this specialised paediatric expertise so as to guarantee the quality and safety of medical care for children. Ultimately, it is simply a question of giving children and adolescents the same guarantees of access to quality care as apply in the field of adult medicine. An imperative with which we imagine everyone can identify.
-  Académie belge de Pédiatrie, groupe de travail, organisation des soins de santé en Belgique, 22 juin 2017.
- The Belgian Academy of Pediatrics website: Recognition of paediatric subspecialties ;
- Why Children's Hospitals Are Unique and So Essential. Casimir G. Front Pediatr. 2019 Jul 23;7:305.