Well before the emergence of Covid-19, an area of interest to us at the Nuffield Trust has been the use of emergency hospital care among children and young people – with suggestions they are more likely to attend A&E “inappropriately” than is the case for other age groups.
In this blog, I look at the patterns of children and young people’s A&E use before and during the pandemic, and discuss what they might tell us about the subject more widely.
Children and young people’s A&E attendances before and during the pandemic
Recent analysis by the Strategy Unit shows significant falls in A&E attendances by people aged 19 and under since Covid-19 started (see chart below).
Yet over the same period, there seemingly have not been large-scale or immediate serious consequences – such as significant increases in children going to A&E too late or increased mortality in under 14s. It’s tempting therefore to conclude that, before March, too many parents and young adults might have been using A&E “inappropriately”.
But by how much are those “inappropriate” A&E attendances down since the pandemic started? One way to find out is to look at attendances where nothing abnormal was detected, compared to those that brought a diagnosis of an injury or illness. It reveals that, during the initial stages of the pandemic, A&E attendances where this was recorded dropped to about a third of their normal levels.
However, the same data shows it wasn’t just potentially inappropriate A&E attendances affected – those bringing a diagnosis of a health care problem also went down by the same scale.
Furthermore, A&E attendances by children and young people in 2019 where nothing abnormal was detected accounted for only 7% of all attendances. That is in comparison to 90% of attendances where a problem was diagnosed – indicating that the majority of attendances were for real issues.
Yet that doesn’t tell us whether those issues were significant enough to warrant emergency care, or whether they could have been reasonably dealt with by other forms of care, such as those provided by GP practices and in the community.
One way to determine that would be to look at A&E attendances defined as non-urgent (cases that are not true accidents or emergencies) or standard (cases without immediate danger or distress) – see chart below.
A&E attendances by 0-19-year-olds: before and after lockdown (2020)
This shows that attendances at A&E for less serious cases did drop during the early stages of the pandemic.
But if you also look at A&E attendances deemed to be serious (i.e. urgent or requiring immediate treatment for preservation of life), the decreases are of a similar scale – indicating again it’s not just “inappropriate” care affected.
Attendance rates for clear-cut emergencies – where it will be more obvious to everyone that treatment in A&E is needed – dropped to a lesser degree and have returned to normal levels quicker. Attendances for burns and scalds, for example, did not drop as much during lockdown, and have since returned to the numbers seen last year.
What does this tell us?
Some of the drops in A&E attendances during the pandemic will be due to lockdown and social distancing measures having a beneficial impact on a child or young person’s health – such as respiratory conditions being helped by less road traffic, or school closures meaning viral or bacterial infections haven’t circulated as freely. But that is unlikely to be the full story.
The fact that attendances dropped prior to lockdown, coupled with decreases in attendances for more ‘appropriate’ cases, suggests that parents and individuals also balanced the risks of Covid-19 against other health care risks, while paying heed to widely used messages about “protecting the NHS”.
The fact that it’s been a different story for clear-cut emergencies might on one hand not be surprising, but it does pose some interesting questions.
Does it mean that in less clear-cut circumstances, parents and individuals have been more willing to just put up with certain aliments and illnesses and not seek emergency care at all? Were they more comfortable in monitoring conditions rather than seek care, until it became clearer that emergency care was essential or not?
Or were they able to seek other forms of care, without the need to use emergency care?
Unfortunately, we do not know enough about out-of-hospital care to know whether this happened. The recent policy focus for children and young people’s health care services has been on boosting that out-of-hospital care, with a push to age-appropriate care closer to home. It shifts the focus away from A&E on its own, with any reductions in attendances just a benefit of the new focus and one measure of its success.
The past few months, however, offer a unique opportunity to inform the implementation of that policy, as well as the longer-term changes for children and young people’s services outlined in it. Knowing more about what has happened could also have a beneficial impact on new policies such as “call before you walk”, which discourages people attending A&E without an appointment.
If we could determine what parents and young people chose to do during this pandemic rather than access emergency care – while also finding out what they thought about the alternatives, alongside their views on the future service they want – it could help to inform the NHS’s short and longer-term recovery from Covid-19.
About this data
- The analysis describes attendances for children and young people (0 to 19 years) at a representative subset of type 1 (24-hour consultant-led) A&E departments in England for the first 26 weeks of 2020 (up to and including 28th June), compared to 2019.
- Pre-lockdown is defined as between the 6th of January and the 8th of March 2020 (weeks 2-10), and after lockdown is between the 16th March and the 17th May 2020 (weeks 12-20).
- Non-urgent care is defined as conditions that are ‘not true accidents or emergencies’. Standard care is classed as ‘Standard A&E cases without immediate danger or distress’.
Fisher E (2020) “Children and young people’s emergency care during Covid-19: what have we learned?”, Nuffield Trust comment.