Ingrid Wolfe

Improving the transition between paediatric and adult healthcare: a systematic review

Introduction The transition between paediatric and adult care for young people with chronic illness or disability is often poorly managed, with adverse consequences for health. Although many agree that adolescent services need to be improved, there is little empirical data on which policies can be based. Objectives To systematically review the evidence of effectiveness of transitional care programmes in young people aged 11–25 with chronic illness (physical or mental) or disability, and identify their successful components. Design A systematic literature review in July 2010 of studies which consistently evaluated health outcomes following transition programmes, either by comparison with a control group or by measurement pre-intervention and post-intervention. Results 10 studies met the inclusion criteria, six of which showed statistically significant improvements in outcomes. Descriptive analysis identified three broad categories of intervention, directed at: the patient (educational programmes, skills training); staffing (named transition co-ordinators, joint clinics run by paediatric and adult physicians); and service delivery (separate young adult clinics, out of hours phone support, enhanced follow-up). The conditions involved varied (eg, cystic fibrosis, diabetes mellitus), and outcome measures varied accordingly. All six interventions that resulted in significant improvements were in studies of patients with diabetes mellitus, with glycosylated haemoglobin level, acute and chronic complications, and rates of follow-up and screening used as outcome measures. Conclusions The most commonly used strategies in successful programmes were patient education and specific transition clinics (either jointly staffed by paediatric and adult physicians or dedicated young adult clinics within adult services). It is not clear how generalisable these successful studies in diabetes mellitus will be to other conditions.

Health services for children in western Europe

Western European health systems are not keeping pace with changes in child health needs. Non-communicable diseases are increasingly common causes of childhood illness and death. Countries are responding to changing needs by adapting child health services in different ways and useful insights can be gained through comparison, especially because some have better outcomes, or have made more progress, than others. Although overall child health has improved throughout Europe, wide inequities remain. Health services and social and cultural determinants contribute to differences in health outcomes. Improvement of child health and reduction of suffering are achievable goals. Development of systems more responsive to evolving child health needs is likely to necessitate reconfiguring of health services as part of a whole-systems approach to improvement of health. Chronic care services and first-contact care systems are important aspects. The Swedish and Dutch experiences of development of integrated systems emphasise the importance of supportive policies backed by adequate funding. France, the UK, Italy, and Germany offer further insights into chronic care services in different health systems. First-contact care models and the outcomes they deliver are highly variable. Comparisons between systems are challenging. Important issues emerging include the organisation of first-contact models, professional training, arrangements for provision of out-of-hours services, and task-sharing between doctors and nurses. Flexible first-contact models in which child health professionals work closely together could offer a way to balance the need to provide expertise with ready access. Strategies to improve child health and health services in Europe necessitate a whole-systems approach in three interdependent systems-practice (chronic care models, first-contact care, competency standards for child health professionals), plans (child health indicator sets, reliable systems for capture and analysis of data, scale-up of child health research, anticipation of future child health needs), and policy (translation of high-level goals into actionable policies, open and transparent accountability structures, political commitment to delivery of improvements in child health and equity throughout Europe).

Improving child health services in the UK: insights from Europe and their implications for the NHS reforms

The coalition government’s Health and Social Care Bill is unlikely to deliver the improvements in children’s health services that are urgently needed. Useful lessons can be learnt from how other European countries deliver healthcare for children, say Ingrid Wolfe and colleagues

Deaths in young people aged 0–24 years in the UK compared with the EU15+ countries, 1970–2008: analysis of the WHO Mortality Database

BACKGROUND Concern is growing that mortality and health in children and young people in the UK lags behind that of similar countries. METHODS We analysed death registry data provided to the WHO Mortality Database to compare UK mortality for children and young people aged 0-24 years with that of European Union member states (before May, 2004, excluding the UK, plus Australia, Canada, and Norway [the EU15+ countries]) from 1970 to 2008 using the WHO World Mortality Database. We grouped causes of death by Global Burden of Disease classification: communicable, nutritional, or maternal causes; non-communicable disorders; and injury. UK mortality trends were compared with quartiles of mortality in EU15+ countries. We used quasi-likelihood Poisson models to explore differences between intercepts and slopes between the UK and the EU15+ countries. FINDINGS In 1970, UK total mortality was in the best EU15+ quartile (<25th centile) for children and young people aged 1-24 years, with UK infant mortality similar to the EU15+ median. Subsequent mortality reductions in the UK were smaller than were those in the EU15+ countries in all age groups. By 2008, total mortality for neonates, infants, and children aged 1-4 years in the UK was in the worst EU15+ quartile (>75th centile). In 2008, UK annual excess mortality compared with the EU15+ median was 1035 deaths for infants and 134 for children aged 1-9 years. Mortality from non-communicable diseases in the UK fell from being roughly equivalent to the EU15+ median in 1970 to the worst quartile in all age groups by 2008, with 446 annual excess deaths from non-communicable diseases in the UK (280 for young people aged 10-24 years) in 2008. UK mortality from injury remained in the best EU15+ quartile for the study period in all age groups. INTERPRETATION The UK has not matched the gains made in child, adolescent, and young adult mortality by other comparable countries in the 40 years since 1970, particularly for infant deaths and mortality from non-communicable diseases, including neuropsychiatric disorders. The UK needs to identify and address amenable social determinants and health system factors that lead to poor health outcomes for infants and for children and young people with chronic disorders. FUNDING None.

Primary Care Access, Emergency Department Visits, and Unplanned Short Hospitalizations in the UK

BACKGROUND AND OBJECTIVE: Demand for unplanned hospital services is rising, and children are frequent users, especially where access to primary care is poor. In England, universal health care coverage entitles parents to see a general practitioner (GP) for first-contact care. However, access to GP appointments is variable, and few patients can see their own regular GP out of hours (OOH). The goal of this study explored the association between access to GPs , emergency department (ED) visits and short hospitalizations (<2 days) in children in England. METHODS: ED visit and short hospitalization rates were investigated in 9.5 million children aged <15 years registered with English family practices between April 2011 and March 2012 by using administrative hospital data. Six access categories ranked all practices according to patients’ reported ability to schedule GP appointments; from national GP Patient Survey data. GP consulting hours were 8:00 am to 6:30 pm on weekdays. RESULTS: There were 3 074 616 ED visits (56% OOH) and 470 752 short hospitalizations over the 12 months studied. Children registered with practices in the highest access group compared with the lowest were 9% less likely to visit an ED (adjusted rate ratio: 0.91 [95% confidence interval: 0.89–93]), particularly OOH compared with consulting hours (10% vs 7%). Children in the highest access groups were equally likely to be admitted for a short stay. CONCLUSIONS: Increasing GP accessibility might alleviate the burden of ED visits from children, particularly during peak times OOH. Short hospitalizations may be more sensitive to other aspects of health systems.

Public health in England: an option for the way forward?

It was clear as soon as it was announced that UK Health Secretary Andrew Lansleys unexpected decision to subject the National Health Service (NHS) in England to revolutionary change would have profound consequences for public health. The White Paper, Healthy lives, healthy people, proposes that the public health function currently based in Primary Care Trusts be fragmented (figure). Some elements will move to the Department of Health, to a division called Public Health England, while others will move into local government. Health-care planning elements might move to proposed Commissioning Consortia and the NHS Commissioning Board, although this is not explicit.

How can we improve child health services

The coalition government’s Health and Social Care Bill is unlikely to deliver the improvements in children’s health services that are urgently needed. Useful lessons can be learnt from how other European countries deliver healthcare for children, say Ingrid Wolfe and colleagues

Health policy research: successes and challenges

This review seeks to explore and explain what health policy research is and why it matters, through pooling the evidence and providing case examples. Alongside examining the types of research involved, and their rationale the paper identifies the challenges taking part in this sort of research may create. Finally the paper suggests how to make clinical research more accessible to policy makers.

UK child survival in a European context: recommendations for a national Countdown Collaboration

The development of a United Nations sponsored Millennium Development Goal (MDG) relating to childhood survival contributed significantly to reducing mortality among children under 5 years old in many countries in the first years of the twenty-first century.1 The development of an independent authoritative mechanism, the Countdown to 2015 Collaboration contributed significantly to global progress towards the goals. While childhood mortality in the UK has also decreased over the past 40 years, the UKs child mortality trends and excess deaths figures compare unfavourably with many European countries.1 ,2 It is increasingly clear that the UK could do better in ensuring the best possible conditions for children to survive and thrive. Several recent publications have highlighted the extent of the problem, and stimulated responses from government and non-governmental sectors.3–7 We propose now that an independent cross-sector mechanism be set up to agree targets for reduction of UK excess child and adolescent mortality, identify gaps in knowledge, monitor progress in reaching goals and make recommendations that contribute towards improving UK child survival. In this paper, we first review the UKs performance on child and adolescent mortality compared with other wealthy countries in order to establish a baseline for future monitoring. We examine why the UK has higher child and adolescent mortality compared with some other European countries, by describing main causes and social determinants of death. Finally we explore what can be done to reduce mortality, and make recommendations to improve UK child and adolescent survival. We used data from the Organisation for Economic Cooperation and Development (OECD) for infant mortality8 and the WHO World Mortality Database for 1–19-year-olds9 to calculate centiles of child and adolescent mortality for a group of comparable wealthy countries identified as appropriate comparators for UK mortality.1 ,10 These countries are the …

Childhood disadvantage and emergency admission rates for common presentations in London: An exploratory analysis

Aim To determine whether emergency hospital admission rates (EAR) for common paediatric conditions in Greater London are associated with measures of child well-being and deprivation. Design Retrospective analysis of hospital episode statistics and secondary analysis of the Index of Multiple Deprivation (IMD) 2007 and Local Index of Child Well-Being (CWI) 2009. Setting 31 Greater London primary care trusts (PCTs). Outcome measures EAR in PCTs for breathing difficulty, feverish illness and/or diarrhoea. Results 24 481 children under 15 years of age were discharged following emergency admission for breathing difficulty, feverish illness and/or diarrhoea during 2007/2008. The EAR for breathing difficulty was associated with the IMD (Spearmans rho 0.59, p<0.001) and IMD indicators of: overcrowding (Spearmans rho 0.62, p<0.001), houses in poor condition (Spearmans rho 0.55, p=0.001), air quality (Spearmans rho 0.53, p=0.002), homelessness (Spearmans rho 0.44, p=0.013), and domains of the CWI: housing (Spearmans rho 0.64, p<0.001), children in need (Spearmans rho 0.62, p<0.001), material (Spearmans rho 0.58, p=0.001) and environment (Spearmans rho 0.53, p=0.002). There were no statistically significant relationships between the EAR of children admitted for feverish illness and diarrhoea or aged under 1 year for any condition, and the IMD, either IMD indicators or CWI domains. Conclusions Housing and environmental factors are associated with childrens demand for hospital admission for breathing difficulty. Some associations are stronger with the CWI than the IMD. The CWI has potential to identify priority PCTs for housing and environment interventions that could have specific public health benefits for respiratory conditions.