How has children and young people’s usage of A&E been impacted by lockdown and social distancing?

Overall, we see greater percentage reductions in visits to A&E for children and young people (aged 0–19) than we do in adults.

The difference is particularly striking for visits relating to illnesses. We see, on average, a 30% reduction in visits for adults, compared with 62% for children and young people. We can also see visits for illness for children and young people fell more sharply than those for adults and are returning to normal levels more slowly.

There is greater variation between age groups for visits relating to injury. We see greater reductions in visits for school-aged children (5–19 years of age) than for other age groups, and visits for this group remain far below normal.

Why are we seeing greater reductions in visits to A&E for children and young people?

The factors driving reductions in visits for children and young people fall under the same broad categories we have discussed in previous blogs. These are:

1. Policy choices made in order to create capacity for COVID-19 patients or to protect non-COVID patients and staff.
2. Changes in patient behaviour, in this case the behaviour of children and young people, and their parent or guardian.
3. Changes in the prevalence of some conditions.

However, the underlying disease burden for children and young people is different to that of adults, and social distancing measures may have led to different lifestyle changes across age groups.

The next section explores how these factors, in addition to the three drivers above, may have led to the reductions in children and young people using A&E.

There has been greater reduction in infections

Schools, colleges and nurseries were closed to the majority of pupils on 20 March 2020, just prior to the national lockdown. This meant a move to home schooling for the vast majority of school-aged children, and a significant reduction in interaction with their peers. These social distancing measures have been effective not only in reducing COVID-19 cases, but also in stopping the spread of other infectious diseases.

We reported previously that there have been reductions in visits to A&E for infectious diseases and respiratory conditions, and that this is likely to be indicative of a reduction in the number of new infections.

We know that, in general, infections are a major driver of childhood visits to A&E. In a subset of major A&E departments in the first 20 weeks of 2019, 65% of visits for illness for people younger than 20 years of age fall under three diagnosis groups where infections are likely triggers for visits (compared with 42% for all age groups). These proportions did not vary significantly for the same period in 2020.

Furthermore, we would expect this reduction in infections to lead to a reduction in visits for children and young people with long term conditions. Asthma, diabetes and epilepsy are three of the most common long-term conditions experienced by this age group; for all three, infection can lead to a worsening of symptoms and potential visit to A&E.

In contrast to this, we might have expected visits for psychiatric conditions to increase. We know that young people in particular have experienced poor mental health during the pandemic. However, visits during the pandemic were still 43% lower than the same period in 2019. This is higher than the 31% reduction seen across all age groups.

The fact that respiratory-related visits remain so low suggests there has been a true reduction in the underlying prevalence of conditions that would lead to such a visit. For example, we would expect upper and lower respiratory infections to reduce with children and young people spending more time at home and less time with their friends. Respiratory related visits for people younger than 20 years of age remain far below those for the whole population (where visits plateau at 50% below normal). This may be because adults are more likely to attend A&E for other respiratory reasons – not linked to infections – or that social distancing measures have had less impact (as adults continue to go to work and shopping, for example).

That said, there is a lot we still don’t know about the impact of COVID-19 on the behaviour of both parents and guardians – and those for whom they care, and how that impacts on condition management and seeking treatment. For example, it is possible that children who are at home with their parents full-time are able to adhere to their medicine timing, frequency and dosage better than while at school. These and other factors may have led to improvements in condition management that have further contributed to the reduction in visits to A&E. That said, parents and guardians may also be wary of attending hospital due to the risk posed by COVID-19, and those with an underlying respiratory condition may be more reluctant than most. Likewise, we know that for the whole population fewer patients were transported to A&E via ambulance and that NHS 111 advised fewer callers to attend A&E. We don’t know exactly how these trends translate to this age group, but this may have further contributed to the reduction.

Visits for injuries are a mixed picture

It is likely that lockdown has had a variable impact on injury prevalence. We know, for example, that active play (running games, ball games and dancing about) has fallen dramatically for children during lockdown, so would expect reductions in injuries relating to sports or play. However, increased time in the home may also bring increased risk of injury, both accidental and non-accidental.

As with illnesses, the majority of visits to A&E for injuries are made up of a small number of diagnoses, with five injury types accounting for 80% of visits across a subset of major A&Es for the first 20 weeks of 2019 (compared with 73% for all ages). These proportions did not vary significantly for the same period in 2020.

We see dramatic reductions in visits to A&E for injuries during the initial period, reaching a low 2 weeks after lockdown. Since then, visits across all diagnoses have been increasing, though remain below normal. The greatest reductions have been seen in visits for sprains / ligament injuries and contusions / abrasions, which remain more than 50% below normal. By contrast, visits for lacerations fell to 56% below normal initially but are now at 20% below normal. Across all injury diagnoses the reductions in visits for people younger than 20 years of age are greater than those seen in the whole population. However, the differences are less extreme than those seen across visits for illness.

We see greater reductions in visits for injury types that are likely to be less severe. For example, there has been a greater reduction in sprains and ligament injuries compared to fractures and dislocations. While this may mean children and young people are having fewer minor injuries, this may also indicate that the threshold for making the decision to attend A&E on the part of both parents and guardians, and those for whom they care, has risen. In the case of minor injuries – such as sprains – parents and guardians may be willing to treat at home, whereas for a head injury they may be more likely to seek medical advice. Similarly, health care professionals – for example NHS 111 and 999 call handlers – may be less likely to recommend an attendance for more minor injuries.

What can we expect looking forward?

Our data show particularly dramatic reductions in visits to A&E for people younger than 20 years of age. When we break down visits by diagnosis, there are indications that some of the more dramatic reductions have been driven by true reductions in prevalence. For example, the reduction in visits for illness can be attributed to reductions in infections, which in turn can be attributed to social distancing measures. Large changes in activity often reflect substitution for activity in other parts of the system, but this doesn't seem to apply here – GP activity for children and young people is also down significantly.

Any reduction in activity naturally leads to concerns about delayed care and the potential for adverse health outcomes. Early evidence has been mixed. There is some evidence that, at least in potentially severe cases, parents and guardians have not delayed visiting A&E, but other studies show a more mixed picture. At the moment it is impossible to know for certain. There is still a lot we don’t know about how parents and guardians, and children and young people have navigated the health and care system during lockdown. We don’t know how many parents and guardians have chosen to care for injuries or illnesses at home, where previously they may have visited A&E, nor do we know how much fear of COVID-19 influenced those decisions.

Autumn will see major changes for children and young people as they return to school and college, and we should expect to see changes in the prevalence of infections and injuries. Where parents and guardians have felt confident to care for minor injuries and illnesses themselves, government and NHS messaging should seek to reassure parents that they generally make good judgement calls for those in their care, and support this with reliable information on what care to seek and when. However, this needs to be balanced with the understanding that making decisions over a person’s care can be frightening and that there is risk of serious harm in a small number of cases. This means increasing public awareness that A&E departments should still be used when needed. Key to this will be building confidence that children and young people can be assessed safely without exposing them or their families to risk of COVID-19, especially if we see a second wave of infections.

Practically, the NHS can work to improve remote and virtual offerings to parents and guardians and those in their care. The NHS has already taken steps to improve the service NHS 111 can provide by recruiting retired and shielding paediatricians to provide specialised advice. Further tailored guidance and advice provided remotely on how to treat children and young people will help ease pressure on A&Es over the winter.

Ruth McConkey is Programme Manager in the Economics team at the Health Foundation.

Dougal Hargreaves is Clinical Senior Lecturer at Imperial College London.

Steven Wyatt is Head of Strategic Analytics at The Strategy Unit.