Burden of disease
We found that DALYS due to neonatal and congenital causes were the commonest cause of burden in the early life course from birth to age 24 years, likely reflecting both the high mortality rate of the early neonatal period and the high levels of sequelae of surviving extreme premature delivery. The predominant causes of burden of disease in younger children are common conditions readily recognised by paediatricians and general practitioners, including skin problems, wheeze and asthma, common infections, injuries and diarrhoea. In contrast, the predominant burden of disease in adolescents and young adults are mental health problems, somatic symptoms such as pain and headache, injuries and long-term conditions. Of these conditions affecting 10-24 year olds, only a minority have been historically the province of paediatricians.
We forecast future DALYS based upon trends over the past two decade, and the changes forecast here have implications for the skills and training of health professionals working with CYP over the next 20 years. Our forecasts suggest that there will be continued falls in overall DALYS amongst infants over the next two decades, potentially reflecting continued gains in neonatal survival. These overall falls in DALYS amongst neonatal causes amongst infants and in cancer in older CYP likely reflect very large improvements in survival that are greater than the rises in morbidity in survivors. Therefore reductions in DALYs do not necessarily indicate a reduced need for workforce or skills related to particular causes, and indeed may be a marker of the impact and quality of current workforce inputs.
We forecast there will be few changes in the overall DALY burden in older age-groups, although there will be considerable shifts in the relative contribution of different causes. Our forecasts suggest that there will be very large falls in many of the causes that have historically dominated disease in children and young people, particularly falls congenital disorders, from a range of infectious diseases and cancers and from injuries. These declines likely represent falls in the prevalence of many infectious diseases and improvements in road safety but also marked improvements in survival from cancer and many congenital conditions
Forecast increases in DALYS from particular causes are likely to indicate a need for additional workforce or a change in training focus. For paediatricians, there will be a need for broader training that includes increased numbers with skills in dealing with mental health problems, broader adolescent health issues as well as the consequences of neonatal survival, such as neuro-disability and epilepsy.
Burden of health and ill health in CYP is likely to change considerably over the next two decades if recent trends continue. The pattern of health and disease facing child health professionals in 2040 is likely to consist of higher proportions of mental health, other adolescent health issues, neurodisability and long-term conditions than currently, and this must be reflected in changes in training requirements for paediatricians and other child health professionals.
The large increases in emergency activity and outpatient (OP) attendances documented across the past decade in young children, of the order of 60-80%, have placed great strain on children and young people’s services in England, as the children’s workforce and service structure has not increased to match it.
Workforce data from the RCPCH shows that whilst consultant paediatrician numbers in England increased 47% between 2007-2017, most of the increase was in specialist rather than general or acute paediatricians, whilst proportions of consultants working less-than-full-time increased. The RCPCH estimated in 2019 that an additional 642 whole time equivalent (WTE) consultant paediatricians were needed to meet demand in England. At the same time that emergency admissions were rising, numbers of 14 hospital beds for children in England fell 16.4% from 5315 in 2007/08 to 4441 in 2016/17, 25 further illustrating increasing strain on the system.
Our most conservative scenario, in which there are no substantial changes in terms of child poverty or health system organisation over the next two decades, predicts increases of 50-145% in ED attendances and 20-125% increases in OP attendances. An alternative scenario where policy action reduces child poverty significantly over the next two decades has a beneficial impact upon these forecasts, although the forecast impact is less than 5% for all activity. These changes will require significant additional workforce and health services resources.
In contrast, integrated care scenarios dramatically reduced projected future activity across all admission types, suggesting markedly lower needs for future additional workforce and capacity. Managing all ambulatory care-sensitive conditions (ACSC) outside the hospital system (high integrated care scenario) could potentially reduce total admissions to at or below 2007 levels by 2040; reductions in increases in ED attendances are predicted to be less dramatic, achieving levels close to those of 2017 over the next two decades. Whilst redirection of 100% of ACSC is unlikely to be easily achieved, the more pragmatic scenario of managing 50% of ACSC outside hospitals (moderate scenario) offers still valuable reductions in forecast activity. Forecast benefits are greater amongst younger children due to higher proportions presenting with ACSC.
Our forecasts suggest that, if drivers of increased activity are not addressed, there will be further rapid increases in CYP emergency and outpatient activity over the next 20 years, requiring significant additional investment in both services and workforce if quality is not to fall. Without concerted action to reduce child poverty, healthcare activity will increase and outcomes worsen. Contrary to these pessimistic scenarios, our findings suggest that development of integrated care for CYP at scale in England has the potential to dramatically reduce or even reverse these forecast increases, reducing strain in the system whilst improving outcomes for CYP and family and young people’s experience of care.
In addition to the conclusions noted regarding workforce and healthcare activity, we also wanted to note some concerning trends in the workforce data itself. NB: all our workforce projections are based on recent trends observed in our paediatric workforce census, and are included to illustrate potential futures unless action is taken.
Trainee less than full time working is forecast to increase from 30% in 2019 to over 60% in 2040. We welcome and encourage this flexibility, as discussed in our working lives content. However, this is of major concern with regards to paediatric trainee whole-time-equivalent (WTE) numbers if the current cap on the number of training places available is not reviewed.
Projecting future numbers of SAS grade doctors, based on recent trends of decline, leads to worrying conclusions about the number there may be by 2030 if action is not taken. This is an important workforce group who need urgent support.
The proportion of community paediatricians is forecast to decrease from around 18% of workforce to 12% of workforce, based on the last ten years of trends. Elsewhere in the project we have discussed the need for more paediatricians to be working in the community to meet the needs of children and families in the future, and this trend therefore needs some attention and thought.
RCPCH. 2017 workforce census overview (2019). https://www.rcpch.ac.uk/sites/default/files/2019-11/soch_workforce_census_overview_2019_-_v4_30.10.19.pdf
RCPCH. Shortage of consultant paediatricians – report (2019). https://www.rcpch.ac.uk/resources/shortage-consultant-paediatricians-report