Growing problems, one year on: the state of children’s health care and the Covid-19 backlog

Over a year ago now, the NHS published its delivery plan for tackling the Covid-19 backlog of planned care. Around the same time, QualityWatch reported on the impact of the pandemic on health care for children and young people in England.¹ That showed, among other things, that the waiting list for planned paediatric hospital care had grown by 22% in just seven months in 2021.

So, more than one year on, what does health care for children and young people in England look like, and is policy-making working effectively to support improving care? This analysis shows that, far from diminishing, the problems facing children and young people’s health care have worsened in many cases.

Hospital waiting lists for planned paediatric care continue to grow, showing little sign of relenting

As of March this year, over 400,000 children were waiting for planned paediatric hospital care in England. That’s over 158,000 more than was the case in April 2021² (see Figure 1). This waiting list is growing faster than the overall waiting list for treatment, having increased by 64% compared to a 43% increase for all planned hospital care. And with the number of children coming on to the waiting list consistently greater than the number starting treatment, growing waiting lists are unlikely to be reversed any time soon. Large numbers (14,628) of children’s operations were also cancelled last year, more so than was the case in 2021.

Many children and young people still face long waits for care, even for serious conditions

While there have been improvements in very long waits (of more than two years) for planned paediatric hospital care over the past year, the average (median) waiting time has gone from 10 weeks in April 2021 to 14 weeks in March this year, with nearly one in 20 children (4.5%) waiting longer than a year.

Even urgent, potentially lifesaving cancer care for children has not been immune to these access issues. In our previous report, the proportion of children under the age of 16 with suspected cancer who waited more than two weeks to see a consultant had increased after June 2020. Since then, this continued to a high in September 2022 of one in four children (25%) not seeing a consultant within two weeks from a referral for suspected cancer. Although there have been some improvements in recent months, in March this year³ more than one in eight (12%) still weren’t being seen within two weeks – with the target being that no more than 7% of children should wait longer than this.

And these issues with access can also be observed in the patterns of GP referrals to hospitals for children (see Figure 2), where we previously noted that GPs were sometimes categorising more of their referrals to hospital as urgent, to try to ensure that their patients are seen quickly.

More worryingly, all this may also be a sign of a decline in children’s health: urgent referrals haven’t declined. Since we last reported, they were still up 37% per week on average from pre-pandemic levels⁴, while routine referrals have decreased by 10% on average per week.

The NHS delivery plan for tackling the Covid backlog of planned care acknowledges that “long waits before accessing planned care can have lifelong consequences on the development of children and young people”. But it is unclear how some of the interventions outlined in the plan, such as surgical hubs and community diagnostic centres, will benefit children and young people, particularly as the former focus on high-volume surgery for conditions that mainly affect older people, such as cataracts and hip replacements.

Policy efforts to improve emergency care offer limited benefit for children and young people

The more recently published delivery plan for recovering urgent and emergency care services does have more mentions of children and young people than the delivery plan for planned care. However, many conversations about problems in emergency care have mainly discussed the flow of patients through the hospital, as well as issues with discharge delays due to problems within social care, both of which mainly affect older patients.

Yet we have shown that there has been substantial deterioration in A&E waiting times, even for the youngest patients. In July 2019, 94% of babies under two years of age left A&E within four hours, but by July 2022 this had dropped to 81%. That’s nearly one in five babies under two waiting longer than four hours. This figure also predates the most recent winter (2022/23), when there was increased emergency care demand from children as there were higher levels of flu, RSV and Strep A circulating.

However, like the interventions in the NHS planned care delivery plan, it is hard to see how the policy and funding announced by the Secretary of State to ease pressures last winter would have benefitted children and reduced their waiting times: for example, one of its main focuses was on block-booking of beds in residential homes.

Both the recovery plan and the recent announcement outline other approaches to help with future problems in emergency care. But again, most of these are unlikely to benefit children as much as they would adults. Community care plans to prevent the use of emergency care are mainly focused on the older population, and the bulk of private care provision is designed for conditions that are more prevalent in older patients.

This lack of focus is surprising, given that emergency attendances for children and young people, have historically been high, and remain so, particularly for those under the age of 15. In 2021/22, children under 15 accounted for over a fifth of all emergency attendances (21%), with a rate of 475 emergency A&E attendances for every 1,000 children under 15. That’s actually higher than the rate of attendances for people over 15 (384 for every 1,000). Only people aged 80 or over had a higher rate during that period (705 for every 1,000 people over 80).

One positive of the urgent and emergency care recovery plan for children and young people is that there will be more specialist children’s physical and mental health support provided by NHS 111. But this does assume that NHS 111 will be the first port of call for children and young people, or when parents and carers are worried about the health of a child.

It's not just about hospital and emergency care

These plans for recovery focus on hospital care and emergency care, and for planned care they only look at physical health. Yet our previous analysis showed that issues with children and young people’s health care during the pandemic were much broader than this.

Some waiting lists for community-based services show improvement, while others continue to grow

Based on August 2021 data, we previously showed that some children’s community services had reduced levels of care activity compared to pre-pandemic levels. They also had large waiting lists and were experiencing backlogs.

Updated data reveals a mixed picture on how waiting list sizes for those services have changed (see Table 1). Children’s community nursing services have dramatically decreased their waiting lists, but they have increased for both community paediatric services and children and young people's speech and language therapy. In October 2022, increased demand and staff availability were cited as the most important things preventing reductions in waiting lists for these services.

Table 1: Children and young people’s community care waiting list sizes in March 2023 compared to August 2021

^{Source: NHS England, Community services waiting lists (date accessed 11/05/2023) and NHS England, Supplementary Information, 21 December 2022 – Information on community health services waiting lists (date accessed: 08/03/2023).} 

The length of waits for community paediatric service and children and young people's speech and language therapy are also an issue (see Table 2). In March this year, the largest proportion of those on the waiting list for community paediatric service had waited between 19 and 52 weeks, and more than one in 10 children had waited more than a year. 

Table 2: The proportion of the services waiting lists by weeks waiting in March 2023 

^{Source: NHS England, Community services waiting lists (date accessed 11/05/2023).}

In a recent analysis of mandatory health visits for children, the Health Service Journal suggested that “a fifth of infants are not receiving one or more of their five mandatory health visiting reviews across the first two years of life, with rates still substantially below pre-Covid levels”.

Despite these issues, there has been little information on how the NHS plans to support the recovery of community services for children and young people, as it has done for adults.

The crisis in children and young people’s mental health care is deepening

In our previous report, we highlighted across several measures that the state of children and young people’s mental health and their care was a serious concern.

Since then, we have seen a continued growth in the number of referrals for people aged 18 and under to children and young people's mental health services (see Figure 3)⁵. In the six months up to February this year, there were over 432,500 referrals – more than doubling the number of referrals compared to the same period in 2019/20. This compares to only a 1% increase in referrals to mental health services for adults (aged 19+)⁶ between September 2022 and February this year.

There has also been an increase in the number of children and young people being referred to urgent and emergency crisis mental health care teams.⁷ In the six months up to February this year, there were on average 2,373 of these referrals per month, compared to an average of 1,938 per month during the same period in 2019/20.

The Children’s Commissioner reported in March this year that waiting times have increased between being referred to children and young people’s mental health services and the start of treatment. They also show that “the percentage of children who had their mental health referrals closed without accessing treatment has increased, back up to nearly a third”.

Furthermore, although there have been improvements in waiting times for treatment ⁸ of eating disorders since we last reported, between January and March this year 21% of those under the age of 19 still waited longer than a week to start treatment after an urgent referral, with 18% waiting longer than four weeks after a routine referral for an eating disorder – considerably higher than the target that no more than 5% of patients should wait longer than those periods. The number of children⁹ attending A&E for eating disorders also continues to be greater than adult A&E attendances for eating disorders.¹⁰

BBC analysis of NHS Digital’s data since our last report also showed an increase in the number admissions to hospital for self-harm in the UK for those aged eight to 17, at the same time as a decrease in admissions for self-harm in all ages. They also found that the 8–17 age group made up more than a quarter of total self-harm admissions.

Recently, the government announced it will be developing a Major Conditions Strategy, which will include mental ill health and will take over from previous mental health plans. The risk, however, is that this strategy is so big that children’s mental health will be dwarfed by the other conditions, and our analysis highlights that it must not be overlooked or overshadowed in its development.

Deepening of problems across children and young people’s care is showing few signs of abating

While there are some positives, on balance the problems facing children and young people’s health care have not diminished since our report last year, and in many cases they have worsened.

Waiting lists for children and young people’s planned hospital care and some community services are still growing. Waiting times for children under the age of 16 with suspected cancer to see a consultant are still elevated compared to pre-pandemic waiting times, and still above national targets. Children with eating disorders continue to show up in A&E, which is not the best environment for them to be treated – doing so more than adults for the same reason.

As a population, children have needs that are different from the adult population, yet delivery plans and recovery initiatives aren’t giving those needs the consideration they deserve. Scrutiny  of plans rarely looks at whether those plans work specifically for children’s and young people’s needs. This lack of focus and oversight could result in a further worsening of children’s health care services.

Timely health care for children and young people is vital. Not delivering interventions at a specific age or developmental stage can have a lifelong impact on a child’s healthy development, and can have knock-on effects in other parts of their lives. Failure to address these ongoing issues would let down a generation of children and young people.