In our fourth blog about winter pressures on the NHS, we look at leaving hospital and returning h...
As a paediatric registrar working in London, for me winter is synonymous with long and stressful shifts. Over the past decade there has been an increase in emergency admissions as well as A&E attendances, especially for infants. Those on the frontline are experiencing mounting workload pressures, particularly over winter months.
We offer good paediatric care in the UK, but it could be much better. Worryingly, we have one of the highest infant mortality rates in Europe, with poor health outcomes strongly linked to rising child poverty and social inequalities. Understaffing and service design issues exacerbate the problem.
To illustrate what this means for patients over winter, let’s consider the fictional case of baby Ollie, a nine-month-old who was premature and spent the first month of his life in a special care baby unit.
Ollie developed a cough and runny nose a few days ago.
Coughs and colds are more common in children over winter. A common viral respiratory infection responsible for increased admissions during this period is respiratory syncytial virus (RSV). To an adult it’s just a runny nose. For certain groups of children, especially premature babies and infants with pre-existing medical conditions, RSV can be quite serious.
Ollie’s mum is worried that he is drinking less than normal, so she books him in to see a GP.
Providing paediatric care in the community, especially by GPs, is complicated. Firstly, the demand for GP appointments is high: children and young people aged 0-15 years account for around 18.9% of the population (while adults aged 65 years or older account for 18%), with estimates suggesting that children make up 25% of GP workload.
Secondly, access to paediatric expertise in primary care is lacking. It has been stated that one in three GPs have not had a paediatric rotation as part of their GP training. The Royal College of General Practitioners highlighted this issue as long ago as 2011, proposing plans to make paediatric training mandatory for all GPs.
Ollie is seen by his GP who is concerned about his breathing. He is referred to A&E for a specialist paediatric review.
A&E is busy. It’s clear that while patients like Ollie need to be there, lots of other children don’t. More children than ever are attending A&E to seek medical care. 4.4 million children aged 0–15 years presented to A&E in 2015/16, an increase of 7.6% compared to 2014/15. Although the exact figure varies by source, the rate of inappropriate paediatric presentations to A&E is around 15%.
Despite drives to improve education to direct the public to walk-in centres, minor injury units and pharmacies, the overwhelming belief by parents and caregivers is that A&E is the most reliable and time-efficient access to medical care for their child. It’s easy to blame the public, but this over reliance on A&E reflects a growing need to address paediatric service organisation.
Ollie is reviewed by the on-call paediatrician and it is decided that he needs admitting to the ward for oxygen and fluids. He takes the last room available on the ward. Any further children who need to be admitted will have to be transferred to another hospital.
Short-stay admission rates for children are increasing. Children admitted to hospital were spending an average of 1.64 days in hospital in 2015/16, down from 1.99 days in 2006/07. This high-volume turnover often works in favour of paediatric wards, with most hospitals developing short-stay paediatric units to deliver ambulatory care. This is a great example of how children’s health care can and should be adapted to best meet the needs of children.
Ollie’s nurse also has five other patients, two of whom are also unwell with breathing difficulties. Ideally, she wouldn’t be looking after so many high-dependency patients, but the ward is short-staffed.
Sadly, the rising demands of the job often make paediatrics a speciality that faces poor recruitment and retention. Challenges in financing training, uncertainty over Brexit, and poor retention rates have all contributed to nursing shortages.
Staffing issues also extend to doctors. A growing proportion of paediatric consultant posts remain vacant, and applications to paediatric training fell by 27.5% between 2015 and 2017.
The Royal College of Paediatrics and Child Health’s Paediatric Rota Gaps and Vacancies Survey 2017 revealed a 23.4% vacancy rate in paediatric registrars. In units with resident consultants, 51.9% used consultants to cover registrar shifts. 72.3% of departments that participated in the survey reported winter pressure issues, with the majority identifying insufficient staffing and recruitment difficulties as leading contributors to these.
24 hours later, Ollie’s condition is deteriorating and he needs support with a breathing tube. This means he’ll have to be transferred to a paediatric intensive care unit (PICU). Unfortunately, the only PICU bed available is more than a hundred miles away.
Respiratory illnesses in winter, particularly in infants, drive the annual peaks in PICU bed demand. However, it’s not only physical bed space that’s the issue, but also the availability of highly-skilled PICU nurses to look after critically unwell children.
The PICAnet 2017 annual report identified that only 55% of England’s PICUs are staffed at the recommended levels. It also found that around 20% of referrals made to PICU were initially refused, and of those, around 64% were due to not enough staff being available to nurse the child safely. Like Ollie, these children may be referred to units hundreds of miles away, resulting in delays to specialist care.
What will future winters bring for children?
Fortunately, patients like Ollie should fully recover this winter thanks to the care provided by a highly dedicated workforce. However, improvements to the organisation of paediatric services are much needed, and giving children’s services a bigger policy platform would help.
Children and young people make up a sizeable proportion of our population and make extensive use of the NHS, especially of GP and A&E services. Yet adult care, particularly for older people, currently dominates policy debates and is often the focus of media coverage about health care during winter.
It is vital that policymakers don’t lose sight of children and young people as the NHS navigates service transformations across the UK.
Dr Susannah Pye is a paediatrician and Clinical Fellow at the Health Foundation, @susannah_pye