It's time: A new era for paediatrics and child health in Australia

Authors


  • Conflict of interest: None declared.

Professor Frank Oberklaid, Centre for Community Child Health, Royal Children's Hospital Melbourne, Parkville, Vic. 3052, Australia. Fax: 9345 5900; email: frank.oberklaid@rch.org.au

Abstract

The Australian College of Paediatrics (ACP) was established in 1978; part of the stated rationale was to ‘acquire equal status to other colleges in medicine’ . . . and to become . . . ‘to which governments, or other organisations dealing with children, could officially turn to for advice’. After less than 2 decades, the ACP ceased to exist, and paediatricians became members of the Paediatrics and Child Health Division of the Royal Australasian College of Physicians (RACP). Many would now argue that the decision to dissolve the ACP and instead become a division within the RACP, though not taken lightly and made for what seemed at the time to be good reasons, might have been a mistake. While there have been some benefits, overall the public profile and national influence of paediatricians has been diminished. Paediatricians as a group have had little influence on policy formulation as it pertains to children and families, and the present administrative arrangements within the RACP raise considerable bureaucratic barriers for paediatricians to be able to contribute in a constructive and timely manner. It is suggested that paediatricians cannot be effective advocates for the health and wellbeing of children when they are but a relatively small and powerless group that resides within a large body of professionals whose primary interest is in various aspects of adult medicine. It is time that paediatricians (re)established their own college and controlled their own destiny. While such a step is not without its challenges, many would argue that it is an essential and timely step if we are to address our political and public health responsibilities.

Key Points

  • 1Paediatricians have an important advocacy role to play in children's health.
  • 2Current institutional arrangements do not allow effective and timely advocacy, and as a result the public profile of paediatricians has diminished.
  • 3It is time for paediatricians to again take responsibility for addressing our political and public health responsibilities and re-establish our own independent college.

There are a number of reasons why professional colleges, societies and associations are established. Initially, the rationale may be simply fellowship, to allow professionals working in isolation to come together both socially and professionally. However, more recently, most have moved beyond fellowship to play a role in advocacy and public policy, the organisation of scientific meetings, professional education and the establishment and maintenance of standards through examinations and a program of ongoing professional education. It is interesting to look back in time to see how Australian paediatricians have come together, initially informally, then establishing an association and then a college, and more recently as a Division of the Royal Australasian College of Physicians (RACP).

The idea of paediatricians coming together to form a professional association goes back more than a century. In the booklet ‘A History of the Australian College of Paediatrics 1950–1980’,1 Hamilton writes that, ‘in 1906 the Melbourne Paediatrics Society was formed as an association closely connected with the Children's Hospital, but not with the British Medical Association. Much later in 1921, the New South Wales paediatricians formed the paediatric section of the British Medical Association. The Paediatric Society of Queensland was formed in 1949 . . .’ In 1948, the Australasian Medical Congress, organised by the British Medical Association in Australia, agreed to set up a committee ‘to consider the establishment of a paediatric association in Victoria’.1 In that same year, the annual meeting of the Paediatric Society of Victoria agreed that a sub-committee should be appointed to consider the formation of an Australian Society of Paediatrics. Subsequently, an Australian Paediatric Association was indeed formed in 1950, the Paediatric Research Society in 1967, and a section on paediatric surgery in 1973. Following the publication of a 1975 document ‘Community Needs of Paediatrics’, a section on social and preventive medicine was established in 1977. Finally, the Australian College of Paediatrics (ACP) was established in 1978, ‘a move which was essential to acquire equal status to other colleges in medicine. It also became a body to which governments, or other organisations dealing with children, could officially turn for advice’.2

While the College did indeed increase the profile of paediatrics in Australia, for a number of reasons, it did not take the step of becoming an examining body, even though the Australian Medical Council gave informal advice that they did not foresee any problems if such a decision was to be made. Membership, and then Fellowship, of the RACP continued to be a mechanism for official recognition as ‘consultant physician’ for the purposes of attracting consultant rebates under Medicare. Over time, under the umbrella of the RACP, paediatricians came to run all aspects of paediatric exams, and had significant input into aspects of RACP functioning that were relevant to paediatrics and child health.

However, tensions remained between the paediatricians and their adult medicine colleagues. Some of these would no doubt be well documented in minutes of meetings of the Council of the ACP; it was a common perception, rightly or wrongly, that paediatricians were treated with a lack of respect, and that paediatrics was perceived in some way to be of a lesser status than adult medicine. Numerous attempts were made by a number of well-intentioned people to repair this relationship. However, in the early 1990s, the ACP Council passed a unanimous motion that the College investigate the possibility of becoming its own examining body. The intent was clear – this was the first step in breaking the nexus between the ACP and the RACP.

The details of the various negotiations and discussions of several working parties during these years will need to wait for the post-1980 history of paediatrics in Australia to be written. Suffice to say that the ACP ceased to exist, and instead morphed into the Paediatrics and Child Health Division of the RACP. As one of the only two divisions within the RACP – the other being the Division of Adult Medicine – it was thought that this structure would give paediatricians a degree of autonomy. Because fellowship of the RACP was still the ‘ticket’ to consultant practice, because paediatricians were also physicians, and because of the view that paediatricians were better being part of a larger body given the uncertain external political environment, this move was generally (although not unanimously) supported at the time.

With the passage of time and the benefit of hindsight, many senior paediatricians – including some who were closely involved in those negotiations – would now see this as a mistake. Certainly it is a widely held opinion that the merger has not been a success. While there have been some benefits to paediatricians – for example, participation in the well-conceptualised continuing professional development program – the ability to be an effective public advocacy group has suffered as the RACP has organised itself to bring together a range of different (adult) disciplines. An unintended consequence is that the profile that paediatricians had achieved with the ACP is now diminished. There are numerous examples of the relative invisibility of paediatricians on the national stage. The Paediatrics and Child Health Division was not consulted during the development and implementation of the four-year-old health check – there was a two-page list of organisations consulted, but the group who could have provided the most relevant and informed advice was not included; the early childhood agenda that has emerged over the past decade has seen the involvement of individual paediatricians, but not the RACP; the now rapidly emerging children's mental health agenda is also noteworthy for the absence of any formal consultation or links with paediatricians, even though individual paediatricians have been asked to be involved in various federal government working parties.

At present, there is no mechanism, except through the policy bureaucracy of the RACP, for paediatricians as a group to have any formal input into future emerging issues that are of great interest and relevance to children and their families. This includes important initiatives such as national health reform and the National Disability Insurance Scheme. There are so many health policy issues that are unique to childhood that it does not make any sense for paediatricians' advocacy for these issues to be linked to adult physicians and have to be submitted through the RACP. The growing evidence that many chronic and complex conditions seen in adults have their origins in pathways that begin early in childhood provides the context for what should be a vigorous and ongoing advocacy campaign for increased intellectual and financial resources to be focused on the early years; paediatricians should be leading this effort, along with colleagues in other professions. This then raises another issue: there are no structures that allow paediatricians to link with other professional groups who have an interest in and work with children, such as psychologists, speech pathologists, mental health professionals, educators and others.

Howard Williams wrote that ‘In 1954 the National Health Act forced the Association to come to grips with its political and public health responsibilities’.2 More than half a century later, it is salutary to again ask that question. Is the present arrangement appropriate for paediatricians as a group to come to grips with our political and public health responsibilities? I would argue that the answer is a resounding no!

Significant numbers of paediatricians feel that the RACP no longer meets their needs, and already groups of paediatricians have either set up their own societies or are considering it. Peter Goss, in his President's report of the Australian Paediatric Society 2012 writes that ‘the society originated 30 years ago with a group of like-minded general paediatricians who felt isolated both professionally and socially. In the mid 1990s, following the loss of the ACP, the society welcomed many suburban general paediatricians who felt unaligned and unsupported by an ever distant RACP.’ Their intent was to further expand the society to include other professionals with an interest in paediatrics, although for various reasons, this has not happened. More recently, a group of paediatricians with an interest in developmental and behavioural paediatrics have set up a working party to investigate the possibility of establishing an Australian Society of Developmental and Behavioural Paediatrics. Also, in a move intended to allow paediatricians ‘to be a more dynamic and responsive voice for the health of children and young people’,3 it is proposed that a Society for Child and Youth Health be established. The fact that this has even been contemplated speaks volumes about the barriers to effective child and youth advocacy that exist under the present governance arrangements. It is instructive to see the influence and profile that our British colleagues have developed since they formed their own Royal College of Paediatrics and Child Health (coincidentally at around the same time as the ACP was subsumed by the RACP).

Many have now come to the position that it is time that Australian paediatricians formed their own college, and that many of the considerations that led to the merger with the RACP over a decade ago are no longer pertinent. This is not a decision to be taken lightly, and one can articulate arguments for and against such a move. Some of these issues are canvassed as follows:

Financial: There are concerns that a free-standing college would not be financially viable. This may have been the case 20 years ago, but the numbers – and the memberships paediatric fellows and trainees pay to the RACP – add up to a very healthy revenue stream. It has been said that the exams are self-funding – if this is indeed the case, then they would not be a drain on resources.

Infrastructure: There are concerns that the cost of building a parallel infrastructure to manage continuing medical education, the process of running exams, etc. would be prohibitive. However, in the first instance, it may be more feasible to purchase these services from the RACP during a period of transition, while proper due diligence is performed and a business case is established to examine the feasibility and desirability of establishing a separate infrastructure.

Fragmentation of the profession: Many are concerned about the fragmentation of physicians as a group, that the size of an institution matters, and that paediatricians may not have the critical mass to function efficiently or be an effective advocate. There are many instances in the Australian setting of professional groups fewer in number than paediatricians forming their own colleges.

Specialist paediatricians identify strongly with the RACP: In years gone by, there was an argument that specialist paediatricians wanted an ongoing association with their adult specialist physician colleagues, and, for this reason, opposed a split. However, specialities these days tend to have there own meetings anyhow, making a link with the RACP less important.

Clearly, the establishment of a College of Paediatrics and Child Health will not happen quickly or easily, and it is a process that should not be rushed. A separation could be managed amicably (as the recent establishment of the Australian College of Intensive Care Medicine demonstrated) and close cooperation with the RACP could occur. Nobody would argue that children's health and wellbeing is the sole domain or responsibility of paediatricians; any new structure should embrace our non-paediatric colleagues in appropriate structures that need to be determined. The interests of specialist paediatricians and paediatric surgeons need to be addressed, as do the needs of colleagues practicing in rural and regional areas. All this can and should be done in a spirit of inclusion, consultation and collaboration.

The benefits of becoming our own college are, I believe, self evident, and the perceived risks are manageable. Until paediatricians have the courage to stand up and fulfil their leadership role in working for the health and wellbeing of Australian children, I do not believe that we can adequately discharge our ‘political and public health responsibilities’, as Howard Williams stated so many years ago.2 It is time.

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