We know that measuring quality of care is difficult. It is an even bigger challenge with children, since prevalence of paediatric conditions is low and indicators often need to be age and development stage specific.
We also cannot monitor quality because data is not available or collected. The National Child and Maternal Health Intelligence Network has done an excellent job in compiling available child health indicators but there are still very few that allow us to look at changes in quality of care over time.
So what do we know?
The little we do know about the quality of child health services is not too reassuring. At the request of the Chief Medical Officer’s 2012 Annual Report , the recently published report by the Children and Young People’s Health Outcomes Forum summarised the historical trends for all the available quality of care indicators for children (some of these we have also been monitoring in the Quality Watch programme).
Here is what the authors of the report found for children:
- Despite improvement in childhood mortality over time and UK performing well on injury mortality, it lags behind other European countries on non-communicable disease mortality.
- There has been improvement in several areas – diabetes care, road traffic accidents, women smoking during pregnancy, teenage conception and school achievement - however, the report finds that wide inequalities and variations remain.
- For several indicators such as proportion of low birthweight babies, obesity and overall emergency admissions there has not been much consistent change across the country.
- Finally, there has been deterioration on several indicators - trends in A&E attendances, as well as hospital admissions for infant feeding difficulties, bronchiolitis and self-harm have been increasing. Also, emergency admissions for specific conditions such as respiratory infections for under-fives have been rising and the deprivation gap for all admissions for adolescents as well as obesity has been widening.
The authors’ main recommendations suggest the need to address mortality from non-communicable diseases, geographical variation and socioeconomic inequalities and the rising use of urgent/emergency healthcare services by children and young people, especially those with long term conditions. Certainly, we need to congratulate services where progress had been made – but more importantly further understand and analyse the areas where there’s been deterioration or lack of improvement.
For example, what else do we know about the care children with chronic conditions receive?
According to the Epilepsy12 clinical audit, care for children with epilepsy has improved but there is still a large gap between what they should receive and the care they currently receive. Similarly for asthma, audits carried out by the British Thoracic Society help understand the quality of care provided to children with asthma but the 2014 review into asthma deaths found evidence of inadequate care for children and young people resulting in unnecessary deaths. Care for children with diabetes has been improving over time but still lags behind the care adults get .
Based on the little information we have, there is room for improvement. However, there is still a lot we don’t know. Especially, about the care children receive in primary care - between their A&E visits, hospital admissions and outpatient appointments, or the quality of mental health services.
Any new developments?
It is great that new indicators are currently being developed to be included in the NHS Outcomes Framework. These include time to diagnosis, children and young people’s experience of health services including mental health, indicators tracking the transition to adult services as well as indicators capturing the integration of care for children and young people.
In addition, the set of indicators recently proposed by researchers from Oxford University on the quality of care for children in primary care is also very welcome and should be further explored as currently only a few areas of care for children and young people is incentivised through the Quality and Outcomes Framework.
While we are still at the beginning only, we welcome all these initiatives as they should bring us closer to properly understanding the quality of care children and young people receive throughout the entire care continuum. We especially welcome child health on the political agenda as a key solution to addressing future NHS sustainability issues.
The greater risks
In an ideal world, an understanding of and commitment to measuring quality of care would precede any major reforms, service delivery changes or improvement initiatives. This is no different for children but for them the link between process and outcomes can play out over much longer timescales. The consequences of not knowing whether they receive safe, timely and appropriate care during their foundation years could potentially be catastrophic and certainly will have a lifelong impact on both physical and mental health .
In some instances unsafe or inadequate care may also lead to unnecessary cost to the society. Mental health is a clear example where the costs of late intervention could be reduced with timely and effective interventions. Providing timely care for young people with mental health disorders (i.e. emotional, conduct and hyperkinetic) can prevent a range of short term and life time costs, not only in healthcare but also in education, criminal justice and quality of life for the children and their carers.
So maybe it is time that we also start listening to our children.
Kossarova L (2015) ‘Children’s health: seen but not heard?’. Nuffield Trust comment, 23 April 2015. https://www.nuffieldtrust.org.uk/news-item/children-s-health-seen-but-not-heard