Challenges to children’s health care in an ageing Australia

As a society ages, adults become a larger proportion of the population. However, in Australia, the demographic reality is that while children have become a smaller proportion of the population, their absolute number has increased modestly.1,2 Thus, solutions for the increased care requirements for older people cannot be intentionally or unintentionally associated with a diminution of the medical workforce required for children.

Ensuring an adequate health care workforce is of vital importance to all countries. Much interest is being focused on the importance of caring for the increasing numbers of the aged in many developed nations.1,3 The proportion of the populations of both the United States and Australia who are aged over 65 years is increasing rapidly1,2 and the health care needs of these individuals will require additional workforce resources.1,4

In Australia, primary care is delivered by general practitioners.5 To address the growing needs of the older population, there has been a significant effort to increase the number of GPs to ensure primary care access.6 At the same time, there are unrecognised demographic trends currently taking place in the composition of GP practices nationally that parallel the demographic trends of the population as a whole. These trends have important implications for the current and future care of children in Australia.

One of these demographic trends is also occurring in the US among family physicians. For example, as older people have increasing life expectancy, and family physicians have relatively static numbers of patients in their patient panels, “turnover” in general practices and the opportunity to add new (paediatric) patients is increasingly limited.7 In Australia, examination of Bettering the Evaluation and Care of Health (BEACH) data from the past decade demonstrates a significant decrease in the proportion of GP visits by patients under 15 years of age across the country. This is despite an increase in the survival of children with chronic diseases.8 Whether the absolute number of visits for children has fallen is currently unclear but must be investigated. Regardless, such findings demonstrate a change in the demography of GP practices, with a trend towards GPs providing proportionally less care to children relative to the care they provide to adults.

Even with the expected increase in the overall number of GPs in Australia in the next decade, this finding raises significant issues for the health care system. As children become a smaller proportion of GP practices, it is realistic to question whether GPs will continue to devote the time and effort needed to stay up to date on paediatric issues when they will have fewer opportunities to use such knowledge. GPs will constantly be challenged with the ever-increasing complexity of caring for more adults with multiple chronic conditions in their practices. The situation also begs the question as to whether some GPs will begin to limit or discontinue providing care to children, especially in specific locations with smaller proportions of children and a more rapidly ageing population. New strategies may also emerge in which some GP practices become “adult only” or “older people only” to provide care for this population. This trend is already believed to be occurring among some family physicians in the US.7

Another related issue is whether the nature and duration of consultations that children receive in general practices are changing. Recent consumer satisfaction data in Australia demonstrate ready availability for acute paediatric problems (eg, ear infection).9 However, the increased complexity of multiple chronic conditions among the ageing population will require an increased number of longer consultations. If GPs’ patient bookings become more commonly filled with such visits for older people, questions arise as to whether children will receive fewer longer consultations for preventive care (eg, nutrition counselling, developmental assessments) and chronic illness. In other words, will children be “crowded out” of non-acute and preventive care visits?

The decrease in the proportion of children in the overall population also has important implications for the future training of GPs. Already, some GP training programs are concerned about their ability to provide both inpatient and outpatient clinical settings with sufficient children having common chronic illnesses (eg, asthma) for their trainees to gain competency in their acute and longitudinal care. Such deficiencies may become more common as the ageing population trend continues. With childhood obesity, mental health problems and other antecedents of adult illness now occurring more frequently, this would be a worrisome trend.

In the US, shortages in the health care workforce for children are mostly found in the paediatric subspecialties, especially in rural areas.10 There has been little research in Australia regarding the availability of paediatric subspecialty care, especially for Indigenous populations and children living in rural areas.6,8 With increasing survival of children with complex conditions and chronic diseases, the demand for paediatric subspecialty care in Australia is rising. The proportion of such care actually provided by paediatric-trained subspecialists rather than adult-trained subspecialists is currently unknown. This must be determined to assess the true need for such providers nationwide, both inside and outside major metropolitan areas.

Exploration of these issues is important and urgent for medical workforce planning. Government and professional entities entrusted with assessing provision of the continuum of health care for the children of Australia, monitoring GP training, and overseeing the continuing education of GPs should investigate whether changes have been occurring that may lead to a decrease in the quality of care for this important segment of the population. Such efforts will ensure that the unique needs of children are not unintentionally lost in the current emphasis on the growing ageing population.