Growing problems, in depth: The impact of Covid-19 on health care for children and young people in England

This year’s QualityWatch scrolling data story explores the dramatic and concerning effect of the pandemic on children and young people's health and the care they receive. This accompanying briefing explains the findings in more detail and discusses the potental implications for the younger generation.

Briefing

Published: 18/02/2022

Access and waiting times Patient experience
Hospital care Mental health Children and young people

Children and young people have not been immune to the wide-ranging effects of the Covid-19 pandemic. Children are 10 times less likely than adults to have been hospitalised with the virus, but their access to health care has been badly disrupted and their mental health has been disproportionately affected. Often forgotten or overlooked during the Covid response, children have been negatively impacted by the pandemic with a potential for long-term consequences. Here we explore in more detail some key impacts of Covid-19 on children’s health care, as shown in our new scrolling data story.

At the onset of the pandemic, much attention was focused on shielding the elderly and clinically vulnerable. Evidence has since shown that children and young people have suffered greatly as a result of the pandemic and the measures taken to control it. The surge in demand for mental health care in children has been unprecedented, with sharper increases than for adults. The number of children waiting for eating disorder treatment has quadrupled. Paediatric services have not been protected from the growing waiting lists for hospital care. And vulnerable children, such as those with special educational needs and/or disabilities, have been particularly affected.

The importance of maintaining and improving children and young people’s health should not be underestimated. Healthy children are more likely to become healthy adults. Barriers to good health can disadvantage people into adulthood, and result in unfair differences between groups. Understanding the effects of the pandemic on children’s health and care is therefore the first step to making a change.

Who do we mean by ‘children and young people’?
Perhaps surprisingly, there is no standardised age group definition of children and young people across health care datasets. In the findings below, we have included the age group wherever possible. But for some measures, there is simply not an agreed definition between health care providers.

How many children have been hospitalised by Covid-19 infection?

Covid-19 infection has a considerably lower burden of illness in children compared to the elderly, and is very rarely fatal. Nevertheless, as of mid-January 2022, there had been a total of 15,939 hospitalisations with Covid-19 in children (aged 0 to 17). Using population data, this represents a hospitalisation rate of 132 per 100,000 children. While this is not insignificant, the hospitalisation rate for adults (aged 18+) was almost 10 times higher at 1,252 per 100,000 adults.

The wider effects of the pandemic on children and young people have in many ways been greater than the Covid-19 infection itself.

What has been the trend in support for young people with long-term conditions during the pandemic?

Around 1.7 million children in England have a long-term condition such as asthma, diabetes or epilepsy, and the country fares worse internationally in some important aspects of child health. The GP Patient Survey asks people aged 16 and over if they have had enough support from local services or organisations to help them manage their condition in the last 12 months. The results show that between 2018 and 2021, ‘feeling supported’ dropped by 6 percentage points for both young people (aged 16 to 24) and adults (aged 25+). This illustrates a continuation of a worsening trend, which is likely to have been exacerbated by the partial closure of community services and disruption to general practice during the pandemic.

Notably, young people are less likely than adults to report that they receive enough support. In the 2021 survey (fieldwork 4 January to 6 April), almost a third of young people with a long-term condition said that they did not receive enough support. Young people with conditions relating to arthritis, autism, learning disability and mental health were least likely to say they received enough. This may be having knock-on impacts on other aspects of their wellbeing and education.

Support from local services or organisations to help manage long-term conditions 18/02/2022

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What happened to GP referrals to hospital care after the outbreak of Covid-19?

A GP referral is the primary method by which a patient is able to access specialist care. As the pandemic struck, routine referrals to hospital care for children and young people fell by 89% (week beginning 13 April 2020) and urgent referrals fell by 79% (week beginning 6 April 2020), compared to pre-Covid levels. This is similar to the decline seen across all other specialties, and relates strongly to the drop in GP appointments at the time.

[Increased urgent referrals] may be a worrying sign of a deterioration in children’s health, with presentations of illness occurring later and at a worse stage of disease.

The number of GP referrals to hospital care for children and young people gradually increased again after the first wave of Covid, but this occurred more rapidly for urgent referrals than routine referrals. By the winter of 2021, urgent referrals were up to 47% higher than pre-Covid levels but routine referrals were the same or lower than they were previously. This may be a worrying sign of a deterioration in children’s health, with presentations of illness occurring later and at a worse stage of disease. It may also be that GPs are categorising more of their referrals as urgent, trying to ensure that their patients are seen quickly.

Percentage change in GP referrals for children and young people compared to a pre-pandemic baseline 18/02/2022

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Note:  

* baseline = the average number of referrals between 7 October and 22 December 2019

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How has Covid-19 affected community care for children and young people?

In response to the Covid-19 pandemic, many community services were advised to stop or partially stop in order to release capacity for other parts of the NHS. In June 2020, a framework was set out to restore community health services for children and young people.

The table below shows some key statistics for community services in August 2021, with data provided to us by NHS England and Improvement. It highlights significant backlogs for community paediatric services and speech and language therapy for children and young people. Although many services had restored activity or were exceeding pre-pandemic levels, others were still operating at a lower level of activity than before the pandemic. This is due to social distancing constraints, workforce vacancies and other factors. As a result, children and young people are having to wait longer and are struggling to access community care.

Community services provision for children and young people in August 2021
 

Waiting list*
Restored services experiencing
a backlog

Activity of restored/partially restored services compared to pre-Covid

Community paediatric services

Over 40,100

4 in 5 services

40% have reduced activity

Speech and language therapy for children and young people
 

Almost 51,800

3 in 4 services

48% have reduced activity

Community nursing services for children and young people (planned care and rapid response teams)

Almost 28,000

1 in 6 services

9% have reduced activity

* There may be some underreporting as organisations were still compiling this information.
Source: Data provided by NHS England and NHS Improvement.

What has happened to the waiting list for planned paediatric hospital care?

In March 2020, the NHS postponed non-urgent planned care in order to free-up inpatient and critical care capacity and prepare for Covid-19 patients. This was followed by national guidance in July, which outlined targets to recover planned hospital activity. During the pandemic, the total waiting list for planned care grew, and was almost 6 million in October 2021. Some 5% of those were waiting for paediatric services.

Since data on planned paediatric hospital care started being published in April 2021, the waiting list has grown from 245,654 to 300,465 in November 2021 – a 22% increase in just seven months. This compares to a 17% increase for planned services for all age groups over the same time period, with increases in some specialties such as dermatology (37%) being larger than others, like general surgery (9%), for example.

The number of patients joining the waiting list for planned paediatric hospital care is consistently higher than the number starting treatment. Hospital activity is not keeping up with demand for services, and so children and young people are waiting longer for required consultations and treatments. It is concerning that the number waiting over the 18 week target grew to 94,901 in November 2021, and 952 had been waiting over two years for paediatric services. These are unacceptable times for children to wait for health care.

Waiting list for planned paediatric hospital services 18/02/2022

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How have waits for children with suspected cancer to be seen by a consultant been affected?

Following an urgent GP referral where cancer is suspected, patients have the right to be seen by a cancer specialist within two weeks. Waiting times for children (aged <16 years) with suspected cancer to be seen by a consultant have worsened during the pandemic. In November 2019, 6.0% of children waited longer than two weeks and this increased to 15.7% in November 2021. Waiting times for adults have followed a similar trajectory, although they are slightly worse than for children.

During the first wave of Covid-19, there was also a significant drop in the number of first consultant appointments for suspected cancer. Although these have since recovered, this is worrying because it may represent delayed appointments or even appointments that never took place, leading to cancers being diagnosed at a later stage of disease.

First consultant appointments for children with suspected cancer and percentage seen after two weeks 18/02/2022

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What has happened to demand for mental health care in children and young people?

The pandemic has led to unprecedented levels of demand for mental health care in children and young people. In 2021, one in six children in England had a probable mental disorder, a similar rate to 2020 but up from one in nine in 2017. Early evidence suggests that pandemic restrictions including school closures may have aggravated known triggers for poor mental health, through reduced social interaction, isolation and academic stress. 

The pressure on children and young people’s mental health services is clear: some 337,125 0-to-18-year-olds were referred to mental health services between April and September 2021, up 81% on the same period in 2019 (186,496). This compares to only an 11% increase in referrals to mental health services for adults (aged 19+). Furthermore, the number of children and young people referred for urgent or emergency crisis care increased by 59%, with over 15,000 referrals made between April and September 2021.

This surge in demand for children and young people’s mental health services is leading to worsening waiting times. One in five waited more than 12 weeks for a follow-up appointment with mental health services between April 2020 and March 2021. Long waits such as these are worrying as people’s mental health conditions can deteriorate while they wait to access support.

A closer look at eating disorder care

Mental health services have faced a record number of eating disorder cases in children and young people. The number of children (<19 years) waiting to start treatment quadrupled, from 481 in quarter 2 (July to September) of 2019 to 860 in quarter 2 of 2020, and 2,083 in quarter 2 of 2021. Despite numbers starting treatment at higher levels than ever before, with a peak of 3,452 in quarter 1 (April to June) of 2021, waiting time performance is clearly worsening. In quarter 2 of 2021/22, 37% of urgent cases waited over a week to start treatment, and 35% of routine cases waited over 4 weeks to start treatment – against targets that no more than 5% of patients should wait longer than those time periods.

Waiting times for treatment for children and young people with an eating disorder 18/02/2022

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The surge in demand for eating disorder treatment and longer waiting times have had serious consequences on the ability to access timely care, and conditions have worsened as a result. The number of children and young people (<19 years) attending A&E with a primary diagnosis of eating disorder doubled during the pandemic, from 107 in October 2019 to 214 in October 2021.

A&E attendances with a primary diagnosis of an eating disorder 18/02/2022

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Source:  

Emergency Care Data Set (years 2019 to 2021) Copyright © 2022, re-used with the permission of NHS Digital. All rights reserved.

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A closer look at mental health diagnoses in emergency departments

Additionally, children and young people (<19 years) attending A&E with a primary diagnosis of a mental health condition are spending longer in the department compared to other diagnoses. In October 2021, 65% of children attending A&E with an eating disorder, 50% attending with depressive disorder, and 48% attending with personality disorder spent over four hours in the emergency department, compared to 19% of all children attending with any diagnosis. These results can be corroborated by data from the Royal College of Emergency Medicine, who have reported that the provision for a child in crisis in the emergency department is poor. Significant improvements will be needed to meet the target for a 24/7 crisis service for children and young people by 2023/24.

In conclusion

The Covid-19 pandemic and the nation’s efforts to control the virus have had a dramatic impact on children and young people’s health, care and wellbeing. Schools were closed, expected health care appointments did not take place, and children’s mental health deteriorated. By the time services began to be restored, waiting lists had ballooned and, under significant pressure, the NHS has not been able to keep up with demand for care.

Early intervention and prompt treatment are particularly important for children and young people, as poor health in childhood can have lifelong consequences. This is clearly the case for childhood cancer, where fast diagnosis and treatment is time-critical, but is also warranted for many other conditions ranging from childhood obesity to diabetes management. The growing waiting lists for planned paediatric care, coupled with the increase in urgent GP referrals, signal that access to timely care is being severely compromised and that children are suffering as a result.

Community services have not escaped the pressures of the pandemic, and children’s services are facing significant backlogs. One serious effect of the nationwide lockdowns was the negative impact on children and young people’s speech, language and communication. The inability to access services including speech and language therapy puts children at risk of a range of negative outcomes related to their education, social interactions and behaviour. These disadvantages are affecting children who already have a greater level of need, and so are exacerbating inequalities.

The sharp increase in children and young people with mental health problems is a serious concern. Services are facing unprecedented levels of demand, and young people are waiting longer to receive mental health care. In particular, there has been a surge in eating disorder cases, and conditions are deteriorating to the extent that a greater number of children and young people are attending A&E departments. The challenges that mental health services are facing are currently unsustainable, and should be prioritised with a high level of urgency.

It is clear that health care services for children and young people, just like adults, are facing an uphill battle to recover, but they rarely get the same level of scrutiny or exposure in recovery discussions. If we want to build back fairer, children’s health should be prioritised, but historically this has not been the case. Children and young people have been severely impacted by the pandemic, and more support and funding for services should be put in place in order to avoid disadvantaging a whole generation of people. Without further action, the impacts of the pandemic will be compounded and will be felt for a long time to come.


The analysis for the measures that used the Emergency Care Data Set was conducted in SAS and the code is available here.

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