26 June 2017
Lucia Kossarova - Nuffield Trust - image

Lucia Kossarova

Senior Research Analyst
Nuffield Trust

In April we published our latest Focus On report, looking at trends in emergency hospital care for children and young people over the past 10 years. Based on the data and measures we analysed, we found that, while the emergency hospital setting is the right place for very sick children and young people, improving access to high-quality care outside this setting could help reduce some unplanned hospital care. We found:

- A rise in emergency admissions among infants, which raises questions about maternity and community care

- A rise in same-day discharges and slower increase in readmission rates for this group, which may suggest that appropriate care is being provided in the hospital (whether some of this care could be provided in the community is a different question)

- Emergency readmission rates for poisoning by other medications and drugs among older children are of particular concern, and signal issues with the accessibility and quality of mental health services and broader early support for children and young people

Following on from the report, in June we held a breakfast seminar with a wide range of experts representing different professions and patients to explore further what may lie behind our key findings. Our discussion during the event centred around four questions and provided some possible explanations that should be explored further.

Infant emergency admissions

First, what lies behind the sharp increase in infant emergency admissions and what can we do about it?

We hypothesised that the increased survival of premature infants that require intensive medical care, premature discharge and access to/quality of care in the community may all help to explain these trends. The findings from the 2002 Cochrane review of eight randomised controlled trials on the effects of early postnatal discharge were inconclusive. Varying definitions of ‘early discharge’, the level of support and advice offered in the hospital, the quality of midwife support at home, and the heterogeneity of the studies, are some of the examples of the challenges encountered in the review. A systematic review currently underway should help provide the much-desired additional evidence on the effect of early postnatal discharge on outcomes for infants.

Understanding variation in the quality of care and level of support provided before and after postnatal discharge should be explored together with other possible causes including support for deprived families.

Preventable admissions

Second, what can we do about the continued prevalence of potentially preventable emergency admissions for conditions such as asthma?

Potentially preventable asthma admissions were discussed at length. There is clear evidence available on how to control asthma and help prevent exacerbations that lead to hospitalisations, yet results from the recent national asthma audit carried out by the Royal College of Emergency Medicine clearly highlighted how guidelines are not adhered to and that discharge advice is ‘sporadic and needs standardisation’. These findings are very concerning. Without an appropriate follow up in the community, children, young people and adults are likely to return to A&E and be admitted.

A simple step that includes a call from the practice nurse/GP to the young person or the family of the child following an A&E visit/hospital admission to create an asthma management plan could help in further reducing asthma emergency admissions. However, the lack of skills in primary care may be an obstacle in effective management of conditions, including asthma: a survey of 3405 General Practice nurses showed that 43% said that they did not feel their nursing team has the right number of appropriately qualified and trained staff to meet the needs of patients. ‘Overly effective’ asthma reliever medication is also part of the problem as it brings an exacerbation under control in the short term but it does not manage the child’s asthma appropriately in the longer term. Dr Andrew Whittamore of Asthma UK gave a presentation on some of these issues at our roundtable event and has written more in a blog on this website.

Following up with frequent A&E attenders, ensuring that care is provided according to existing guidelines and that staff in the community have appropriate skills to provide the necessary advice and care would be the sensible next steps.

Mental health

Third, what does the rise in hospital emergency care use for young people with poisoning say about the quality of mental health services?

Participants at our roundtable event noted that child and adolescent mental health services (CAHMS) are paid for under block contracts so there is no incentive to increase capacity, unlike for other hospital admissions for children and young people. The increase in hospital emergency care use for young people with poisoning may therefore be a genuine increase and reflect the increasing prevalence of mental health disorders rather than a by-product of the financial payment system. The significant cuts to early intervention services that may catch young people in need early is likely to be a contributing factor to the increase. CAHMS services are a scarce resource and upskilling a range of other professionals outside the hospital to spot early signs when children and young people are in need was highlighted as essential.

Focusing on early intervention and support for children and their carers, upskilling across the system and providing treatment early on are likely to help reduce some of these emergency presentations.

More of the same or doing things differently?

It is difficult to see how care seeking and provision can move away from the hospital emergency setting without implementing changes that would improve early and easy access to appropriate care elsewhere, including providing the required additional investment (not only financial). While the existing system perpetuates a continued use of hospitals which have an incentive to admit, examples from new models of care are showing how these can be overcome when people start to think differently about a problem, and without changes to financial incentives or other large scale re-organisation. The range of different new and simple solutions – for example, integrating primary and secondary care through phone/email contact, embedding paediatricians in primary care MDTs, paediatric nurse led clinics, upskilling of staff, continuity of care that helps educate and empower families and others – should therefore be given space to flourish. Early evidence from some models suggests that they are successful in reducing hospital care use and evidence from other evaluations is needed. For this to happen patience is required before quickly moving on to new (but often not so new!) solutions. As one roundtable participant noted, there may be a need to ‘stand still, implement and evaluate’ - there is no quick fix.

Understanding the general and specific needs (including broader determinants of health) of children, young people and their families, and organising care to meet these needs together with strengthening early and easy access to appropriate expert paediatric and child health assessment in the community, are two of the four key principles around which new models of care are and should be designed to improve health outcomes. In addition, it is essential to link up information, data, communication and care, and focus on improving the health literacy and education of families as well as professionals.

Children should be prioritised

Children and young people don’t make the headlines, unless there is a major incident. What’s required to change this focus and attitudes has not been resolved. Children should be prioritised – not only because it is their right to receive the same quality of services as adults but also because there will be a personal and economic benefit down the line. It was clear to everyone in the room that without making children and young people a national priority and intervening early, we will not see a change in the trend of hospital emergency care use in the future.

We hope to build on the evidence from this piece of work and explore some of these questions in our research programme around children and young people.

Comments

Hi, I have followed this report with interest (http://rolobotrambles.com/emergencyadmissions/). I'd like to pick up this sentence: "Participants at our roundtable event noted that child and adolescent mental health services (CAHMS) are paid for under block contracts so there is no incentive to admit, unlike for other hospital admissions for children and young people" I am hoping his implies that there is little to incentive to change services if you are on a block contract as opposed to clinicians admitted because of the financial benefit. I raise this point as the Nuffield Trust/Health Foundations are influential organisations and the next sentence: "The increase in hospital emergency care use for young people with poisoning may therefore be a genuine increase and reflect the increasing prevalence of mental health disorders rather than a by-product of the financial payment system" does very much suggest there is a belief of a direct relationship between a specific medical condition and the ability to raise income for that condition. I think it is important, that if there is direct evidence of clinical activity occurring on the basis to generate income, that this is shared as this has huge implications for the delivery of health services in the UK. It is not something I recognise at all in my clinical practice. Dr. Damian Roland BMedSci BMBS MRCPCH PhD Consultant in Paediatric Emergency Care Honorary Associate Professor (SAPPHIRE Group – Leicester University) University Hospitals of Leicester NHS Trust
Damian Roland (not verified)
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Hi Damian, Thanks for your comments and tweets on this issue. As we say in the introduction, this blog is intended to provide a summary of the discussion that took place among a group of expert stakeholders at a roundtable event that followed publication of our report on emergency care for children and young people. The event, held under Chatham House rules, was designed to help start discussions looking at the underlying reasons for the trends identified in the report and provide ideas for further research. The discussion was wide-ranging and this blog is not a summary of all the evidence. Nor does it represent the views of either the Nuffield Trust or Health Foundation. The issue of payment mechanisms was raised several times during the discussion but always in the general context of the incentives they provide at the provider (hospital) level, rather than the behaviour of individual clinicians. Where there was some ambiguity on this we have clarified in the text above. Financial incentives come up frequently in other research, particularly relating to new models of care for children and young people. This is an area of great interest so we appreciate your reflections. - The QualityWatch team
dan.watson
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