The Data-Driven Approach: Strategies for Understanding Inequality in Paediatric A&E attendances

Key messages:

Half of all paediatrics A&E attendances are from children and young people from the most deprived areas
Worrying parallels are seen in the lack of primary care provision, and the mistrust of people from deprived areas in their GPs, partially mitigated by higher numbers of doctors in A&E
To address inequalities in healthcare provision, we need to understand the context – this is where data can help
Four key areas to investigate are: causes for utilisation, complexity of patients, the wider context and the potential benefit of novel initiatives.

Unrelenting trends

Trends in persistent health inequalities remain a key policy issue. The COVID-19 pandemic laid bare the drastic health inequalities that exist among populations served by the NHS. Here we want to focus on inequalities among children, specifically how to identify them and take practical steps to address them.

A&E attendances among children for the most deprived population are higher compared to the least deprived in the UK. Although measures stratified by IMD quintiles show disparities across Trusts, insights are limited as the data is not available at the patient-level.[1] Even pre-pandemic, in 2015/2016, the most deprived Children and Young People (CYP) overall were 58% more likely to go to A&E than the least deprived (Nuffield Trust).
In our data, almost half of all paediatric A&E attendance are accounted for by the two most deprived quintiles across children aged 0 to 17 years.

What is behind the disparity?

The British Social Attitudes Survey from 2019 found that parents with children under the age of 5 living in the most deprived areas were the most frequent users of A&E in the preceding year, and they perceived it most difficult to obtain a GP appointment compared to families living in less deprived areas. Additionally, they expressed less trust in their GP but tend to utilise the internet more often to self-diagnose (BSA).

The inequality in primary care provision across IMD quintiles is evidenced by the above chart, where the most deprived areas have one whole less GP FTE per 10,000 patients compared to the least deprived. Sadly, this gap has been widening, rather than closing, as equitable workforce distribution remains a major challenge. Perhaps as a way to mitigate this and respond to the increased A&E utilisation, there are considerably higher numbers of A&E doctors across all grades in more deprived areas. Although this intervention responds to the observed differences in A&E utilisation by deprivation, workforce restructuring strategies are not enough without addressing the underlying issues causing greater inequalities (King’s Fund).

Why is this problematic?

A&E is often not the right place to provide care to children who may have more complex needs that span school settings, as well as community and secondary care (asthma, diabetes, epilepsy). The busier a paediatric A&E department, the less well suited to fully understand parents’ concerns and provide education to prevent re-admission.

The higher utilisation in A&E services reveals that the current efforts to move care in the community are failing children in most deprived areas, as A&Es respond to a lack of primary care and community investment. The increased demand for emergency services in more deprived areas is likely due to a combination of differences in need and issues with adequate primary care provision and utilisation.

Uncovering what drives higher A&E demand is paramount, especially if it is matched by lower primary care utilisation. This is because the long-term risk is fragmented children care, as A&E does not provide continuity and a holistic assessment of the wider context which is often needed in CYP.

How data can help uncover the root cause.

Data is a powerful tool that can support this quest. Here we propose four areas for investigation that are accessible to all providers, to start building solutions:

• Identify the causes for utilisation: Devise a clear picture of the main causes driving A&E utilisation to target and streamline services. Asthma is often cited as a primary cause of healthcare utilisation among children. This opens the opportunity to provide services in schools, such as the My Asthma in School (MAIS) intervention which conducted educational and self-management workshop to children. The intervention was successful: 91.4% of participants (n=1814) reported the workshop changed their perspective on asthma (PFS).

• Determine the complexity of patients: Are patients in more or less deprived areas presenting with more severe conditions requiring more treatment? Use admission rates from A&E, extent of treatment provided and attendance rates in minor/majors to find out. Parents of children living in areas of higher deprivation may wait longer to seek healthcare as other commitments take priority, such as working. On the other hand, a substantial proportion of ED attendances are non-urgent, especially in younger children (EMJ). Education in school, communities and GPs can have vast effects in both reducing unnecessary attendances to A&E and improving help-seeking behaviours.

• Understand the wider context: We have demonstrated that GP shortages in deprived areas may be a barrier for patient access. Other services such as pharmacies and other community services (e.g. health visitors, community and school nursing) may be equally affected and should be investigated. In Greater London, Child Health GP Hubs have been set up to address a shortage of GPs. These hubs are specific to paediatric children and provide more streamlined care by following a joined up care model (Imperial).

• Evaluate the benefit of novel initiatives: Could there be a benefit to integrating on-site primary care in children’s A&E? Combining community and trust data may reveal benefits in developing paediatric-specific ambulatory care centres sited in A&E. These could see children with less-acute conditions that present to A&E and provide more holistic care. Similarly, more specific paediatric services in primary care, and targeted education for primary GPs and nurses could support parents’ confidence in primary care providers, and combat the perception that paediatric A&E may provide a better service.

[1] The findings are also limited to latest available data resulting in temporal inconsistencies across analyses.