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Why are acute admissions to hospital of children under 5 years of age increasing in the UK?
  1. Sarah Neill1,
  2. Damian Roland2,3,
  3. Matthew Thompson4,5,
  4. Alison Tavaré6,
  5. Monica Lakhanpaul7
  1. 1 Faculty of Health and Society, University of Northampton, Northampton, UK
  2. 2 Health Sciences, University of Leicester, Leicester, UK
  3. 3 Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Hospitals, Leicester, UK
  4. 4 Department of Family Medicine, University of Washington, Seattle, Washington, USA
  5. 5 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  6. 6 West of England Academic Health Science Network, Bristol, UK
  7. 7 General and Adolescent Paediatrics Unit, UCL Institute of Child Health, London, UK
  1. Correspondence to Dr Sarah Neill, Faculty of Health and Society, University of Northampton, Northampton NN2 7AL, UK; Sarah.Neill{at}northampton.ac.uk

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Children’s use of hospital services in the UK has been increasing rapidly since the late 1990s.1–6 Findings from the latest QualityWatch report show significant increases in emergency hospital admissions for infants (23%) and young children aged 1–4 years (11%) between 2006/2007 and 2015/2016 (data have been adjusted for population increases in each childhood age group), while children over the age of 15 years showed a decrease in emergency admissions6 (see box 1 for their definition of emergency admission).

Box 1

Definition of an emergency admission

‘An admission to hospital that is unpredictable and at short notice because of clinical need. This admission can come via a variety of routes, including the hospital’s A&E department, a general practitioner, a consultant clinic or a bed bureau. Our definition excludes transfers of admitted patients from other hospital providers in an emergency’.6

This paper discusses some of the theories and research which provide some insight into the increase in hospital admissions for infants and children under 5 years of age in the UK. Research has been identified in the following areas: social expectations of parents with a sick child, the media and parental anxiety, access to primary care, acuity of the illness, thresholds for admission, duration of hospitalisation and readmission rates, and the impact of health policy, each of which is discussed briefly below.

Social expectations of parents with a sick child

The unwritten rules of society place pressures on parents to conform to social expectations. When their children are acutely ill, parents are expected to contain the management of the illness within the family if the illness is minor and to seek help if the illness is serious.7 Parents learn from experiences, in the early days as parents, that they will be subject to felt or enacted criticism if they seek help at the wrong time, or in the wrong place for the level of severity of the illness.8 This is not surprising given the promulgation of the concept of ‘inappropriate attenders’ that underpins the thinking of many professionals in first contact services.9–11 Parents are left to judge the level of illness, often without detailed safety netting advice12 (see box 2 for a definition of ‘safety netting’).

Box 2

Definition of safety netting

‘In healthcare, safety netting refers to the provision of information to help patients or carers identify the need to consult a healthcare professional if a health concern arises or changes’.31

When parents seek medical help for their children, they are doing so because they feel they can no longer manage the illness independently.13 Consequently, if they are unable to secure the help they need from one part of the service, they will try another. In the absence of adequate safety netting, each encounter is likely to increase parent’s anxiety.14 Conversely Maguire et al 15 found that giving safety netting advice reduced the likelihood of reconsultation, and therefore presumably parental anxiety. Anecdotally emergency department (ED) staff report that they are more likely to admit a child when they perceive the child’s parent(s) to be very anxious, presenting a possible reason for reduced admission thresholds. This experience is supported by evidence of increased investigations16 and increased antibiotic prescribing17 when parents are anxious.

Media-induced fear factor?

Parents’ media-associated fear of meningitis has been identified in several studies.13 18 19 The rise of social media and 24/7 internet access to news reports has increased everyone’s access to information, not necessarily with the tools with which to assess its veracity. There is a difficult balance to strike between raising awareness and raising anxiety for parents. Consequently, it is important to evaluate interventions that aim to inform the public.

Internet searching is parents’ default mode when searching for information about a specific illness, after a consultation, often leading to additional anxiety and/or uncertainty as the information available is inconsistent and parents say they do not know what to trust.20 This finding reveals a lack of adequate safety netting,12 leaving parents needing to seek information elsewhere, from sources less likely to criticise or from people who do not know them, such as EDs.8 If decisions about admission are based on professional’s awareness of parent’s anxiety levels, this could be a contributory factor to rising admissions. That said, listening to parent’s concerns should be central in any consultation, as they are the expert on their child. The National Institute for Health and Care Excellence21 recommends taking parent’s concerns into account when assessing the severity of the child’s illness.

Access to primary care

Many of the papers, reporting the rise in admissions, have focused on identifying conditions amenable to treatment in primary care (primary care-sensitive) or common infections, implying that these children should have been cared for in primary care.2 4 6 Yet where general practitioners (GP) practices provide greater accessibility, the numbers of children admitted to hospital for short stays did not change, although their use of ED does decline.22 Accessibility seems to be a bigger issue out of hours. The most common reason for parents to call NHS 111 was because their GP surgery was closed.23 NHS 111 provides easy access to advice in contrast to the multistep process faced by parents wanting to see a GP out of hours, although the advice is often to see your GP, possibly indicating limitations of the telephone triage process or a risk-averse culture. Other parental concerns include the lack of continuity of carer, which parents attribute to GP’s high workloads, resulting in a lack of knowledge about each other and a consequent lack of trust,19 which can lead to parents seeking a second opinion elsewhere.24 One of our team reports the loss of capacity in general practice for same-day follow-up consultations, which may also contribute to additional help seeking elsewhere. As yet no published evidence has been identified that explores the impact of this loss of capacity for same-day follow-up. There is evidence, though, that the loss of continuity in general practice is associated with increased hospital admissions.25–27

Increasing acuity?

Any discussion concerning increasing demand for healthcare should consider whether or not the increase is a consequence of increasing severity of illness in the population served. Serious infections are rare in childhood28 and inhospital mortality rates are falling, suggesting that fewer very sick children are being admitted to hospital,6 partly as a consequence of improvements in immunisation against cases of meningitis and pneumonia.4

Emerging evidence on acuity levels is inconclusive. While Koshy et al’s5 review of admissions for acute throat infection, one of the top 10 reasons for emergency admission, concluded that severity of that illness had not increased in line with the increase in admissions, Roland et al’s29 more recent assessment of acuity in a large tertiary children’s ED found, as a proportion of all children presenting, that it was stable, if not increasing. It is important to recognise that ‘acuity’ is a poorly defined term and represents the amalgamation of a spectrum of measures (physiological, observational and subjective). This ambiguity may explain why the evidence is inconclusive concerning whether or not increasing acuity explains the increase in hospital admissions.

Lowered thresholds for admission

The ‘threshold’ of any admission is a multifaceted decision. There is a purely clinical component that ranges from need for critical or intensive care, which would be undisputed by a majority of professionals, to softer clinical interventions such as the observation of feeding. Layered on top of this are also parent and carer desires (see Social expectations of parents with a sick child section), bed availability (there is an implicit pressure to discharge borderline cases if beds are not freely available) and professional biases. The latter is complex in itself but relates to education and experience, previous adverse events and communication skills.30 A doctor at the beginning of their paediatric training almost by definition is going to be more risk-averse than a consultant of 10 years’ standing. The logic would then follow that an emergency and urgent care service staffed by a higher proportion of those with child health experience, although not necessarily paediatricians, would be able to better quantify and manage risk. However, even taking into account experience increasing awareness of high-profile media cases involving medical error and an increased risk of litigation have likely pushed all professionals to a slightly higher risk-averse state.

Duration of hospitalisation and readmission rates

Duration of hospital admissions is shorter than ever before; one consequence of this shorter hospital stay is an increase in readmission rates,6 adding to the number of acute admissions. Such short admissions need to be supported by effective safety netting so that children are discharged in the care of parents who have sufficient information to care for their children independently as they recover from their illness.

Impact of health policy

Some UK policy decisions may have had an unintended impact on children’s admission rates. Changes to GP contracts in 2004, allowing them to opt out of out-of-hours care, have been linked to the increase in childhood admissions to hospital.2–4 However, the coincidence in the timing of the GP contract change and increasing admissions does not equate to causality. Cecil et al’s3 time series analysis concluded that although primary care policy reforms had led to increases in admission for children with chronic conditions that could be managed in primary care (primary care-sensitive conditions), short-stay admissions for infectious illness, they suggested, were more likely to be related to lowered thresholds for hospital admission and/or the admission of children for observation as a consequence of the 4-hour wait target in UK EDs. The continuing trend, despite improvements in childhood mortality and morbidity, suggests that a broader, more holistic, integrated approach to the issues is needed.

In conclusion

This short review has found little evidence that increasing admission is related to increased acuity; instead it has revealed a complex interplay of health policy-driven targets, access to primary care out of hours, loss of continuity in general practice, reducing length of stay and increasing readmission rates, limited safety netting, and the impact of social media and social expectations on parents and professionals. Gill et al 4 concluded that the rise in admissions for common infectious illness in children under 5 years represented ‘a systematic failure of the NHS in assessing children with acute illness that could be managed in the community’, a conclusion also derived from Saxena et al’s2 earlier work. Further research is needed to understand the impact of the whole of the child’s journey to hospital admission, so that interventions can be developed to safely care for children with acute illness at home rather than in hospital.

References

Footnotes

  • Contributors SN drafted the first version of the paper. Coauthors then added missing text, comments on and edited the first draft of the text. SN collated the edits and comments and revised the paper. SN shared the feedback from the first draft with the coauthors, who made suggestions which were used to inform revisions of the text.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.