Elsevier

The Lancet

Volume 381, Issue 9873, 6–12 April 2013, Pages 1224-1234
The Lancet

Series
Health services for children in western Europe

https://doi.org/10.1016/S0140-6736(12)62085-6Get rights and content

Summary

Western European health systems are not keeping pace with changes in child health needs. Non-communicable diseases are increasingly common causes of childhood illness and death. Countries are responding to changing needs by adapting child health services in different ways and useful insights can be gained through comparison, especially because some have better outcomes, or have made more progress, than others. Although overall child health has improved throughout Europe, wide inequities remain. Health services and social and cultural determinants contribute to differences in health outcomes. Improvement of child health and reduction of suffering are achievable goals. Development of systems more responsive to evolving child health needs is likely to necessitate reconfiguring of health services as part of a whole-systems approach to improvement of health. Chronic care services and first-contact care systems are important aspects. The Swedish and Dutch experiences of development of integrated systems emphasise the importance of supportive policies backed by adequate funding. France, the UK, Italy, and Germany offer further insights into chronic care services in different health systems. First-contact care models and the outcomes they deliver are highly variable. Comparisons between systems are challenging. Important issues emerging include the organisation of first-contact models, professional training, arrangements for provision of out-of-hours services, and task-sharing between doctors and nurses. Flexible first-contact models in which child health professionals work closely together could offer a way to balance the need to provide expertise with ready access. Strategies to improve child health and health services in Europe necessitate a whole-systems approach in three interdependent systems—practice (chronic care models, first-contact care, competency standards for child health professionals), plans (child health indicator sets, reliable systems for capture and analysis of data, scale-up of child health research, anticipation of future child health needs), and policy (translation of high-level goals into actionable policies, open and transparent accountability structures, political commitment to delivery of improvements in child health and equity throughout Europe).

Introduction

The health care needs of Europe's children are changing as a result of variations in the diseases, disabilities, and social factors that affect their lives. Infectious diseases have become easier to prevent or cure, and non-communicable diseases increasingly dominate paediatric practice. Health services have not adapted sufficiently to these changes and, in some instances, fail to deliver high-quality care. European health systems need to develop new models of care to meet children's current and evolving health needs. Although rare disorders, such as childhood cancers, cardiac anomalies, and some neonatal problems need highly specialised care (provided in selected centres), common problems—eg, asthma, diabetes, behavioural disorders, mental health problems—can be cared for in the community to enable children and their families to live as normally as possible. Development of better systems will probably need reconfiguring of services across the interfaces between hospitals, primary care, and public health. However, these changes are very difficult to achieve because the boundaries between specialties and health-care delivery organisations are often points of contention in both health-care professionals and policy makers. Although the 15 pre-2004 countries of the European Union (EU15) face common challenges, they are responding in different ways, which show their differing histories, organisational structures, financing systems, and professional roles. These variations provide many opportunities to learn from others' experiences, especially because some countries are achieving much better outcomes than are others.1

Key messages

  • •

    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 pre-2004 countries of the European Union had child mortality closely similar to that of Sweden (the country with the best rate), more than 6000 deaths per year could be prevented.

  • •

    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.

  • •

    First-contact care services 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.

  • •

    Child-health indicator sets with reliable and uniform systems for data collection would ease efforts to monitor needs and improve services.

  • •

    Awareness of the importance of investment 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 implemented policies with accountability structures to ensure delivery. Investment in social protection policies for the earliest years and the most vulnerable children will improve health, reduce inequities, and accumulate advantages throughout the life course.

In this paper, we review child health and the determinants of child health in the EU15 and evidence for how well health-care needs are met by services. We will then examine different approaches to important aspects of paediatric practice—namely, services for children with chronic disorders and first-contact care—because, together with public health and social determinants, health services are essential to improve children's health. These variations between countries provide learning opportunities. We focus on countries that have had better outcomes than others, because such countries show what can be achieved, and on countries that have assessed attempts to reconfigure services to meet needs, because they can show how to achieve changes. Finally, we set out a plan to improve the health of Europe's children.

Section snippets

Child health in Europe

Child survival has improved greatly in the past three decades in all EU15 countries as a result of improvements in public health, health care, and wider societal factors (figure 1; appendix). A concomitant shift in the distribution of causes of childhood deaths has occurred (figure 2)—specifically, deaths from infections and respiratory causes have fallen while the proportion attributable to non-communicable diseases has risen. In 2009–10, the most frequent causes of death in children aged 1–14

Meeting health needs

Health services for children, as an important and modifiable determinant of health, are the main focus of this paper. The rate of deaths from disorders that are amenable to health care is a measure of effectiveness.11 Two common illnesses show variability in outcomes and thereby scope for improvement. Pneumonia is the most common serious bacterial infection in children presenting in primary care,12 and deaths in childhood from this disease should be avoidable in most cases. However, death rates

Learning from experience in delivery of care

European health systems have been slow to adapt to the changing patterns of childhood morbidity and mortality. Although there is a broad consensus that many non-acute health services could shift from hospital-based to community-based delivery, thus improving access and responsiveness and reducing costs, most countries have yet to do so. Such changes, however, should not compromise the provision of highly specialised and acute emergency care. The challenge is to find innovative ways to address

Care of chronic disorders

Care of chronic disorders in adults has been high on the policy agenda in many European countries for the past decade, exemplified by the widespread use of elements of the chronic care model.18 The research informing chronic care has shown that several factors are consistently associated with successful health-care delivery for adults—namely, shared practice with common guidelines; conducive organisational arrangements, such as colocation of health and social services; information sharing;

First-contact care

One of the greatest challenges facing health professionals working with children is how to distinguish potentially serious illness from minor problems. 17–57% of patients attending emergency departments have problems that are judged to be non-urgent or minor by clinicians and could have been dealt with in primary care.28, 29, 30, 31, 32 However, the high death rate from some acute disorders (eg, meningococcal and respiratory diseases) in some countries suggests that there are also children who

Whole-systems plan

Although some successes in the improvement of the health of children in Europe have been noted, much more remains to be done to improve services and ultimately health. Changes in practice are contingent on supportive planning and policy. A whole-systems approach is needed. Problems that need action can be thought of as a 3×3 plan with three general themes—practice, plans, and policy—each with three specific actions (figure 6).

Chronic care model

The preceding sections have shown the substantial scope to change the ways in which care is delivered to children and their families. In view of the growing numbers of children with chronic disorders in Europe, development of models of care for children is a major priority. This development will be a substantial change from a hospital-centric model to a model in which primary care and secondary care providers and public health services work closely together. Focusing of efforts on prevention of

Indicators

Meaningful understanding and international comparisons of the health needs of children and the ways in which health systems respond necessitate appropriate data. Development of indicators for children is particularly challenging because of the so-called four Ds— ie, developmental change, dependency, differential epidemiology, and demographic patterns—which are unique issues in children's health and lives.52, 53 To ensure that indicators are transferable between countries is important. Examples

Evidence

The UN Convention on the Rights of the Child offers a framework for policies to support child health and wellbeing,70 and the European Council has issued guidelines on child-friendly health care.71 However, much more could be done to translate these high level goals and supporting evidence into policies at the national and European levels. Investment in child-centred public health interventions and social policies will improve health and reduce inequities and accumulate advantages for

Implementation of 3×3 plan for European child health

The arrangements for delivery of health care in the EU are the responsibility of member states, even though many of the inputs into delivery systems, such as health professionals, drugs, and technology, are subject to European law. Furthermore, some risk factors in children and young people are also subject to EU laws and policies–eg, tobacco, food, and alcohol consumption. The EU has substantial influence through its convening power and the Framework Programmes that fund health research. It

References (77)

  • S Hajioff et al.

    The health of the Roma people: a review of the published literature

    J Epidemiol Community Health

    (2000)
  • N Parekh et al.

    Health inequalities of the Roma in Europe: a literature review

    Cent Eur J Public Health

    (2011)
  • J Armour-Marshall et al.

    Childhood deaths from injuries: trends and inequalities in Europe

    Eur J Public Health

    (2012)
  • I Wolfe

    Child Health

  • E Nolte et al.

    Does health care save lives? Avoidable mortality revisited

    (2004)
  • A Van den Bruel et al.

    Serious infections in children: an incidence study in family practice

    BMC Fam Pract

    (2006)

  • WHO European Mortality Database

  • HR Anderson et al.

    International correlations between indicators of prevalence, hospital admissions and mortality for asthma in children

    Int J Epidemiol

    (2008)
  • L Reindal et al.

    Hospital admissions for wheezing and asthma in childhood: are they avoidable?

    J Asthma

    (2006)
  • C Fuhrman et al.

    Hospitalizations for asthma in children are linked to undertreatment and insufficient asthma education

    J Asthma

    (2011)
  • JP Mackenbach et al.

    The unequal health of Europeans: successes and failures of policies

    Lancet

    (2013)
  • JE Epping-Jordan

    Improving the quality of health care for chronic conditions

    Qual Safety Health Care

    (2004)
  • B Åhgren

    Chain of care development in Sweden: results of a national study

    Int J Integr Care

    (2003)
  • BA Van der Linden

    The birth of integration; explorative studies on the development and implementation of transmural care in the Netherlands 1994–2000

    (2001)

  • Bringing networks to life—an RCPCH guide to implementing Clinical Networks

    (2012)
  • J Jones

    Parents' views about “Team around the Child”

    (2006)

  • RCGP Child Health Strategy 2010–2015

    (2010)

  • Quality and Outcomes Framework guidance for GMS contract 2011/12

    (2011)
  • G Tamburlini

    Child health and child health services in Italy

    Medico e Bambino

    (2012)

  • Hans Michael Strassburg: Sozialpaediatrische Versorgung in Deutschland

  • R Szczepanski

    Schulungen bei chronischen Erkrankungen

    Kinder und Jugendarzt

    (2010)

  • Children and young people's health outcomes strategy: report of the Children and Young People's Outcomes Forum

  • C van Uden et al.

    Development of out-of-hours primary care by general practitioners (GPs) in the Netherlands: from small-scale rotations to large-scale GP cooperatives

    Fam Med

    (2006)
  • J Dale et al.

    Primary care in the accident and emergency department: II. Comparison of general practitioners and hospital doctors

    BMJ

    (1995)
  • AW Murphy et al.

    Randomised controlled trial of general practitioner versus usual medical care in an urban accident and emergency department: process, outcome, and comparative cost

    BMJ

    (1996)
  • G Pearson

    Why children die: a pilot study 2006; England (South West, North East, West Midlands), Wales and Northern Ireland

    (2008)
  • RG Feltbower et al.

    Diagnosing childhood cancer in primary care—a realistic expectation?

    Br J Cancer

    (2004)
  • GA Pearson et al.

    Why children die: avoidable factors associated with child deaths

    Arch Dis Child

    (2011)

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