The rising challenge of children’s urgent and emergency care

A call for an integrated approach to care redesign for services for infants, children and young people.

Blog post

Published: 24/04/2017

Infants, children and young people are high users of healthcare services, with two and half times more emergency department attendances by children aged fifteen and under than by people aged 80 and over, and yet they rarely feature in our newspaper headlines on the NHS.

Children must be considered equitably to adults in all aspects of healthcare and we are pleased to see this QualityWatch report focussing on children and young people.

The report highlights the continuing increase in both emergency department attendances and emergency admissions to hospital; with a 20% increase in overall emergency admissions (all ages) and worryingly a 30% increase for the under ones and a 28% increase for one to four year olds between 2006/07 and 2015/16.

The reasons behind these increases are complex. While many attendances require little or no medical intervention, each one tells us that a parent or young person was worried, and either unable or unsure how to access a more appropriate service. GPs remain the most widely used and trusted source of advice for the parents of sick children but an increasing proportion of children and young people are now being admitted to hospital through emergency departments and not through their GP.

If we are to tackle these pressures, we need to be looking seriously not only at sustained investment in healthcare services, but also at the way in which services are set up. In general, children and young people should not be admitted to a hospital if it is possibly avoidable and the Five Year Forward View (and the new Sustainability and Transformation Partnerships) call for a whole system approach to care redesign in England. This must include a focus on what works for infants, children and young people and their families.

We need to deliver better care for children in the community with closer working between primary care and paediatricians. As set out in the Royal College of Paediatrics and Child Health’s Facing the Future: Together for Child Health standards, this includes networks of care, GP-consultant ‘hotlines’, support from community children’s nursing teams and more GPs being given the opportunity to undertake a paediatric placement in their training. We also need to help children and young people and their families navigate the plethora options available to them, including NHS 111 and self-care at home, with better signposting and safety netting.

Alongside increasing attendance and admission rates, the duration of admissions is reducing and ‘zero-day’ (less than 24 hours) admissions are increasingly common for children and young people. The report highlights a 17% fall in the mean length of stay following emergency admission between 2006/07 and 2015/16.

Admissions of shorter duration can be partly explained by the inherent nature of the conditions children and young people present with, mainly low acuity conditions with rapid recovery times. And while rapid recovery may be common, so too is rapid deterioration and a period of observation with access to acute care facilities can be useful to more accurately determine a child’s clinical trajectory. Staffing in hospitals should promote review by experienced staff early in the pathway.

The priority for clinicians is to manage children safely and effectively, in the most appropriate setting. For some, this will require an admission to an inpatient ward, but there are many other children who can be safely managed within a Short-Stay Paediatric Assessment Unit (SSPAU), preventing an inpatient admission. Admission to an inpatient ward for a child for less than a day can be unsettling for both the child and family and comes with an unnecessary financial cost to the service.

SSPAUs have emerged as a hub for the provision and coordination of emergency ambulatory care and last month the Royal College of Paediatrics and Child Health published new Standards for Short Stay Paediatric Assessment Units, reflecting the fact that these units are becoming a key way of treating children and young people quickly and effectively. SSPAUs and paediatric emergency departments also provide a good opportunity for paediatricians and GPs to train together.

Demand on the system is unlikely to decrease, but adapting how and where care is delivered can help cope with the pressures more efficiently. Clearly there is more to be done if we’re to ensure the very best health outcomes for children and young people in the UK.