No doctors, no nurses. More than half of the schools do not have nursing offices, and as much as 70 percent in rural areas. There are only a few dentists. Nurses provide medical assistance in classrooms, canteens and basements – informs the Supreme Chamber of Control.
- School-age children and adolescents are not provided with consistent and comprehensive health care
- Apart from the insufficient number of doctors, there is a lack of cooperation and coordination between entities responsible for their treatment, e.g. primary care physicians, specialists and nurses
- The student care system does not function, and only selective and fragmented preventive measures are taken instead
In 1999, after the reorganization of health care for children and school-age adolescents, doctors and dentists disappeared from schools when the family doctor was introduced. However, this did not mean that nurses and school hygienists would no longer function in educational institutions.
Fig. Reorganization of health care for children and school-age youth
The school headmaster should provide students with the possibility of using the health prophylaxis and pre-medical care room. NIK warns that this is not the case, because access to them in schools is limited. A significant number of schools simply do not have them. Their absence makes it impossible for the school nurse and hygienist to properly implement the services.
There are large disproportions in the number of schools with pre-medical aid offices between the city and the countryside. There are definitely more schools in the cities that have them. In rural areas, there are offices in only one third of primary and middle schools.
Fig. Average percentage of schools with a preventive healthcare and pre-medical aid clinic in 2014-2017 (XNUMXst half of the year)
The Supreme Audit Office notes that the system of health care for students currently operating in Poland, especially in the field of prophylaxis, does not guarantee the health safety of this population. This is evidenced by the increasing number of children and adolescents with health problems.
In 2016, the greatest health problems among children and adolescents aged 5-18 were: spinal deformities – over 219 thousand, allergies (bronchial asthma) – nearly 195 thousand, refraction and eye accommodation disorders – nearly 187 thousand, obesity – 93 thousand, anemia – over 52 thousand, development disorders – nearly 51 thousand, thyroid diseases – almost 47 thousand. Compared to the previous year, the greatest increase was recorded in the case of diagnosed thyroid diseases by 2,3 thousand. (by over 5%), cancers by over 2,2 thousand. (by nearly 15%), anemia by 1,8 thousand. (by 3,6%). On the other hand, the number of children with diabetes increased by 1%.
Fig. Health problems of children and adolescents in 2016 (in thousands)
According to the Supreme Audit Office, the number of medical personnel caring for school children and youth is insufficient. This makes it difficult to ensure equal access to treatment and extends the waiting time for it. It is true that the number of primary care physicians (POZ) in 2016 increased by 2015% compared to 9, by 9,5%. the number of nurses increased by 17 percent. dentists, but the way care is organized inefficiently uses existing financial and personal resources. There are still large disparities in the number of doctors in the territorial distribution. For example, the highest rate of primary care physicians per 10 children and adolescents were recorded in the Śląskie Voivodeship – over 80, and the lowest in the Łódzkie Voivodeship – 30. However, the largest number of school nurses / hygienists was per 10 thousand. children and adolescents in the Podkarpackie Voivodeship – 29, and the lowest in the Łódzkie Voivodeship – 2,6. The same was the case with specialist doctors. In 2017, their number increased by 3,5%. compared to 2015, however, there are still regions of the country where they are particularly lacking. The highest rates determining the number of pediatric specialists per 10 thousand students were recorded in the Lodzkie Voivodship. The most unfavorable situation for patients was in the Lubuskie voivodship, where there was no specialist in seven specializations, and in two the indicator was the lowest in the country. In this way, the entire population of children and adolescents was not ensured equal access to preventive and therapeutic services.
Fig. Increase in the number of doctors of particular pediatric specializations in 2017 compared to 2015.
NIK also draws attention to the age structure of the medical staff, especially the large percentage of staff over 60 years of age. An upward trend in this age group occurs among primary care physicians and school nurses.
Fig. Age structure of medical staff providing preventive health care in 2017.
A large percentage of doctors over 60 are also among pediatric specialists. In this respect, the situation is particularly bad in three specializations – pediatric surgery (over 39% of doctors over 60), pediatric neurology (39%), and pediatric otolaryngology (nearly 37%). This may, in the perspective of several years, result in the departure of a significant number of specialists from the profession, and thus reduce the availability of health services.
Meanwhile, the Minister of Health has not developed indicators defining the desired number of medical staff caring for children and adolescents of school age in relation to the size of the population. Therefore, he was not able to reliably assess whether the number of specialists in particular fields is sufficient in relation to the needs.
In a few schools, students can also use dentists’ offices. There are only about 600 offices, which is over 7 percent. the total number of them (8,6 thousand). Their highest percentage was recorded in the Lubelskie Voivodeship – over 22 percent. There are no dental offices at all in schools in the Lubuskie and Podkarpackie voivodeships.
In our country, over 50 percent. 3-year-old children have decayed teeth. The percentage of primary school students aged 12 with at least 1 permanent tooth removed due to caries is nearly 2%, and in youth aged 18 it is nearly 9%.
Fig. The percentage of dental offices in schools in the total number of dental offices in 2017 (first half of the year)
Although the number of accidents in schools is decreasing year by year – from 71 thousand to in the school year 2014/2015 to nearly 60 thousand. in 2016/2017, they still happen quite often. They most often occurred in primary schools (nearly 47% of all accidents in three years). The lowest number of accidents occurred in basic vocational schools (1,6%). Students most often succumbed to them during physical education classes and during breaks. Their cause was mainly inattention and inadvertent strike.
Fig. Accidents among students at schools in 2014-2017
NIK estimates that a large number of accidents, especially in primary schools, require the presence of a nurse in order to provide quick medical assistance. In most schools, she is the only person with a medical background.
However, NIK points out that school nurses or hygienists often provide health services to students in rooms that do not meet the appropriate conditions. Such a situation took place in five out of 11 controlled medical entities. The reason was precisely the lack of offices. That is why school nurses or hygienists took care of students in the so-called substitute rooms, e.g. classrooms, teachers’ rooms, library, school canteen, and even in the basement. In some schools without health clinics, services were provided at the seat of the medical entity or at the office of another school closest to the location.
According to the Supreme Audit Office, the working time of nurses in schools requires a change. Currently, it depends on the number of students, not the school’s working time and the attendance of students. In this situation, in smaller schools, the nurse may come to school only once or several times a week, or every day for just a few hours. Pupils should be looked after by nurses in the amount of time directly proportional to the timetable, not their number in the school.
In addition, the NIK inspection showed that nurses were not available at school even at that time, which resulted from the number of students covered by the care. This applied to seven out of 11 controlled healthcare entities (nearly 64%).
In order to improve the availability of preventive healthcare in schools and equipment for offices, special funds were guaranteed in the state budget in 2017. Voivodes transferred them to local governments in the form of subsidies. However, the interest was lower than expected. Out of 16 self-governments controlled by the Supreme Audit Office, only six (over 37%) submitted applications for co-financing the equipment of 55 offices. The reason was the lack of interest of local governments in the conditions of functioning of nurses in schools. This may be proved by the fact that out of 16 audited local government units, nine did not financially support schools at all in running or creating offices. As explained, the reason for this, in turn, was the lack of requests from school principals for such support or difficulties with the premises of institutions in allocating an appropriate room for an office.
In addition to funds for the equipment of surgeries from the state budget, funds were also allocated for the purchase of medical vehicles in which dental services will be provided.
16 dentbuses (one for each voivodeship) cost nearly PLN 24 million. The selected supplier of the vehicles already delivered them in December 2017. Until the NIK audit was completed, i.e. in March this year, they were not put into use and were kept in deposit with the seller. Until then, the National Health Fund had not signed any contract for the provision of dental services in dentobuses – in seven voivodeships no entity joined the proceedings in this respect. The reason is the low valuation of services provided in dental offices “on wheels”.
At the end of May 2018, as reported by the National Health Fund, dental services in dentbuses were provided in six voivodeships – Lubelskie, Lubuskie, Łódzkie, Mazowieckie, Wielkopolskie and Zachodniopomorskie. In some voivodships there were still problems with finding service providers. Competition procedures in this respect were still ongoing in the following voivodeships: Małopolskie, Opolskie, Pomorskie and Świętokrzyskie. These dentobuses are still in deposit with the seller.
The National Health Fund announced that in order to increase interest in signing contracts with the National Health Fund, it plans to correct the valuation of services provided in dentobuses (the draft ordinance is currently being prepared).
Dentobuses were to enable dental care for children and adolescents, mainly in smaller towns, where it is not available in the immediate vicinity. However, according to the Supreme Audit Office, they will not even provide preventive dental services, let alone treatment. The reason is, among others the number of schools that ‘on wheels’ would like to reach. For example, in the Dolnośląskie Voivodeship, out of 690 primary schools, as many as 333, i.e. 48 percent. is located in the village. There are even more such schools in the Mazowieckie voivodship – 942 schools, ie 64 percent. while in the Wielkopolskie voivodeship there are 739 of them, ie 66 percent. all outlets.
NIK emphasizes that the purchase of dentobuses is a temporary measure that does not solve the essence of the problem. It will not ensure the improvement of the dentition in children and adolescents.
From the NIK survey completed by over 3,5 thousand parents and guardians show that 65 percent. of respondents support the creation of doctor’s offices in schools. Even more, because 71 percent. of the respondents spoke out in favor of the creation of dental offices there. On the other hand, half of the parents were against compulsory immunization in schools.
The NIK survey also shows that:
- 50 percent parents assessed the care of a school nurse or hygienist in 84 percent. schools, at a moderately satisfactory level
- 46 percent parents were very satisfied with the care provided by doctors, in 3 percent. schools
- 42 percent assessed prophylactic care of a dentist, including 6 percent. schools, at a moderately satisfactory level
National consultants in the fields of medicine relating to children presented a disturbing picture of the situation of medical staff in their reports. They pointed to the problems of, inter alia, staff shortages that will deepen in the coming years due to retirement of medical personnel, inequalities in access to specialist doctors and specialist education. However, their opinions were to a small extent taken into account when assigning specialization places for doctors and dentists.
Another problem is the dispersion of healthcare among students. It is performed by various entities that often do not cooperate with each other. For example, there was no flow of information between the primary care physician and the school nurse or hygienist, e.g. in the scope of the performed balance tests, compulsory vaccinations and screening tests. Such a situation makes it impossible to ensure consistent and comprehensive care for the student.
In the opinion of the Supreme Audit Office, it is necessary to develop and implement a system allowing for reliable and effective cooperation between a primary care physician, a school nurse or hygienist and a dentist. For this, the currently insufficient cooperation of a doctor and a nurse with parents for the health of their children is also necessary.
The Chamber points out that there is also no coherent system of monitoring and supervision over the manner of providing care for children and youth, its effects, the availability of guaranteed services and the quality of health services. Without it, a reliable analysis and improvement of the system cannot be performed. In the opinion of the Supreme Audit Office, the supervision system should particularly take into account the implementation of preventive health care in primary health care by family doctors, nurses and nurses / hygienists, and by dentists in dental treatment.
In the opinion of the Chamber, the system of obtaining data from balance tests conducted by primary care physicians and screening tests conducted by nurses does not ensure full and consistent monitoring and supervision of preventive care for children and school-age adolescents.
NIK warns that the number of people evading the obligation to vaccinate is growing year by year. In 2017, there were over 30 of them, i.e. 30 percent. more than in 2016. From 2013 to 2017, the number of people refusing compulsory vaccinations increased by over 305%.
According to the Supreme Audit Office, this upward trend may, in the future, result in an epidemiological threat and a resurgence of diseases considered today as “extinct”. For example, there is a systematic increase in whooping cough (whooping cough). in 2016, the number of patients increased by over 224 percent. compared to 2014. There are also more cases of measles. In 2016, their number increased by over 177%. compared to 2015
Fig. Increase in the incidence of infectious diseases in 2016 / Source: Own study of the Supreme Chamber of Control, based on data from the report of the State Sanitary Inspection “Sanitary condition of the country in 2016”
Source: Own study of the Supreme Audit Office, based on data from the report of the State Sanitary Inspection “Sanitary condition of the country in 2016”.
The Minister of Health did not know the number of people (parents or guardians) punished for avoiding the vaccination obligation and the number of children and adolescents who did not receive compulsory preventive vaccinations due to medical indications. He also did not analyze the impact of educational activities on the increase in vaccination of this population.
The minister noticed problems with the functioning of preventive health care for students. Work is underway on the law on health care for students. Its draft, in February 2018, was included in the list of legislative and program works of the Council of Ministers. The expected date of entry into force of this act is September 1, 2018. In the opinion of the Supreme Audit Office, it is not very realistic.
Wnioski
Bearing in mind the need to ensure comprehensive and systematic health care for children and school-age youth, the Supreme Audit Office sends requests to the Minister of Health for:
– to analyze the functioning of the system of care for children and school-age youth with a view to providing comprehensive and coordinated care in the field of health promotion, prevention, treatment and rehabilitation;
– ensuring a monitoring and supervision system over the organization and method of providing health care to students, in particular preventive care, its effects, the availability of guaranteed services and the quality of health services provided at the regional level;
– development of indicators defining the necessary number of medical personnel providing health care for children and teenagers at school age;
– taking effective measures to ensure an adequate number of medical specialists in children’s fields of medicine on the basis of the developed indicators, in particular in rural areas and smaller towns, by allowing them to specialize in this field and creating appropriate incentives for specialists to work in these areas;
– taking effective measures to ensure an adequate number of nurses in schools in order to take care of pupils in the amount of work proportional to the schedule of school hours;
In addition, NIK submits requests to the Minister of Health for legislative actions aimed at:
– determination, by way of a regulation, of organizational standards of conduct in preventive health care for students, in order to ensure the appropriate quality of healthcare services;
– developing, in consultation with the Minister of National Education, standards for the functioning of health prophylaxis offices in schools for each educational level, necessary to provide each student with optimal preventive health care;
– collecting data, as part of public statistics, on the performed dental prophylaxis tests and the oral health condition of children and adolescents at school age, which will allow, inter alia, to assess the degree of caries advancement and to counteract this phenomenon.
The Supreme Audit Office also requests that the work on the law on health care for students be intensified.