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How equitable is the NHS really for children?
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  1. Elizabeth Cecil
  1. Faculty of Life Sciences and Medicine, King's College London, London, UK
  1. Correspondence to Dr Elizabeth Cecil, Faculty of Life Sciences and Medicine, King's College London, London WC2R 2LS, UK; lizzie.cecil{at}kcl.ac.uk

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Health inequalities present a major challenge for the UK National Health Service (NHS), which has set that reducing health inequalities is a key priority in the 2019 NHS Long Term Plan.

New research confirms that use of healthcare services is deeply inequitable, and reflects inequitable access to healthcare for children.1 The COVID-19 pandemic has exposed and compounded effects of inequity across all ages. There are promising initiatives that integrate healthcare for children and aim to mitigate inequities in healthcare. However, healthcare alone cannot rebalance health inequalities and government policies need to address the wider determinants of health.

Background

The key components of high-quality healthcare are accessibility, effectiveness, responsiveness, safety and equity.

Access is particularly important for children and young people (CYP) as they are frequent users. Young children for routine vaccinations and developmental checks, as well as for unplanned care because they are more susceptible to infectious diseases than older children and adults. Moreover, the epidemiological transition from infectious to non-communicable disease as the main burden of disease across all age groups affects CYP too. These changes have resulted in a substantial increase, over recent decades, in health service use among CYP for long-term conditions. Emergency admissions for long-term conditions in adolescents are now more common than for injuries.2 Moreover, as the Mental Health of Children and Young People in England, 2020 Survey suggests, around 20% of young people (27.2% of young women and 13.3% of young men) are likely to have a mental health disorder. These CYP identified with a potential mental health condition compared with those without were more likely to seek help for a health concern (36% compared with 6.5%).

Equitable access to care is a platform for equitable use, and defined by ensuring care quality does not vary because of a child’s ethnicity, geographical location or socioeconomic status. Yet even in the UK, where there is a free, and supposedly universal healthcare system, the availability of medical care tends to vary inversely with the need in the population.3 The Inverse Care Law is particularly evident for children. Not only do parents from higher income groups know how to make better use of the health service for their children, their children are also registered with more accessible general practices, the first port of call for health care needs in the UK.4 The COVID-19 pandemic has been a major challenge for the NHS, and it is likely that inequalities in access to healthcare for children have increased.

Determining patterns of health service use for children is vital to investigate what is happening with demand generally, and specifically to understand trends in inequalities in access to healthcare. This can support the NHS and its role in reducing health inequalities, a key priority in the 2019 NHS Long Term Plan.

Investigating patterns in health service use

In this issue of Archives of Disease in Childhood, Coughlan et al 1 present an important new study that investigates health service use in a population-based retrospective cohort study of 1.5 million children aged less than 15 years in England, between 2007 and 2017. The authors assessed patterns of health service use across five composite ethnic groups and deprivation quintiles, based on the child’s residential postcode.

This important work demonstrated that patterns of health service use among children from deprived compared with affluent neighbourhoods differed significantly. Children from the most deprived group had fewer GP consultations and outpatient attendances but were much higher users of emergency care both for emergency department visits and emergency admissions. Similarly, patterns of health service use among children differed between ethnic groups. Children from Asian ethnic groups were high users of primary care while notably children from black ethnic groups had significantly lower outpatient use than other ethnic groups. The findings also suggested a widening of health inequalities over the study period. This manifested itself in the difference in children’s use of scheduled and unscheduled care between children living in affluent and deprived neighbourhoods.

This matters because emergency care, especially for non-urgent healthcare needs, is disruptive for families, may expose CYP to the risks of hospital-acquired infection or overmedicalise self-limiting conditions and detract care from those in more need. These contacts are also costly to the NHS. Good-quality planned care provided in outpatients and primary care can reduce avoidable emergency department contacts and hospital admissions. The substantial levels of unmet need among children living in socioeconomically disadvantaged neighbourhoods and those from black ethnic groups found in this paper are worrying and need addressing.

There are limitations in these findings which the authors acknowledge. They encountered incompleteness of coding for ethnicity (there was 12.2% missing data) and recognise the complexities around definitions and nature of ethnicity which may mask significant within-group differences. However, they feel these factors do not undermine their findings.

Towards NHS solutions to improving healthcare inequalities for children

The backdrop to this study is that the NHS has not adapted to meet the changing, and heavy, needs of CYP. Care delivery is, however, beginning to change. In recent years, health services have started developing across the UK to improve the healthcare provided to CYP. The changes focus on improving health and providing timely care that integrates primary and secondary care in a convenient location, improving accessibility, and using data to shape services according to need.

Two such services are highlighted below.

In Northwest London, Connecting Care for Children is a paediatric integrated care model bringing GPs and paediatricians together in child health hubs where healthcare can be delivered around the needs of the child to improve care and experience, and inequalities may be identified through closer multidisciplinary team working.

The Children’s and Young People Health Partnership (CYPHP) in Lambeth and Southwark, in South London, is novel in its vision.5 It functions as a partnership between healthcare providers in primary and secondary care, local councils, commissioners and academia. CYPHP has produced a CHILDS framework (https://childsframework.org) for applying population health tools to deliver bio/psycho/social care proportionate to need, and aims to address health inequalities highlighted by Coughlan et al. Instead of being reactive to healthcare demands, CYPHP actively and systematically interrogates electronic health records to identify children who may benefit from early intervention, health promotion and bio/psycho/social specialist care—care which treats CYP across their biology, psychology and socioenvironment.5

Since the Inverse Care Law ‘operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced’, it is vital that more new services are built and managed around the needs of local CYP populations, and not by market forces.

Healthcare alone cannot rebalance health inequalities. CYP’s health is influenced by social, economic and environmental factors. Tackling these wider determinants of health is essential in ensuring a healthy population. Yet this is not reflected in government policy, recent reduction in benefits has resulted in a national increase in child poverty.

The COVID-19 pandemic has caused major challenges for the NHS and highlighted the inequalities in health within the UK but there is hope that healthcare providers can narrow the widening inequalities in healthcare for CYP. It is important that providers not only build resilient, child-focused systems that are effective and safe, but also provide a system for continually measuring and improving access to healthcare for all children regardless of their backgrounds.

References

Footnotes

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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