The epidemic that reveals the crisis. The high circulation of bronchiolitis, this viral respiratory infection which mainly affects children under the age of 2, has been saturating pediatric emergency services since the end of October. To the point that around thirty children were transferred from Ile-de-France to hospitals located more than 100 kilometers from their homes.
This epidemic outbreak is above all indicative of a deeper crisis. Degraded working conditions, lack of staff, devalued specialty … With the help of several actors concerned, franceinfo dissects this crisis which is shaking pediatrics.
Why are we talking about the crisis in pediatrics today?
This autumn’s bronchiolitis epidemic, which was particularly early and virulent, raised awareness. During the week of October 31, Public Health France pointed to “very high number of emergency room visits and hospitalizations for bronchiolitis and at levels higher than those observed at epidemic peaks for more than 10 years”. An exceptional situation which forced the Minister of Health, François Braun, to trigger the national emergency plan at the hospital.
“It was the bronchiolitis that turned things around, but it was largely predictable”, believes Mélodie Aubart, neuropediatrician at the Necker-Enfants Malades Hospital in Paris. She is also a member of the Pediatrics Collective, at the origin of the letter to the President of the Republic, in which more than 4,000 caregivers denounced, Friday, October 21, “a glaring deterioration in the care provided to children” who puts them “daily in danger”.
Can this crisis be resolved in the short term?
The crisis will last longer than the outbreak of bronchiolitis. It comes at a particularly tense time for paediatrics, which is struggling to attract practitioners. For example, at the Lenval hospital in Nice, for lack of recruitment, it is impossible to open the “winter beds” planned each year to deal with the bronchiolitis epidemic. “By hospitalizing 15 to 20 children a day, we lack four to five beds to function normally”regrets Philippe Babe, head of the pediatric emergency department of Lenval. “We went up to eight hours of waiting in the emergency room, it’s unprecedented”worries the specialist.
The situation is the same throughout France. Due to a lack of staff, 21 nursing positions are vacant in the pediatric intensive care unit of the Garches hospital (Hauts-de-Seine), i.e. 50% of the workforce, noted The world in September.
How much does France lack paediatricians?
The hospital is not alone in facing a shortage of specialists. Liberal pediatrics also knows “a significant demographic decline“, pointed out the General Inspectorate of Social Affairs(PDF) in a 2020 report. “Currently, eight departments have a density of less than one pediatrician per 100,000 inhabitants”, notes the Igas again. A study by UFC-Que Choisir, published Tuesday, November 8, notes that a quarter of children under 10 live without a pediatrician within a 45-minute drive.
The situation is likely to worsen because of many retirements, who are not replaced, for lack of young practitioners available. In all, 44% of liberal pediatricians were over 60 in 2020, according to Igas. A direct consequence of the numerus clausus, which limited the number of medical students until 2020. “We have been calling for the training of 600 pediatricians in boarding schools per year for 20 years, whereas at that time only 250 pediatricians were trained”recalls Brigitte Virey, president of the national union of French pediatricians (SNPF).
Why do caregivers shun this specialty?
Pediatrics does not attract future doctors. This is partly explained by “a duty of permanence and continuity of care [les gardes effectuées la nuit, les weekends et les jours fériés] particularly important, especially in pediatric emergencies”, according to Igas. Added to this is a generation effect: younger practitioners refuse to sacrifice their family life. “You can’t blame themconcedes Philippe Babe. On the other hand, this means that to replace a retirement, it takes 1.5, or even two young people.
In addition to working conditions, this disaffection with paediatrics is explained by the lack of recognition of the specialty. A lack of symbolic and financial recognition. “For years, the motto was: ‘small patients, small means’, with the idea that anyone could do pediatrics”regrets the neuropediatrician Mélodie Aubart.
For a hospital, a visit to the emergency room is less profitable when it comes to a child under 15 than for an adult, since the reform of emergency financing, in force since January 1, 2022. This situation is experienced as an injustice by paediatricians and contributes, according to them, to devalue the specialty.
Their liberal colleagues are not better off, since they are at the bottom of the income scale of liberal doctors, with an income lower than that of general practitioners, still notes Igas.
In this sector, is the shortage of caregivers limited to paediatricians?
No, it concerns all health professionals. On the nursing side, for example, working conditions have deteriorated over the years, according to Mélodie Aubart, from the Collectif Pédiatrie. Technological advances and staff reductions have led to only the most seriously ill children being cared for in hospital. Consequence: nurses have to manage more technically and psychologically complex cases. “Caregivers are more affected when it comes to children, explains Thierry Amouroux, of the National Union of Nursing Professionals (SNPI). The problems are tenfold compared to adults, because we do not accept that children are victims of institutional mistreatment for economic reasons.”
Childcare nurses and childcare auxiliaries also suffer from the lack of recognition of their specialty. The childcare nurse diploma has not changed since 1983. Above all, this specialty is not compulsory to practice in the pediatric wards at the hospital, “unlike nurse anesthetists, some of whose acts cannot be performed by other nurses”, argues Vincent Lautard, nurse and lawyer. Also in question, the initial training of “generalist” nurses. Since 2009, the course no longer includes an internship or compulsory training in paediatrics. “With this deletion, fewer people choose paediatrics”observes Thierry Amouroux.
What are caregivers asking for to get out of this crisis?
Childhood professionals are asking for more resources and better recognition. “We must recognize the expertise of pediatriciansargues Brigitte Virey. We are always asked to justify ourselves, whether at the level of general practitioners or other specialists, which makes the specialty very unattractive.
For the hospital, the heads of the pediatric resuscitation services claim, in a column published by the newspaper South West, compliance with the ratios of paramedical personnel in relation to the number of open beds, and an improvement in working conditions. In its report, Igas also recommends better training of general practitioners in pediatrics.
How is the government responding to this alert?
The Minister of Health, François Braun, announced on November 2 an envelope “around 400 million euros” aid for services under tension, “including pediatric wards”. The following week, he clarified that“just over 250 million euros” would be dedicated to “doubling of night hours for all hospital staff (except for doctors, where it is multiplied by 1.5)”as well as the critical care premium for childcare nurses and childcare assistants“which were excluded until now for technical reasons”. But these measures are far from sufficient, according to the Collective Pediatrics.
The Minister also intends to reform the health system in depth and the place given to paediatrics. For this, he announced the holding of the assizes of pediatrics in the spring of 2023.
I’m too lazy to read everything, can you give me a summary?
The bronchiolitis epidemic returns every year, but this year, the tensions linked to the lack of personnel make the situation critical in the pediatric emergency services. So much so that many hospitals are forced to transfer small patients miles from home, for lack of beds.
The situation is not only tense in the hospital, it is also in the liberal sector. A quarter of children under 10 live without a pediatrician within 45 minutes of their home. The fault, essentially, of a massive departure of retired practitioners, who are not replaced.
According to Brigitte Virey, president of the SNPF, this shortage of young practitioners is due to the numerus clausus, which for years limited the number of students who could choose pediatrics as their specialty. But not only. Early childhood professionals denounce a lack of recognition of their specialty. Ditto in the nursing ranks, where the specialty dedicated to children is little recognized.