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Understanding case mix across three paediatric services: could integration of primary and secondary general paediatrics alter walk-in emergency attendances?
  1. Lloyd Steele,
  2. Nicky Coote,
  3. Robert Klaber,
  4. Mando Watson,
  5. Michael Coren
  1. Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
  1. Correspondence to Dr Lloyd Steele, Department of Paediatrics, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London W2 1NY, UK; lloyd.steele{at}


Objective To understand the case mix of three different paediatric services, reasons for using an acute paediatric service in a region of developing integrated care and where acute attendances could alternatively have been managed.

Methods Mixed methods service evaluation, including retrospective review of referrals to general paediatric outpatients (n=534) and a virtual integrated service (email advice line) (n=474), as well as a prospective survey of paediatric ambulatory unit (PAU) attendees (n=95) and review by a paediatric consultant/registrar to decide where these cases could alternatively have been managed.

Results The case mix of outpatient referrals and the email advice line was similar, but the case mix for PAU was more acute. The most common parental reasons for attending PAU were referral by a community health professional (27.2%), not being able to get a general practitioner (GP) appointment when desired (21.7%), wanting to avoid accident and emergency (17.4%) and wanting specialist paediatric input (14.1%). More than half of PAU presentations were deemed most appropriate for community management by a GP or midwife. The proportion of cases suitable for community management varied by the reason for attendance, with it highestl for parents reporting not being able to get a GP appointment (85%), and lowest for those referred by community health professionals (29%).

Conclusions One in two attendances to acute paediatric services could have been managed in the community. Integration of paediatric services could help address parental reasons for attending acute services, as well as facilitating the community management of chronic conditions.

  • health services research
  • health service

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What is already known on this topic?

  • Many health services could shift from the hospital to the community.

  • Reasons for use of acute services are multifactorial and complex.

  • Secondary services need to overcome organisational boundaries and historic cultures around the way specialists work in order to help primary services optimise the care they provide.

What this study adds?

  • Approximately half of paediatric ambulatory unit (PAU) attendees are suitable for community management.

  • The most common reasons for attending PAU reported by parents are referral by a community health professional, not being able to get a general practitioner appointment, not wanting to attend accident and emergency and wanting specialist input.

  • The nature of cases referred to general outpatients suggests a significant proportion could be managed in the community through integrated care initiatives.


There is a broad consensus that many health services could shift from the hospital to the community.1 2 Key to achieving this change is integration or, perhaps more accurately, making connections.3 Secondary services need to overcome organisational boundaries and historic cultures around the way specialists work in order to help primary services optimise the care they provide.1 In North West London, initiatives are already in place to achieve this through the Connecting Care for Children programme.4 5 These include outreach hubs, joint general practitioner (GP)–paediatrician clinics run in GP practicesand an email and telephone hotline service, a service run by hospital paediatricians that provides specialist input to the community remotely.5 7

The use of healthcare services has become a focus of health research in recent years, particularly in relation to the diverse needs of service users and the appropriate use of services.8 In addition to GP practices and accident and emergency (A&E), there has been a proliferation of other first-contact care services such as NHS 111, community pharmacists, urgent care centres and ambulatory care units.9 10 These can lead to families accessing care across a number of different settings, resulting in duplication of cost and effort, gaps in information and communication and a lack of continuity of care.11

In this service evaluation, we assessed presentations to three different paediatric services in the North West London region: a paediatric ambulatory unit (PAU), a general paediatric outpatient clinic and a virtual integrated service (an email advice line). We aimed to gain a greater understanding of case mixes across these services, reasons why parents attended PAU in this region of developing integrated care, parents’ awareness of other healthcare services and where PAU cases could alternatively have been managed.



We prospectively reviewed 534 consecutive general paediatric outpatient referrals (22 October 2015–21 May 2016), the traditional method of communication between primary and secondary care.


We retrospectively reviewed 474 emails that were referred to our email service (1 January 2015–9 September 2015), recording the case referred and what input was requested. This more novel communication route between paediatricians (registrars and consultants) and community health professionals aims to provide a response within 48 hours.

Paediatric ambulatory unit

We prospectively surveyed 95 parents (28 September 2015–23 October 2015) attending PAU using an anonymous questionnaire. This was initially piloted for a 1-week period to improve the logistics of the process. We asked parents why they attended and what they would do if the PAU was not available (a blank space question to explore what other first-contact services parents were aware of). We also asked for parents to score accessibility, waiting time, satisfaction with diagnosis/treatment and overall experience using Likert scales, as well as the Friends and Family Test, their postcode and their GP practice. Clinical notes for every attendee were retrospectively reviewed by a paediatric consultant or registrar at the end of each day to decide where these patients would have most appropriately been reviewed from a list of options (GP, A&E, hospital review (including rapid referral clinic) and midwife review).

We assessed attendances at the PAU at Hammersmith Hospital, London. This unit is open Monday to Friday from 09:00 to 17:00. Patients can walk in to be seen without an appointment but can also be signposted to the service by GPs or other healthcare professionals. In London, 22 hospitals now have some form of PAU,10 which are considered an effective alternative to A&E for the assessment and early management of acutely ill children.10 12

Statistical analysis

Results were analysed using SPSS V. (SPSS, Chicago, Illinois, USA). The χ2 test was used to assess whether there was a significant difference in the percentage of cases suitable for community management by the reason for attendance.


Case mix comparison and use of the email advice line

We found a similar case mix between paediatric outpatient referrals and the email advice line (table 1). This suggested that the email service could have been used more frequently prior to outpatient referral. Of the cases discussed via email, community health professionals asked for advice on: cause and/or investigations (31%), management (29%), referral (29%), result interpretation (5%) and whether a service was available, notably paediatric electrocardiograms and counselling (5%).

Table 1

Fifteen most common cases for paediatric outpatients, the paediatric email service and the PAU

Parents and PAU

Paediatric consultants and registrars felt that approximately 50% of PAU presentations could have been appropriately managed in the community setting by the GP (48.3%) or midwife (2.3%), with the remainder most appropriate for hospital review (including rapid referral clinic) (31.0%) and A&E (18.4%). Despite this, only a minority of parents of children in whom community management was deemed most appropriate would have attended their GP if the PAU was not available (9.5%) (figure 1), with the most common response being to attend A&E (47.6%). Awareness of other services was low (4.8% of attendeess would have used private services, 3.2% would have used urgent care centres/walk-in centres, 1.1% would have consulted their midwife and 1.1% would have phoned NHS 111).

Figure 1

Where paediatricians felt each case at the PAU would most appropriately have been reviewed, and where parents would have gone if the PAU was not available. A&E, accident and emergency; GP, general practitioner; PAU, paediatric ambulatory unit.

Parental reasons for attending the PAU were: referral by GP/midwife/nurse/health visitor (27.2%), not being able to get a GP appointment when they desired (21.7%), wanting to avoid A&E (17.4%), specialist paediatric input was desired (14.1%), being advised by NHS direct (4.2%), being advised by their school (1.1%) and not being registered with a GP (1.1%). There was no response in 5.3% of cases. The proportion of cases suitable for management in other settings varied significantly by the parental reason for attendance (p=0.012), with those stating they were unable to get a GP appointment having the greatest proportion of cases suitable for community management (85.0%) and those referred by community health professionals having the least (29.2%) (figure 2).

Figure 2

Reason for attendance at PAU subdivided by where paediatricians felt each case would most appropriately be managed. A&E, accident and emergency; GP, general practitioner; NHS, National Health Service; PAU, paediatric ambulatory unit.

Patients generally lived close to both their registered GP practice (median 0.6 (range 0.1–13.1) miles) and the PAU (1.35 (0.1–7.1) miles). Parental satisfaction with PAU was high, with a 100% positive response to the Friends and Family Test and positive mean scores for accessibility (4.7/5), waiting time (4.3/5), diagnosis and treatment (4.7/5) and overall experience (4.6/5).


We found that approximately half of PAU attendees were suitable for community management. Despite this, many parents would have attended A&E rather than their GP if PAU was not available, and very few would have used alternative services. The proportion of cases suitable for community management varied by parental reason for attendance.

Our results are consistent with a previous report that demonstrated that more than 60% of children attending A&E were suitable for GP review.10 In the context of rising attendance rates for children and young people at acute services,13 new models of care to address this issue have been high on the agenda.10 14 15 Integrated services are a major part of this.16 17

The role for the provision of specialist support in the community through integrated care initiatives is most recognised with chronic conditions. We observed a potentially greater role for the use of the paediatric email advice line prior to referral of children with more chronic complaints to outpatients. This virtual service was used to help optimise work-up, diagnosis and management plans of children in the community. In addition, when secondary care was needed, it helped direct referrals when appropriate, including to other integrated services, to help ensure that children were seen in the right place, by the right person, at the right time. Our experience over many years has shown that such virtual integration is best used in the context of face-to-face working, including joint GP–paediatrician clinics and multidisciplinary team meetings. These involve a variety of healthcare professionals in the management of children with complex conditions and help to build relationships between primary and secondary care providers, lowering the threshold for open, honest and supportive communication in the future.6 Although more suited to helping manage chronic conditions in the community, these integrated initiatives could impact the use of acute services through their wider benefit of changing the perception of primary care services. One study showed that after attending a joint GP–paediatrician clinic, parents were more likely to take their child to the GP again- at least in part due to the specialist links they perceived the GP to have had.6 In our cohort, 21.7% of PAU attendees reported that they attended due to the belief their child needed or would receive specialist care.

There are also wider benefits of integration to community health professionals, from whom 22.7% of PAU attendees were referred. In addition to the aforementioned widened network of clinical support provided, integrated care initiatives also provide educational opportunities for community health professionals. These are important as up to 40% of GPs spend no time in formal paediatric training,10 and although GPs remain the most widely used and trusted source of advice for parents of sick children, there is a desire from parents that the service is strengthened.18 GPs largely report improved professional capabilities and there is evidence for reduced hospital referrals with integration initiatives.5 6 A previous study also suggested this, reporting that as the level of support available to GPs increased, so did the proportion of A&E cases they were able to manage.19

We observed the greatest proportion of cases suitable for community management were those in which parents stated they were unable to get a GP appointment. Discussion with a local GP suggested that appointments were generally available, including extra out-of-hours appointments during evenings and weekends. Previous research has shown that the majority of urban urgent care attendees do not contact their GP prior to attending,20 with most attending because of convenience and ease of access.20 In our study, the PAU was rated highly for accessibility and overall experience, again suggesting this may have been a more important driver for unscheduled care use than GP availability. Changing the perception of primary care services may be important in influencing acute attendances and may may be especially important to this cohort,24 as although they were seeking acute care, they were also acknowledging that consulting their GP would be the most appropriate course of action.  Integration initiatives may help improve the perception of primary care services by bringing specialist care to the community and reinforcing the view that the GP practice is the ’trusted place' to be.24

Limitations of this service evaluation

Our results were limited to a single centre and thus may not be generalisable, and the sample size assessed was small. Although numerous national reports into children’s services have stressed the importance of integrated services, systematic evidence for efficacy currently remains limited.21 Having more evidence that integrated care is an efficient model of care and one that resonates with the public will be important in meeting funding challenges and changing commissioning strategies. Evidence may be available with the results of the ongoing Models of Child Health Appraised study, which aims to identify the optimal models of children’s primary healthcare across Europe.22


Taking specialist care to patients, establishing relationships between professionals and upskilling GPs are all important mechanisms common to integrated care initiatives that can strengthen the primary care service.23 They also have influences on both parent and professional in promoting the use of local community settings in the future. The case mixes we observed suggested that more outpatient referrals and non-severe acute cases could be managed in the community, and we suggest that integration on a wider scale will be important in facilitating this.



  • Contributors LS acquired data and initially analysed and interpreted data. NC, RK, MW and MC helped with study conception and interpretation of data. LS drafted and revised the paper and is guarantor. NC, RK, MW and MC revised the paper. All authors approved the final version.

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

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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