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GPs go forth

'Systematic failure' has led to steep rise in paediatric emergency admissions, study finds

A ‘systematic failure’ by GPs and hospitals has led to a 20% increase in children under five being admitted to hospital for conditions that should be managed in the community over a decade, researchers have claimed.

The UK researchers found an increase each year in emergency admissions in England over the last decade and they concluded that changes to GP responsibility for out-of-hours work and the ‘four-hour wait’ target in A&E may be to blame.

Their report in Archives of Disease in Childhood looked at Hospital Episode Statistics (HES) and Office for National Statistics mid-year population estimates for 739,000 children under 15 admitted to hospital in 2010, up from 594,000 in 1999.

Even when accounting for the surge of births in the UK, there was still a 28% increase in the rate of emergency admissions between 1999 and 2010, with a 24% increase in admissions in those aged between one and four and a 52% increase in admissions in children under 12 months old.

The total number of admissions for primary care sensitive conditions rose by 18%, with a 30% rise in acute conditions (upper and lower respiratory tract infections, gastroenteritis and urinary tract infections), though rates of admission for chronic conditions (asthma, diabetes and epilepsy) fell by 5.6%.

The researchers found that while there was little change in admissions lating between one to two days, there was a twofold increase in admissions lasting less than one day.

The data follow the pattern of rising numbers of preventable emergency admissions, with a recent study showing numbers overall have risen by 40% in a decade despite extra resources being ploughed into programmes aimed at preventing such admissions.

The study’s authors offered many reasons for this increase, including more children being taken to primary care for assessment, and a decrease in the threshold for referral to hospital in primary care. Other reasons include an increase in parents taking their child straight to hospital, and GPs receiving less training in the triaging of children with potentially serious illness.

The study also said the four-hour target in A&E departments had led clinicians to admit rather than observe, and that ‘unintended financial incentives’ created by contacts and payment tarrifs that reward admission could also be a reason for the increase.

The study’s authors concluded: ‘The continuing increase in very-short-term admission of children with common infections suggests a systematic failure, both in primary care (by general practice, out-of-hours care and NHS Direct) and in hospital (by emergency departments and paediatricians), in the assessment of children with acute illness that could be managed in the community.’

The rise may also reflect an increased reluctance by parents and doctors to tolerate uncertainty, they said.

They added: ‘Unplanned hospital admission is costly for the healthcare system and for children, straining finite hospital resources. Once admitted, children are at risk of hospital-acquired infections, medical errors, drug reactions and emotional trauma.’

A reduction in unplanned hospital admissions for children was one of the targets in the 2012/13 NHS Outcomes Framework.

Readers' comments (8)

  • I am not sure the need to carry out this research. Most GPs would have given this info for free! What the authors need to do was to talk to GPs ( qualitative analysis)for the reason(s), why referrals are increasing.
    The sad reality is the fear of litigation and the NICE guidance on the ' sick child'

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  • Harry Longman

    The evidence is supported by our experience in general practice: many (most?) mothers perceive it is difficult to get an appointment with a GP. Fear understandably means they won't wait - they take the baby to A&E, and the rest is clinical history. The answer is to remove the barrier to access, which means the perception changes, and mothers will consult their GP with the baby appropriately. We know many practices now offering patients under 30 minutes to contact their GP, and it is less work.

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  • To admit an ill child where the diagnosis is not clear and who subsequently gets better is seen by many Paediatricians as an "unnecessary" admission but failure to admit an ill child where the diagnosis is not clear and who becomes seriously ill or dies can be a career-changing event for the GP!

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  • Most GPs with decent experience and qualification would not admit a child without a reason. Sometimes it may seen unneccesary for secondary care physicians but we are dealing with different level of care - we make decision in under 10min, the senior medical staff will often have several hours with several observations from their junior staff/nurses before making the decision.

    Mind you, I recently had a child with intususception which the tertially centre's registrar oncall thought I was being over cautious when I tried to admit the child......

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  • Vinci Ho

    The figures are there by all arguments but are the conclusions they drew fair? I am not too sure .
    Remember those days before Meningitis C vaccine , how often did you come across a child being sent back home once , twice and then diagnosed meningitis on the third visit?
    There is an argument of striking a balance between treating minor conditions in community and not to omit the fact that many overwhelming conditions in children present themselves with relatively trivial or non specific symptoms and signs . In the perfect world , only children with serious and life threatening conditions were admitted .
    It is easy to criticise from the point of view as an academic with retrospective evidences. The danger here is you can easily become the 'tool' of the government which is pushing for this cut in hospital admissions purely on cost.

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  • I bet most were well baby , ie admitted after being delivered.

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  • Tom Caldwell

    If the admissions from primary care are so clearly inappropriate presumably the paediatric team considers them suitable for discharge within say 15 minutes of assessment........ no they consider them suitable for discharge after several hours and repeated observation which it is not possible to deliver in primary care.

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  • Kadiyali Srivatsa

    Colin Powell in his article state we need a simple tool to help inexperienced junior doctors and primary care to help identify potentially serious illness in children. It looks as if he has gone through books and not searched for tools in the internet.

    I developed a simple tool in 2003 when I worked as a Salaried GP in a Nurse-led practice to help them decide who they must refer to consult me.

    Unfortunately this work was not one the nurses working in the Nurse led Practice or local walk-in-clinic because the nurses will only get to help manage flu, rash and simple UTIs.

    Please check how a my simple tool based on our clinical acumen and not statistically significant or nurses observation could have saved NHS this embarrassment and certainly prevented thousands of children psychologically damaged by hospitalisation. I have also created Apps that can be downloaded and used ...FREE

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