High UK child death rates unfairly blamed on GPs

"Almost 2,000 British children a year die from 'avoidable' causes because family doctors lack training in paediatric care," The Independent alarmingly claims.

The story comes from a review of health services for children across 15 countries in the European Union. It found that while child survival rates have improved greatly in the past 30 years, many countries are not keeping pace with changing patterns in child health.

Increasingly, non-infectious chronic disorders such as asthma have become causes of disability and death, as have accidental causes such as poisoning and injury.

The review found that the UK is second-to-last in the 'league table', with nearly 2,000 more child deaths each year than Sweden, which had the lowest death rates.

The authors of the review point out that in the UK, the first point of contact for families – the GP – often receives no specific training in child health beyond undergraduate degree level. It goes on to argue that UK services should be reorganised so that they are able to respond to children's health needs more successfully.

Where did the story come from?

The study was carried out by researchers from several European centres, including the UK institutions the London School of Hygiene and Tropical Medicine, the University of Oxford, and Imperial College London. It was supported by the European Observatory on Health Systems and Policies and the National Institute for Health Research.

The study was published in the peer-reviewed medical journal The Lancet.

Understandably, the Independent's report concentrates on the UK, although its claim that untrained GPs are to blame for 2,000 child deaths annually conflates two separate pieces of information from the review.

The report found that in the UK there are 1,951 excess child deaths every year compared with Sweden. It is also critical of the lack of specialist training in child health for GPs in the UK, pointing out that recent inquiries into child deaths have drawn attention to the failure of primary care to recognise and manage severe illness.

But while a link between excess child deaths and a lack of specialist training in child health for GPs may be implied by the review, it cannot be proven. There may be other factors at work that could also account for the difference between UK and Swedish mortality rates.

What kind of research was this?

This review of child health services forms part of a series published by The Lancet examining the health of people in Europe. 

The authors say that the healthcare needs of European children are changing, with infectious diseases easier to prevent or cure and other chronic disorders such as asthma, diabetes and behavioural problems becoming more important.

Their paper looks at the way the 15 countries that joined the EU before 2004 (Luxembourg, France, Austria, Finland, Denmark, Spain, Belgium, Sweden, Italy, Germany, Netherlands, UK, Ireland, Portugal and Greece) are responding to common challenges.

The paper reviews child health in these countries and the evidence for how well healthcare needs are met in each country. It also examines different approaches to services for children with chronic disorders, as well as the quality of 'first contact', or primary, care. In the UK, this is usually provided by the family GP.

What did the research involve?

The researchers carried out comprehensive reviews of the relevant medical literature using a range of search strategies for all relevant reports published by the WHO, the UN, the EU, the Organisation for Economic Co-operation and Development, and European professional societies.

They defined children as those aged 18 years or younger. However, as data was not always available some comparisons were restricted to children younger than 14 years.

To compare child health and services in the 15 pre-2004 countries of the EU, they focused on child mortality data from the World Health Organization (WHO). 

What were the basic results?

The study does not publish results in the same way a scientific trial would. Instead, it highlights and compares the outcomes on child health in different countries and discusses the different ways that services are organised.

Survival overall

It found that child survival has improved greatly in all 15 countries in the last 30 years as a result of improvements in public health, healthcare and wider social factors. Deaths from infectious and respiratory causes have fallen, while those attributable to other (non-communicable) diseases have risen.

It found that the three most common causes of non-communicable disease are neuropsychiatric disorders (mainly depression), congenital abnormalities, musculoskeletal disorders (lower back
pain), and respiratory diseases (mainly asthma).

The UK

The report says that there are wide variations in child health between the 15 countries, as well as within each country. These variations are in terms of health outcomes, life chances and mortality. The report found that the country with the lowest child mortality rate (at 29.27 per 100,000 children aged under 14) is Sweden.

• the UK, with a rate of 47.73 per 100,000, is second-to-last
• the UK has the highest number of excess child deaths a year (1,951) compared with Sweden
• the UK also has the highest rates of deaths from pneumonia among children aged 0-14 years (1.76 per 100,000)
• of eight countries in the EU (Sweden, Portugal, Finland, Italy, Austria, Germany, Spain and the UK), the UK has the highest mortality rates from asthma both among children aged 6-7 and children aged 13-14

Health systems and models of care

The authors point out that while care for chronic disorders in adults has been high on the agenda in many European countries, the same is not true for children. Close co-operation between different services for child care has been developed in some countries such as Sweden and the Netherlands.

The report points out that although there are incentives to provide similar 'joined-up' multi-agency chronic care treatment for adults in the UK, almost no such measures exist for children.

First-contact care

The report focuses on various issues for children's first-contact care, highlighting that training for family doctors in child health remains highly variable between countries. It says that most GPs in Sweden receive at least three months' specialist training in child health, and often work closely with doctors and nurses specialising in child health. The UK has a more segregated model where GPs may not receive any specific training in child health beyond what they received as an undergraduate, and they tend to work separately from paediatricians.

How did the researchers interpret the results?

The researchers say that:

• Child health systems in Europe are not adapting sufficiently to children's evolving health needs, leading to "avoidable deaths, suboptimum outcomes, and inefficient use of health services".
• If all the 15 countries had child mortality similar to that of Sweden (the country with the best rate), a total of more than 6,000 deaths per year could be prevented.
• New chronic care models for children are needed to improve care and outcomes for non-communicable diseases and ensure better quality-of-life for children and families. Several countries have made progress in development of chronic care services and offer lessons for others.
• The quality of first-contact care services (primary care) and outcomes for children in Europe are highly variable. Flexible models, with teams of primary care professionals trained in child health working closely together, might offer a way to balance expertise with access.
• Awareness of the importance of investment in health in the earliest years is growing. Individual countries and European Union-wide organisations should strengthen investment in child health and health services research.
• Politicians and policy makers should do more to translate high-level goals for child health into policy. Investment in social protection policies for the earliest years and the most vulnerable children will improve health, reduce inequities and accumulate advantages throughout life.

They argue that, "Policy makers often seem reluctant to translate into policies the increasing evidence showing that the foundations of life-long health are built through greater investments in the early years of life," continuing that, "Until national and European governing bodies are willing to accept this challenge, the outlook for child health in Europe will remain uncertain."

Conclusion

This is an important paper that has found large variations in both child mortality rates and the delivery of health services to meet children's needs within the initial 15 countries of the EU.

As the authors say, child health has improved over the last 30 years but the healthcare needs of children are changing. It is important that policies, systems and practices are developed that can face this challenge and that countries learn from each other.

This does not mean, as The Independent's headline suggests, that Britain's GPs do not have enough training to give children the medical care they need.