Addressing the inverse care law: the role of community paediatric services.

BACKGROUND: Children's health suffers disproportionately from the effects of poverty. The inverse care law states that those who need care the most are the least likely to receive it. Community paediatricians are well placed to address health inequalities in children. AIMS: To explore, using routinely collected data, whether we address health inequalities and the inverse care law, particularly for certain conditions targeted by our specialty. METHODS: Five years of data were analysed, during which health equity audits have led to service changes in order to tackle inequities. The data include postcodes, allowing each child to be assigned to a deprivation quintile, and a range of diagnoses, including five sentinel conditions: attention deficit hyperactivity disorder (ADHD) on medication, autistic spectrum disorder (ASD), epilepsy, cerebral palsy and Down's syndrome. This allowed analysis of the caseload by deprivation index for these conditions, comparison with the background population and exploration of time trends. RESULTS: The number of children on the caseload and their distribution across the quintiles remained stable. The proportion of deprived children (i.e. in the lowest two quintiles) on the caseload over the last five years taken together is 56%, compared to 44% in the background population. The numbers of children with ADHD on medication has almost quadrupled in deprived quintiles and doubled in the least deprived quintile, while the numbers of children with this diagnosis in the most deprived is four times that in the least deprived. Numbers of children with ASD have also increased in each quintile. In contrast, the number of children with epilepsy and cerebral palsy did not show much variation, but those from deprived quintiles made up a greater proportion of the caseload. CONCLUSIONS: Routine data collection demonstrates that inequalities are addressed using all four quality domains of service provision and sentinel conditions more likely to affect deprived children are targeted. We believe it is possible for all services to collect and analyse data thus with minimal effort, thereby providing a foundation from which to address the inverse care law.

Preventing paediatric admissions for respiratory disease: a qualitative analysis of the views of health care professionals.

RATIONALE: The number of emergency paediatric admissions is increasing each year. The reasons for this are unclear but may include increasing demand from parents, changes in GP working patterns, and an increase in unnecessary admissions. Respiratory disease is the commonest diagnostic category for emergency admission in childhood. AIMS: To generate hypotheses for reduction in unnecessary admissions for respiratory disease by qualitative analysis of the views of health care professionals, to determine the proportion of preventable admissions as perceived by clinicians, and to assess the modified Paediatric Appropriateness Evaluation Protocol against clinicians judgements of appropriateness of admission. DESIGN: Eight health care professionals analysed clinical data from primary and secondary care for 94 cases that were admitted to an emergency assessment unit and received a hospital discharge diagnosis of respiratory disease. They assessed whether each admission was appropriate, whether it was preventable, and how it might have been prevented. RESULTS: A total of 31% of cases admitted to the assessment unit (29/94) were classified as preventable by the majority of professionals assessing the case. Provision of additional support, monitoring, and observation in the community was cited as a means of prevention in 33/94 cases. There was poor agreement between the modified PAEP and clinicians' assessments of appropriateness of admission (kappa 0.1). CONCLUSIONS: If the agreed views of these experienced doctors and nurses are correct, provision of additional services in the community could be an important means of preventing emergency admissions for respiratory disease. This hypothesis should be tested by further research including the views of families. The study provides further evidence that the modified PAEP may not be valid for use in UK practice. If inappropriate admission rates are to be used to measure effectiveness of services we need to develop an objective measure of appropriateness valid for use in the UK.