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Final warning on the need for integrated care systems in acute paediatrics
  1. Damian Roland1,2,
  2. Ingrid Wolfe3,4,
  3. Robert Edward Klaber5,6,
  4. Mando Watson5
  1. 1Sapphire Group, Health Sciences, University of Leicester, Leicester, UK
  2. 2Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, University Hospitals of Leicester NHS Trust, Leicester, UK
  3. 3Department of Women and Children’s Health, King’s College London, London, UK
  4. 4Institute for Women and Children’s Health, King’s Health Partners, London, UK
  5. 5Department of Paediatrics, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
  6. 6Academic Centre for Paediatrics & Child Health, Imperial College London, London, UK
  1. Correspondence to Dr Damian Roland, Health Sciences, University of Leicester, Leicester LE1 7RH, UK; dr98{at}leicester.ac.uk

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The term ‘acute’ is not synonymous with emergency but this better describes the needs of the 4.42 million children1 (age 0–14 years) who presented to emergency departments in 2017–2018. This huge expansion of ‘emergency’ presentations has taken place relatively quickly (in 2008–2009 there were 2.66 million) and has challenged traditional paediatric services. A decade ago, an unwell child would have presented to their general practitioner (GP) and if necessary referred to see a general paediatrician on an ‘acute’ take. Pathways to emergency care are now much more plentiful, reflecting attempts to both mitigate demand on emergency departments and the emphasis on patient choice in health policy. Attendances for children (age 0–14 years) have remained at about 20% of all emergency presentations for over a decade1; however, short stay admission (less than 24 hours) is becoming the predominant outcome for most referrals.2 While new pathways into the system have opened up (telephone services, urgent care hubs, etc), this has led to regional variation and confusion for parents.3 We still have old models of professional hierarchies which gate-keep access to secondary care and are often dependent on writing letters (although electronically) with little or no focus on prevention. This negates an important continuum emphasised as early as the 1920 Dawson Report (figure 1) and continues to still present a challenge to policymakers today.

Figure 1

Extract from the Dawson Report, courtesy of King's Fund.

The reasons for these deficits in continuity and comprehensiveness are multifactorial. Certainly, it is likely the UK 2004 General Medical Services contract, which changed out of hours provision, affected care for children along with changing societal expectations in relation to managing simple illness. However, it is also the case that paediatricians have been slow to adapt to the ever-increasing demand for specialist input, advice and/or …

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Footnotes

  • Twitter @damian_roland, @bobklaber, @mandowatson

  • 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; externally peer reviewed.