HC 1048-III Health CommitteeWritten evidence from Dr Ingrid Wolfe, Dr Hilary Cass and Professor Sir Alan Craft (PH 159)

THE IMPLICATIONS FOR CHILD HEALTH OF REMOVING PUBLIC HEALTH FROM THE NHS

Authors:

Dr Ingrid Wolfe, Child Public Health Research Fellow and Paediatrician, London School of Hygiene and Tropical Medicine; Whittington Hospital.

Dr Hilary Cass, Paediatric Neurodisability Consultant, Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London.

Professor Sir Alan Craft, emeritus professor (child health) Newcastle University, Newcastle.

Summary

Children’s health services in the UK are not delivering the highest quality care to children and families.

One major explanation is that currently child public health services lack the expertise, data, and workforce to plan, commission, and improve children’s health care to world-class standards.

Child health data must be improved. This is essential if we are to improve the planning and commissioning of children’s health services to improve outcomes and ensure the NHS is prepared to meet children’s health needs in the future. The role and funding of Public Health Observatories should be strengthened to achieve this important function.

Public health services, which are currently located in Primary Care Trusts, are too far removed from the front line of health care to provide the expert support necessary to advise on service delivery priorities, measuring service outcomes, and improving children’s health services.

Child public health should be developed as a specialist field of expertise, with professionals working at all levels of the health service, as well as within senior levels of Local Authorities.

1. Ill health and social disadvantage start before birth and accumulate through life. Hence investment in health and social welfare early in life has a disproportionate benefit accrued throughout the life course. Giving every child the best start in life is therefore the first recommendation of the Marmot Review.⁽¹⁾

2. We will confine the content of this submission to addressing the role of public health in health services for children because there are distinct differences between children’s and adults’ health services that are frequently overlooked.

3. Indications of the quality of children’s health care suggest that the UK performs poorly in many regards. Examples follow:⁽²⁾

3.1 A confidential inquiry into a sample of children’s deaths showed that there was an identifiable failure in 26% of deaths and a further 43% of deaths were potentially avoidable.⁽³⁾

3.2 Around 50% of children who were subsequently diagnosed with meningococcal infection were sent home after their first consultation with the health service.⁽⁴⁾ The cost to the NHS is over £20 million in legal settlements alone for the past 12 years.⁽⁵⁾

3.3 Over a third of admissions for asthma could have been prevented with better primary care.⁽⁶⁾ The cost of these is over £7,000,000 per year.⁽²⁾

3.4 Over a third of short-stay admissions for infants are for minor illnesses that could have been managed in community settings,⁽⁷⁾ costing over £100,000,000 per year.⁽²⁾ Improving this would mean greater convenience for the family and lower cost to the taxpayer.

3.5 More children in the UK die from illnesses that rely heavily on first-access care (primary care and emergency departments) and which should be preventable, than in comparable European countries. These include pneumonia, asthma, and meningococcal disease.⁽²⁾

3.6 Survival rates for some childhood cancers are lower in the UK than Europe.⁽⁸⁾

3.7 Only 3% of children with asthma have written plans (which are known to be effective) for preventing managing complications at home.⁽⁹⁾

3.8 Only 4% of children with diabetes receive care consistent with guidelines, and many children have preventable complications including death from diabetes.⁽¹⁰⁾

3.9 It is estimated that over a third of outpatient referrals from General Practitioners to Paediatricians would be avoidable with better primary care.⁽¹¹⁾

3.10 Around half of Acute Trusts are weak in paediatric outpatient care, with planned services fitting in around acute care.⁽¹²⁾ However the evidence on disease prevalence and trends shows that efforts should be focused much more strongly on planned care for children with chronic diseases, together with preventive services to improve health in the future.⁽²⁾

4. What underlies these problems in children’s health services?

4.1 NHS health care evaluation focuses on adults’ health conditions and services. There are no comprehensive assessments of children’s health services in the UK. One reason for this is that evaluation methods for NHS care are often more suitable for adults’ health services than children’s. For example waiting times and complication rates for surgery are much more applicable to adults’ than children for whom planned surgery is a minimal part of usual health service use. A further important reason is the lack of reliable routinely collected data on children’s health needs and service outcomes.

4.2 The General Practitioners’ Contract and remuneration and incentive scheme (Qualities and Outcomes Framework) makes scarce mention of children, focusing strongly on adults’ chronic disease management.

4.3 General practitioners are not required formally to train in paediatrics

4.4 There is a serious shortage of paediatricians available to safely fill the number of hospital posts. The workforce shortage causes existing staff to be over-stretched, with acute demands necessarily taking precedence over planned care for children with long-term conditions. One consequence of this is the fragmented poorly coordinated care that so many families complain of, and the poor outcomes associated with many chronic diseases.

4.5 Paediatricians are trained in specialised children’s medicine, whereas an increasing numbers of children are presenting to hospital with minor illnesses. The result is inefficient use of health services and frequently dissatisfied parents.

4.6 Health service planners and commissioners are forced to rely mainly on existing patterns of services use, rather than on the needs of children and families, to drive service configuration, which in turn determines workforce training, numbers, and distribution. This lack of data on children’s health needs leads to a flawed system becoming self-perpetuating.

5. What could public health do to improve children’s health services?

5.1 We believe that Primary Care Trusts have not been as effective at planning and commissioning children’s health services as they should have been. There are three major reasons:

5.1.1 First, the location of the public health function, situated at a distance from the front line clinical world.

5.1.2 Second, the increasing distance between public health professionals and clinicians over the past several years.

5.1.3 Finally, there is a lack of reliable regularly collected data on child health need with which service planners, commissioners, and regulators can monitor and improve services.

6. What are the implications for children’s health services of the current proposed changes to Public Health?

6.1 Removing public health functions from the NHS and locating them within Local Authorities risks further reducing the ability of public health to plan, commission, and improve children’s health services.

6.2 The public health workforce currently is slowly developing skills in child public health, and these risk being undermined as the workforce is further fragmented by removing public health from the NHS.

6.3 We believe public health has a strong role to play, at the highest levels, in Local Authorities. Their role there is essential in tackling the determinants of illness, and in strengthening the determinants of health.

6.3 However, in order to be best-placed to improve children’s health services, public health needs to be brought closer in to the front line of health care.

6.4 Public Health Observatories are essential in providing data on health needs. Progress is being made in improving the paucity of child health data, but there is a great deal more that needs to be done. Reliable data is of fundamental importance in delivering high quality care and in planning and improving services, so the future of public health observatories must not be imperiled if we are to improve our abilities not meet children’s health needs.

7. Our recommendations:

7.1 Planning, commissioning and improving children’s health care is a specialised area of expertise, requiring skills distinct from general public health, health service planners, and commissioners. A child public health specialty should urgently be developed to fill this role.

7.2 Public health observatories must be supported and strengthened in their roles in providing reliable child health data on which to evaluate, plan, commission, and improve children’s health services.

7.3 Child public health specialists should work at the front line of the health service in planning and improving care, and in delivering preventive care. They should work at regional and national strategic levels in planning and commissioning larger scale services, and in planning workforce numbers and distribution.

7.4 Child public health professionals should be involved at all levels of the health service, from advising on service delivery priorities and outcome measures, to assessing quality and advising on improvement measures. To do this well, child public health must develop as a specialty, and work closely with professionals in all aspects of the NHS as well as Local Authorities.

References

(1) Marmot M. Fair Society, Healthy Lives: strategic review of health inequalities in England post 398 2010

(2) Wolfe, I. Cass, H, Thompson, M. et al. How can we improve child health services? BMJ 2011; 342: d1277

(3) Pearson G. Why children die: a pilot study 2006; England (South West, North East, and West 401Midlands), Wales and Northern Ireland. London: Confidential Enquiry into Maternal and Child 402Health2008.

(4) Thompson MJ, Ninis N, Perera R, Mayon-White R, Phillips C, Bailey L, et al. Clinical 404 recognition of meningococcal disease in children and adolescents. Lancet. 2006;367:397–403.

(5) Medical Defence Union. Media Release: GPs face diagnostic difficulties over meningitis. 406 August 2, 2010.

(6) The Asthma Divide: inequalities in emergency care for people with asthma in England: 408 Asthma UK2007

(7) Saxena S, Bottle A, Gilbert R, Sharland M. Increasing short-stay emergency hospital 410 admissions among children in England; trend trends analysis. PLoS ONE. 2009;4(10):e7484.

(8) Gatta G, Corazziari I, Magnani C, Peris-Bonet R, Roazzi P, Stiller C. Childhood cancer survival 415 in Europe. Ann Oncol. 2003;14 Suppl 5:v119–27.

(9) Respiratory Alliance. Bridging the Gap: commissioning and delivering high quality integrated 418 respiratory healthcare2003.

(10) National Diabetes Audit. Key findings about the quality of care for children and young people with diabetes in England and Wales.2007–2008.

(11) Milne C, Forrest L, Charles T, editors. Learning from analysis of general practitioner referrals 437 to a general paediatric department. Royal College of Paediatrics and Child Health annual conference; 438 2010; Warwick University.

(12) Improving services for children in hospital: report of the follow up to the 2005/06 review.: 453 Health Care Commission 2009.

June 2011