Key facts on health services for children and young people
The health of children and young people has improved significantly over the last century. Remarkably few children and young people die. The major killers of children, infectious diseases and accidents, have been largely overcome by a combination of increasing standards of housing, diet and sanitation; and immunisation and universal education. However, nationally, although there are far fewer deaths, longer-term childhood illnesses such as asthma and diabetes have increased; obesity is currently increasing which is likely to lead to a higher level of Type 2 diabetes in a younger population in the future, and accidental injury remains a potentially avoidable cause of hospital admission and death. The current increasing birth rate in Merton includes areas of deprivation. In the current economic situation this could lead to more children in poverty and poorer short- and longer-term health needs. The differences in populations within the borough in terms of ethnicity and socioeconomic factors will also have an impact on the types of health conditions being seen and the services required.
While children in the UK now experience far fewer deaths than 50 years ago, chronic childhood illnesses such as asthma and diabetes have increased. This suggests that the treatment of these conditions has improved vastly and that children can continue to live normal lives even if they have long-term conditions. However, little information is currently available specifically on the treatment of childhood conditions, even through the Primary Care GP Quality and Outcomes Framework, since most of the clinical indicators only relate to adults.
Emergency attendances at hospital
In 2012-13, there were a total of 16,447 attendances at local A&E by 0-19 year olds registered with a Merton GP (source: Merton CCG), which means on average 45 children and young people attended a local A&E every day (note, there is fluctuation by day and season).
The rate of attendances at A&E in 2010-11 was higher in Merton among 0-4 year olds (698.2 per 100,000) compared with London (648.4 per 100,000) and England (483.9 per 100,000). Merton ranked 11th highest out of all London boroughs for the 0-4 age group.
The rate of A&E attendances in 2010-11 was higher in Merton among 5-9 year olds (354.9 per 100,000) compared with London (323.5 per 100,000) and England (255 per 100,000).
The rate of A&E attendances in 2010-11 was higher in Merton overall for 0-17 year olds (483.3 per 100,000) compared with London (438.2 per 100,000) and England (353.9 per 100,000).
A&E attendances for children aged 0-4 years, DSR/100,000, 2010-11.
Emergency admissions to hospital
A review of admissions for conditions common in childhood can provide an understanding of childhood hospital conditions locally and how services are used. Potentially avoidable emergency admissions for conditions in children and young people that could be managed in the community include lower respiratory tract infections and asthma, diabetes and epilepsy.
Emergency admissions in 2011-12 in Merton for asthma, diabetes and epilepsy among under 19 year olds was 223.3 per 100,000, the 11th lowest rate compared with other London boroughs.
Rate of unplanned hospital admissions for asthma, diabetes and epilepsy, under 19 years, 2010-11 to 2011-12.
Emergency admissions in 2011-12 for lower respiratory tract infections for under 19 year olds was 211 per 100,000. The graph below compares Merton with our geographical and statistical neighbours.
Rate of emergency hospital admissions for lower respiratory tract infections, under 19 years, 2010-11 to 2011-12.
Emergency hospital admissions (2006-10) due to injury amongst under 18 year olds was lower in Merton (1,130.8 per 100,000) compared with London (1,229.7 per 100,000) and England (1,443.2 per 100,000).
Emergency hospital admissions (2011-12) due to self-harm amongst under 18 year olds was lower in Merton (43.9 per 100,000) than London (64.4 per 100,000) and England (115.5 per 100,000), although it must be noted that actual numbers are very small.
Urgent care services in South West London
A detailed analysis of children’s health services in South West London was undertaken in 2012.1This identified that access to care for children with urgent care needs can be confusing for parents who must choose between a range of different services e.g. GP services, walk-in centres and A&E departments. The lack of readily accessible primary care services can encourage presentation to A&E departments, which may in turn lead to inappropriate admission to hospital.
The report noted that it was not clear why a rapid rise in emergency short-stay admissions has taken place when it could be argued that the number of severe illnesses in children is decreasing. It may relate to parental anxiety (which could be reduced through improved education and support), new clinical protocols and professionals being risk averse (which may reduce with the advent of a more consultant-delivered service).
The number of A&E attendances nationally has risen steadily in recent years and this increase in attendances is especially pronounced in the treatment of children: according to NHS data, in a typical year in England up to half of infants under 12 months and one quarter of older children will attend A&E. Up to 25% of all A&E attendances at local hospitals are by children aged under 15 years.
Recent data for emergency medical care in South West London showed that:
- Over half of A&E attendances for 0-17 years old were discharged with no follow-up treatment required.
- Only 11% were admitted to the same hospital for further treatment.
- There is significant variation in the number of emergency admissions, length of stay and patient outcomes between hospitals across London.
Length of stay in hospital
The eight graphs below show comparatively how St George’s Healthcare NHS Trust and Epsom and St Helier University Hospitals NHS Trust perform in terms of the inpatient mean length of stay [as recorded] by Healthcare Resource Group (HRG).
Overall in paediatric medicine the average number of bed days for St George’s Hospital were higher than expected and for Epsom and St Helier Hospitals were also slightly higher than expected.
Looking further into this overall position a number of areas can be identified where the average number of bed days is higher than expected. For St George’s Hospital this includes respiratory tract infections, and asthma or wheeze. For Epsom and St Helier Hospitals this includes respiratory tract infections, asthma or wheeze, and febrile convulsions. The findings need to be linked into developing new pathways for children and young people, in particular the pathway for unplanned care particularly in respect of infections and respiratory conditions.
Length of hospital stays by clinical specialty (paediatrics), St George’s Hospital 2011-14.
Length of hospital stays by clinical specialty (paediatrics), Epsom and St Helier Hospitals 2011-13.
Key commissioning implications for health services for children and young people
In light of existing and future financial constraints, and at a time when the birth rate is increasing, there is an opportunity to review children's health services to ensure that in the majority of cases children with both acute and long-term conditions are supported in the community as much as possible, reducing the need for hospital inpatient stays, in particular focusing on:
- ensuring the local pathway for unplanned care is underpinned by a consistent model of care for all organisations
- reviewing data on hospital attendances for children aged 0-17 years, including a focus on 0-4 age group, and reviewing progress on local initiatives to reduce A&E attendances
- how children with long-term conditions can be supported to access the full curriculum in schools and have a smooth transition into adult services.
^Better Services, Better Value, South West London - Children’s Services Clinical Working Group (2012). Final Clinical Report (March 2012).