Children and adolescents up to the age of 18 have been
traditionally cared for in Germany by a mixed system of primary
care paediatricians (PCP’s) and general practitioners (GP’s). In
the cities, most children and adolescents stay with their PCP through
adolescence, but in country areas, children as they get older, are
increasingly seen by GP’s. Children and adolescents with special
needs are cared for by a tight network of PCP in private
practices plus sub-specialists in tertiary centres. Demographic basic
information is presented in Tab. 1.
The general paediatric postgraduate training program (5
years) has been adapted according to the recommendations of the
European Board of Paediatrics (Union of European Medical Specialists
– Paediatric Section). There are 9 paediatric sub-specialities,
each requiring 2 to 3 years of additional training in a tertiary
centre. 70% of the PCP’s work alone and 30 % in group practices.
Practices are for the most part technically well equipped for growth-
and development diagnostics, for the diagnosis of acutely sick
children with a basic laboratory, and with ultrasonic equipment,
spirometry, ECG etc.
90% of practices use computers partially- or exclusively
to keep the medical records.
As in most European countries, german paediatrics has
undergone major changes in the last decades: demographic change
(decreasing number of children), changes in the spectrum of
paediatric illnesses (less severe infectious- but “new”
paediatric diseases), a better survival rate of chronically ill
children and an ever increasing number of children who are cared for
mainly in the ambulatory setting. These developments have resulted in
children’s hospitals becoming less in number and smaller in size,
i.e. the number of beds and length of stay of children have
decreased dramatically. As a consequence, paediatric training
positions in children’s hospitals have also dropped substantially.
Unfortunately, alternative training positions can not be set up in
paediatric practices because they are not paid for. This results in
a lack of a sufficient number of newly trained and an aging
of practising PCP’s. Furthermore, the trend of feminization in
paediatrics continues. Although this has no effect on the quality of
the profession but does however influence working hours. Women place
more value on the compatibility of profession and family, work more
often part time and are less inclined to work outside surgery hours.
In the future, all these trends will most probably put in danger
a comprehensive care of children and adolescents by PCP’s.
A special problem in the german mixed PCP/GP system
is the lack of basic training of GP’s in the field of paediatrics.
GP’s are not required to do any training in paediatrics at all.
Consequently, most GP’s only come in contact with paediatric
patients when they start their own practices. Recently, some have
claimed publicly that this “learning-by-doing” approach is
sufficient to deal with children. When GP’s require a second
opinion, they tend to send their child patients to children’s
hospitals and not to their fellow (neighbour) PCP’s. Hence, there
exists a system of competing rivalry and not one of mutual
Independent of these demographic-structural problems,
new german legislation to restructure the health system is having
a disastrous effect on the interests of paediatric primary care.
It is an avowed aim of the minister of health to strengthen the role
of the GP’s in primary care. Health funds have now been assigned
a central role. They must negotiate health care contracts with
GP’s so that these can function as “gatekeepers”. Patients have
no more free access to other ambulatory doctors. Paediatricians were
also affected by this regulation but massive lobbying forced the
legislators to grant an exemption giving parents again free access to
Expenditure of the health funds for ambulatory medical
care is globally budgeted.
PCP’s and GP’s have a common budget. The
delegates of the German Physicians Association (with paediatricians
being outnumbered and without minority protection) frame the rules as
to how this budget is distributed amongst primary care doctors.
Budgeting also applies individually to doctor’s fees, medical
prescriptions, ergo- and speech therapy and physiotherapy.
The aim of the changes to the health legislation is the strict
control of the costs through rationalization and through competition
of the various health funds and the doctors with one another.
Regrettably, the existing health laws do not formulate any targets
for sustaining good health through health promotion and primary
preventive measures nor do they specify any criteria for the good
medical care of children and adolescents.
Address for Correspondence:
Dr. med. Elke Jaeger-Roman
Deutsche Akademie für Kinder-
und Jugendmedizin e.V.
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