Results

TRENDS IN CHILDREN'S ADMISSIONS

Figure 1 shows trends over the past nine years for all children admitted to children's wards. For paediatrics, we have only used episodes in babies aged over 6 days. This may slightly undercount the few paediatric admissions from home to children's wards at this age. A general fall in children's surgical episodes has been accompanied by an 82% rise in day case work (from 81 879 elective surgical day cases in 1989 to 149 121 in 1997/98). For paediatric medicine, there has been a 26% rise in inpatient episodes between 1989 and 1997 overall, but from about 1993 this appears to have reached a plateau. Both mean and median LOS have continued to fall over this time, reflecting the skewed distribution consequent on the trend to very short episodes. This supports the value of reporting median as well as mean LOS (tables4 and 7).

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Children's ward admissions—paediatric age over 6 days and children's surgical.

View this table:

• View inline
• View popup

Table 7

Length of stay (LOS) in days, reported in paediatrics report of House of Commons select committee16

Discussion

Children make heavy use of hospitals for paediatric and surgical inpatient care, but reported activity in NHS hospital episodes statistics (HES) for the specialty of paediatrics needs to be interpreted cautiously to avoid over estimating usage. At first sight, the HES data suggest a very high level of hospital utilisation for paediatrics, reporting between 900 000 and just over one million episodes each year, with surgical work additional to this. But the paediatric numbers include about 500 000 newborns, both “well babies” and babies receiving special or intensive care.

In fact, the work for inpatient children's wards for both children's surgical and paediatric care is of the order of 737 000 annual episodes (using 1995 as an example, there were 467 000 paediatric episodes and 305 000 for surgery). The Compendium of health statistics published by the Office of Health Economics (OHE) also suggests excessively high levels of usage because they appear to include “well babies” in the numbers they report (table10).3 For example for 1995, OHE report 1 407 000 annual episodes for children. Of these, 1 043 000 inpatient episodes were for the age group 0–4 years. Based on the child population for that year, this would be equivalent to 32.5% of the population being admitted to hospital for either paediatric or surgical care. In our view, supported by reports of The General Household Survey (GHS), this is unlikely. OHE reports 364 000 episodes in that year for the 6 230 746 children aged 5–14 years, equivalent to 5.8% of the child population. In contrast the GHS,6 based on self reporting of admissions for children's surgical and medical care, reports only 9% of the child population age 0–4 years being admitted in 1995, and 4% of those aged 5–14 years. High reported admission numbers in HES cannot be explained reasonably by “episode inflation”, which means multiple episodes (finished consultant episodes) being counted during one hospital stay. These are lower for child admissions compared to any other age group with a ratio of episodes to hospital stays of less than 1.05 (DoH statistics branch). Furthermore, in 1998/99 episodes exceeded hospital stays by only 3.6%. Neither can they be explained on this large scale by some children being admitted on multiple occasions.

Hospital use by children varies between health authorities. The health service indicators for 1994/95, for example, show variation in paediatric admission rates for those aged 0–15 with a mean of 51.5 per thousand child population (range 27.7 to 127).7Eighty-five per cent of admissions were emergencies with an average LOS of 2.6 days. This would equate to about 4–5% of children aged 0–14 years being admitted for care by a paediatrician in any given year. These data are more consistent with GHS reports. The health service indicator data do not include children's surgical admissions, but may have included an unknown extent of newborn work.

Over half of all admissions for children are for surgical care. This proportion varies according to age. Taking 1995 as an illustrative year, 24% of all 0–5 year old children's admissions were for surgical care compared with 61% of admissions for those aged 5–15 years of age. These equate to admission rates of 25.5 per thousand child population aged 0–4 years and of 33.2 per thousand for age 5–14 years. About half of children's surgical admissions are for emergencies. Trends show children's surgical workload falling slightly with LOS and overnight stays becoming shorter. Simultaneously, day case surgery has increased.

Hospital utilisation varies with social class of the population. In one report, 7.2% of the most deprived children were admitted to hospital each year for surgical or paediatric care compared with 5.5 % of the most advantaged.8 Admission rates for children aged 0–4 years for gastroenteritis in the West Midlands ranged over a five year period from 33.4 per thousand child population for the most affluent to 67 per thousand for the most deprived; similar patterns were seen for respiratory infection admissions.9 ,10 Other factors influencing hospital utilisation include proximity to hospital, degree of urbanisation,11 and different clinical practices in primary and paediatric care resulting in different pathways into hospital, for example after self referral to A&E. In one study, 8.6% of 2003 child general practitioner acute contacts seen out of hours in six cooperatives were referred for admission.12 This contrasts with another study showing that a third of non-trauma child self referrals to A&E were admitted.13

Since 1989 the previously rapid increase in paediatric admissions14 has slowed down and length of stay (LOS) continues to decrease (table 5). But even when corrected for the likely overestimates in HES data, utilisation of acute inpatient services is high, especially among younger children. Admissions for inpatient overnight surgical care have decreased (accompanied by increasing trends to day case care).

When planning or reviewing children's inpatient facilities, joint assessment of paediatric medical and surgical bed use is necessary as these are often shared between paediatrics and surgical specialties treating children. Mean LOS is used to compare performance between hospitals on children's wards. It can also be used to determine the number of children's beds required. But it is essential that paediatric statistics relating to children's wards only are used when evaluating data on LOS for calculating children's ward bed requirements.15 Special or intensive neonatal care data need to be excluded because an artificially high LOS would result from the effect of the much longer stays and resulting bed days. This is particularly so because of rise in bed days occupied in neonatal special and intensive care units. Care must also be taken to exclude data on “well babies”. Excluding this newborn data may also reduce the skew of the distribution, making mean LOS a more valid measure.

The number of children's beds is decreasing. In 1990/91, there were 10 009 (1.05 per thousand child population) and in 1995/96, 8868 beds (0.89 per thousand)—an 11.4% decrease.16 The rise in paediatric admissions has been accommodated by reducing LOS and more day case surgery. However the skew towards admission of younger children, many of whom need cubicle accommodation to control infection, has not been accompanied by an increase in the provision of these facilities. Consequently there are likely to be problems during the predictable annual increased demand arising from respiratory and intestinal infections. In future, separate identification of single occupancy cubicles should also form part of any evaluation of need. Attention should be given when designing units to take account both of short stays and new ways in which paediatrics supports primary and A&E services.