Janice Allister

Variation in Recorded Child Maltreatment Concerns in UK Primary Care Records: A Cohort Study Using The Health Improvement Network (THIN) Database

Objectives To determine variation over time and between practices in recording of concerns related to abuse and neglect (maltreatment) in childrens primary care records. Design Retrospective cohort study using a United Kingdom representative primary care database. Setting 448 General Practices. Participants In total 1,548, 972 children (<18 y) registered between 1995 and 2010. Main Outcome Measures Change in annual incidence of one or more maltreatment-related codes per child year of registration. Variation between general practices measured as the proportion of registered children with one or more maltreatment-related codes during 3 years (2008–2010). Results From 1995–2010, annual incidence rates of any coded maltreatment-related concerns rose by 10.8% each year (95% confidence interval 10.5, 11.2; adjusted for sex, age and deprivation). In 2010 the rate was 9.5 per 1000 child years (95%CI: 9.3, 9.8), equivalent to a prevalence of 0.8% of all registered children in 2010. Across all practices, the median prevalence of children with any maltreatment-related codes in three years (2008 to 2010) was 0.9% (range 0%–13.4%; 11 practices (2.5%) had zero children with relevant codes in the same period). Once we accounted for sex, age, and deprivation, the prevalence for each practice was within two standard errors of the grand mean. Conclusions General Practitioners (GPs) are far from disengaged from safeguarding children; they are consistently and increasingly recording maltreatment concerns. As these results are likely to underestimate the burden of maltreatment known to primary care, there is much scope for increasing recording in primary care records with implications for resources to respond to concerns about maltreatment. Interventions and policies should build on this evidence that the average GP in the UK is engaged in child safeguarding activity.

Who comes back with what: a retrospective database study on reasons for emergency readmission to hospital in children and young people in England

Objective To determine the proportion of children and young people (CYP) in England who are readmitted for the same condition. Design Retrospective cohort study. Setting National administrative hospital data (Hospital Episode Statistics). Participants CYP (0-year-olds to 24-year-olds) discharged after an emergency admission to the National Health Service in England in 2009/2010. Main outcome measures Coded primary diagnosis classified in six broad groups indicating reason for admission (infection, chronic condition, injury, perinatal related or pregnancy related, sign or symptom or other). We grouped readmissions as ≤30 days or between 31 days and 2 years after the index discharge. We used multivariable logistic regression to determine factors at the index admission that were predictive of readmission within 30 days. Results 9% of CYP were readmitted within 30 days. Half of the 30-day readmissions and 40% of the recurrent admissions between 30 days and 2 years had the same primary diagnosis group as the original admission. These proportions were consistent across age, sex and diagnostic groups, except for infants and young women with pregnancy-related problems (15–24 years) who were more likely to be readmitted for the same primary diagnostic group. CYP with underlying chronic conditions were readmitted within 30 days twice as often (OR: 1.93, 95% CI 1.89 to 1.99) compared with CYP without chronic conditions. Conclusions Financial penalties for readmission are expected to incentivise more effective care of the original problem, thereby avoiding readmission. Our findings, that half of children come back with different problems, do not support this presumption.

Responses to concerns about child maltreatment: a qualitative study of GPs in England.

Objectives To provide a rich description of current responses to concerns related to child maltreatment among a sample of English general practitioners (GPs). Design In-depth, face-to-face interviews (November 2010 to September 2011). Participants selected and discussed families who had prompted ‘maltreatment-related concerns’. Thematic analysis of data. Setting 4 general practices in England. Participants 14 GPs, 2 practice nurses and 2 health visitors from practices with at least 1 ‘expert’ GP (expertise in child safeguarding/protection). Results The concerns about neglect and emotional abuse dominated the interviews. GPs described intense and long-term involvement with families with multiple social and medical problems. Narratives were distilled into seven possible actions that GPs took in response to maltreatment-related concerns. These were orientated towards whole families (monitoring and advocating), the parents (coaching) and children (opportune healthcare), and included referral to or working with other services and recording concerns. Facilitators of the seven actions were: trusting relationships between GPs and parents, good working relationships with health visitors and framing the problem/response as ‘medical’. Narratives indicated significant time and energy spent building facilitating relationships with parents with the aim of improving the childs well-being. Conclusions These GPs used core general practice skills for on-going management of families who prompted concerns about neglect and emotional abuse. Policy and research focus should be broadened to include strategies for direct intervention and on-going involvement by GPs, such as using their core skills during consultations and practice systems for monitoring families and encouraging presentation to general practice. Exemplars of current practice, such as those identified in our study, should be evaluated for feasibility and acceptability in representative general practice settings as well as tested for efficacy, safety and cost. The seven actions could form the basis for the ‘lead professional’ role in general practice as proposed in the 2013 version of ‘Working Together ’guidance.

Contribution of recurrent admissions in children and young people to emergency hospital admissions: retrospective cohort analysis of hospital episode statistics

Objective To examine the contribution of recurrent admissions to the high rate of emergency admissions among children and young people (CYP) in England, and to what extent readmissions are accounted for by patients with chronic conditions. Design All hospital admissions to the National Health Service (NHS) in England using hospital episode statistics (HES) from 2009 to 2011 for CYP aged 0–24 years. We followed CYP for 2 years from discharge of their first emergency admission in 2009. We determined the number of subsequent emergency admissions, time to next admission, length of stay and the proportion of injury and chronic condition admissions measured by diagnostic codes in all following admissions. Results 869 895 children had an index emergency admission in 2009, resulting in a further 939 710 admissions (of which 600 322, or 64%, were emergency admissions) over the next 2 years. After discharge from the index admission, 32% of 274,986 (32%) children were readmitted within 2 years, 26% of these readmissions occurring within 30 days of discharge. Recurrent emergency admission accounted for 41% of all emergency admissions in the 2-year cohort and 66% of inpatient days. 41% of index admissions, but 76% of the recurrent emergency admissions, were in children with a chronic condition. Conclusions Recurrent admissions contribute substantially to total emergency admissions. They often occur soon after discharge, and disproportionately affect CYP with chronic conditions. Policies aiming to discourage readmissions should consider whether they could undermine necessary inpatient care for children with chronic conditions.

How to protect general practice from child protection

Mike Fitzpatricks views1 are outdated. He begins his article by mentioning the tragic cases of Victoria Climbie and Peter Connelly (Baby P): in both cases the GPs were found to be negligent. He attempts to undermine the whole system of safeguarding. It is a cynical denial of what is a very real problem. He is right to say that we should not be driven by media …

A simple clinical coding strategy to improve recording of child maltreatment concerns: an audit study

Background Recording concerns about child maltreatment, including minor concerns, is recommended by the General Medical Council (GMC) and National Institute for Health and Clinical Excellence (NICE) but there is evidence of substantial under-recording. Aim To determine whether a simple coding strategy improved recording of maltreatment-related concerns in electronic primary care records. Design and Setting Clinical audit of rates of maltreatment-related coding before January 2010–December 2011 and after January–December 2012 implementation of a simple coding strategy in 11 English family practices. The strategy included encouraging general practitioners to use, always and as a minimum, the Read code ‘Child is cause for concern’. A total of 25,106 children aged 0–18 years were registered with these practices. We also undertook a qualitative service evaluation to investigate barriers to recording. Method Outcomes were recording of 1) any maltreatment-related codes, 2) child protection proceedings and 3) child was a cause for concern. Results We found increased recording of any maltreatment-related code (rate ratio 1.4; 95% CI 1.1–1.6), child protection procedures (RR 1.4; 95% CI 1.1–1.6) and cause for concern (RR 2.5; 95% CI 1.8–3.4) after implementation of the coding strategy. Clinicians cited the simplicity of the coding strategy as the most important factor assisting implementation. Conclusion This simple coding strategy improved clinician’s recording of maltreatment-related concerns in a small sample of practices with some ‘buy-in’. Further research should investigate how recording can best support the doctor–patient relationship. How this fits in Recording concerns about child maltreatment, including minor concerns, is recommended by the General Medical Council (GMC) and National Institute for Health and Clinical Excellence (NICE), but there is evidence of substantial underrecording. We describe a simple clinical coding strategy that helped general practitioners to improve recording of maltreatment-related concerns. These improvements could improve case finding of children at risk and information sharing.

How do we identify and support maltreated children

GPs know that accurate up-to-date recording of important diagnoses in primary care, using searchable codes, improve the quality of care due to better and more timely targeting of interventions and improved monitoring.1 Information systems have the potential to transform care. Although not without their criticism, the computerisation of the referral process means that it has been possible to measure and monitor the wait from referral to treatment, and potentially to improve the process.2,3 Improved recording is also critical for policy, for exploring reasons for variation in care, and, in the reformed NHS, it will provide essential information for clinical commissioning groups and the NHS Commissioning Board, where routine data can be used to inform the public health agenda, especially when they contain or can be linked to outcome data. Research databases such as QRisk, the Health Improvement Network, and the General Practice Research Database (Now known as The Clinical Practice Research Datalink) are excellent examples of how routine data may be used to measure quality health outcomes.4 These potential benefits are yet to be realised in GPs’ responses to vulnerable children and young people who give rise to concerns about possible abuse or neglect. A recent study in the BJGP ,5 shows that rates of recording child maltreatment concerns using Read Codes remain well below those expected. An evaluation of the feasibility of standardised coding in 11 practices is …

Emergency admissions across the transition from paediatric to adult care: cross-sectional analysis of English hospital data

Abstract Background Transition from paediatric to adult health services is often sub-optimally achieved for children with long-term conditions. We investigated trends in emergency admissions across the transition from paediatric to adult care. Methods Using Hospital Episodes Statistics data, we analysed 1 186 392 emergency admissions between April 1, 2009, and March 31, 2012, in children and young people aged 10–24 years. We calculated emergency admission rates for this cohort before (10–15 years), during (16–18), and after transition (19–24) using mid-year population estimates as denominators. We stratified analyses by underlying long-term conditions, which we defined by validated International Classification of Diseases 10th revision codes. We excluded injury-related and maternity-related admissions. We used negative binomial regression to determine incidence rate ratios (IRRs). Findings Prevalence rates for emergency admissions increased 64% for girls (29/1000 before transition to 48/1000 after transition) and 17% for boys (26/1000 to 31/1000). This increase overwhelmingly occurred during transition (16–18 years), when rates increased 4·0/1000 per year for girls and 2·3/1000 for boys. At the same time, average length of hospital stay increased from 2·1 to 2·9 days for girls, and 1·8 to 5·0 days for boys (increases of 38% and 186% for girls and boys, respectively). Disparities in admission rates increased during transition, with children and young people from the most deprived quintile more likely than those from the least deprived quintile to have an emergency admission (IRR 1·63, 95% CI 1·60–1·66), and more so than before transition (1·51, 1·45–1·56). The increase in admission rates was driven by underlying long-term conditions: overall, rates increased 14% (IRR 1·14, 95% CI 1·13–1·14), but for children and young people with long-term conditions rates increased 46% (1·46, 1·46–1·47). Rates increased most rapidly for mental health problems, metabolic and endocrine disorders, multiple long-term conditions (both sexes), and respiratory disorders (girls only). Interpretation Our results show that emergency admission rates, duration, and inequalities increase across transition, especially in children and young people with underlying long-term conditions. The extent to which this increase is due to transition within the health service, rather than other developments, requires further research. Our results are in keeping with the widely recognised difficulties that young people face when they transition to adult health services. Funding LPMMW and JW were supported by funding from the Department of Health Policy Research Programme through funding to the Policy Research Unit in the Health of Children, Young People and Families (grant reference 109/0001). RG is supported by awards establishing the Farr Institute of Health Informatics Research at University College London Partners from the Medical Research Council and a consortium of funders (MR/K006584/1).

Burden of recurrent emergency hospital admissions in children and young people in England: a cohort study

Abstract Background In England, the number of emergency admissions in children and young people has increased by 28% since 1999. Evidence is lacking about the contribution of recurrent admissions to the high rate of emergency admissions among children and young people. We quantified the contribution of recurrent admissions to the total burden of admissions in England. Methods We analysed all hospital admissions to the National Health Service in England using Hospital Episode Statistics from 2009 to 2011 for children and young people aged 0–24 years. We followed up children and young people for 2 years from their first emergency admission (index admission) in 2009. We determined the number of subsequent admissions, time to next admission, length of stay, and the proportion of admissions for injury and of children affected by a chronic condition measured by diagnostic codes in all admissions during the 2 years. Findings 869 895 children had an index admission in 2009, resulting in a further 939 710 admissions (of which 600 322 [64%] were emergency admissions) over the next 2 years. We excluded 4371 children (0·5%) with inconsistent records (eg, multiple birth admissions). After discharge from the index admission, 274 986 children (32%) had a recurrent emergency admission, accounting for 41% (n=1 470 107) of all emergency admissions in the 2-year cohort. A few children and young people (37 311, 4%) had four or more emergency admissions. The proportion of patients with recurrent admissions was similar across all age groups. 73 830 first recurrent admissions (26%) occurred within the first month after discharge from the index admission. 360 633 index admissions (41%), in contrast with 459 167 recurrent emergency admissions (76%), were in patients with a chronic condition. Interpretation This snapshot of hospital flow during 2 years shows that recurrent emergency admissions account for a substantial minority of all emergency admissions and predominantly affect children and young people with chronic conditions. Since we only included inpatient hospital data, our analysis provides a limited overview of health-care use. Interventions to reduce re-admissions should consider discharge planning for support by community services for parents caring for children with chronic conditions. Funding LW was supported by funding from the Department of Health Policy Research Programme through funding to the Policy Research Unit in the Health of Children, Young People and Families. This is an independent report commissioned and funded by the Department of Health.

GPs’ role in safeguarding children

The debate between Spence and Masters about whether the modern GP is a key player in safeguarding children from abuse and neglect risks polarising this discussion and wasting the opportunity to make better use of the systems we have.1 Child maltreatment is common and often chronic, but many affected children only occasionally, …