Strengths and limitations
To the authors’ knowledge, this is the first national report of children’s GP consulting patterns in the COVID-19 era. Its strengths include the large study population that is broadly representative of CYP in England and allows comparison with data from the previous 5 years. Therefore, it is highly unlikely the differences found in this study occurred by chance or sample selection effects, or could be explained by longer-term trends in healthcare activity.
Another strength of this study is that the baseline comparison averaged 5 years of data from 2015 to 2019. The mean from 2015 to 2019 is consistent and therefore a good comparator. In a sensitivity analysis comparing GP contacts from 2020 to the year 2019 only had a small impact on the main findings. However, there are some limitations to note in interpreting the findings of this study. In common with other large observational studies, data accuracy and completeness are variable. For example, administrative and clinical codes were used to differentiate face-to-face from remote contacts (see Supplementary Box S1). This may have resulted in some misclassification. In line with the specific aims of this study only contacts with GPs were looked at, and contacts with other providers such as practice nurses, pharmacists, or physician assistants whose roles have expanded in recent years were not examined.
Comparison with existing literature
This study’s findings of falls in GP contacts with CYP are consistent with other reports of a drop in face-to-face contacts in adults and switch to remote contacts during the pandemic lockdowns of 2020.27,28 Unlike a study primarily in adults that suggested primary care contacts returned to pre-pandemic levels,29 this study found that by October 2020 CYP’s contacts had recovered but remained at around 18% below pre-pandemic levels.
Possible explanations for these findings include changing disease incidence, altered health-seeking behaviour, and changes to physician-consulting behaviour and services, all of which appear to have been affected by the pandemic.30 Social distancing measures and lockdown restrictions intended to reduce transmission of COVID-19 will also reduce other circulating viruses. Hence, infectious illnesses, which are among the most common reasons for children’s attendance in primary care, fell during the lockdowns,31 and an increase in incidence of infectious illness may also explain the spikes noted in this study in remote contacts at the start of the first wave of the pandemic in March 2020 and coinciding with schools reopening/restrictions easing in September 2020.32
Strong public messaging to ‘Stay at home, protect the NHS and save lives’ during lockdowns will inevitably have kept some patients away from health settings. Adherence to lockdown measures may have led to more management of minor childhood illnesses at home, and there is evidence from other countries that adults consulted GPs less frequently during the initial lockdown in 2020 for some minor conditions.33 Some parents expressed fear of exposure to COVID-19 from health settings34 whereas others reported incorrectly that GP practices were closed to face-to-face consultations.35,36 Misinformation about the availability of GP appointments and face-to-face consulting has been widely disseminated by social and news media.37
Implications for research and practice
Children’s access to primary care has been falling in the UK and other countries for decades, accompanied by concomitant rises in use of urgent care including emergency department visits and hospital admissions.10,11 Thus pandemic disruptions have had a significant impact against a backdrop of existing pressures to provide GP contacts. The authors estimate that the falls of 41% resulted in 2 785 611 fewer GP contacts with CYP in England from March to June 2020 compared with previous years. However, the finding that GP contacts for respiratory illnesses fell drove a significant part of this decline, which was likely because of reduced transmission from containment measures. Emergency department attendances and child mortality for seasonal respiratory and gastrointestinal infection has reportedly fallen during lockdowns38 but is unlikely to be sustained as schools and educational settings reopen.
The findings of this study that remote contacts with young people more than doubled may indicate the shift to remote consulting by phone or video may have facilitated access to GPs for some younger people who often have excellent digital literacy and access.39 However, there may have also been difficulties in accessing remote care because of lack of space to speak privately and insufficient phone data or internet connectivity to take video calls.40 Access and utilisation challenges disproportionately affect CYP living in more deprived areas.41 Reassuringly, this study found that the total contacts for primary care sensitive conditions such as urinary tract infections, appendicitis, and epilepsy remained relatively high, and international reports confirm the incidence of these conditions changed little during this time.42 There is little evidence of a rise in serious illness in children during the lockdowns,13,38,43 suggesting that relatively few CYP experienced significant harm because of delays in seeking care.
The system-wide reorganisations of 2020 came after several years of primary care reforms. GPs have faced rising patient demand for appointments, an increasing workload because of a shift from hospital specialists to community care, and the demands of an ageing population with complex needs.44 Underinvestment in primary care to meet this rising workload has had an adverse impact on morale, with record numbers of GP principals leaving the profession, and has led to a declining workforce.
It is important to consider key lessons from the recent health system response.45 Although the current study has reported the health system was able to adapt and respond to short-term pandemic disruptions, further work is needed to understand the long-term impact of preventive primary care on CYP’s health.46
Remote and face-to-face consultations both have distinct advantages . Particularly at the start of the COVID-19 pandemic remote consultations offered opportunities for triage and provided practical solutions for GP contact with those shielding or self-isolating.47,48 As lockdown eased and consultation rates increased from July 2020, some GPs reported remote consulting became more time consuming, challenging, and fragmented.48 As the UK emerges from the winter of 2021–2022 with schools fully open, acute infection rates are rising and demand for acute appointments remains high. During the future anticipated peaks in infectious illnesses, such as respiratory syncytial virus, there may be a shortfall in primary care capacity for increased demand and need for face-to-face assessments to ensure safety and quality of children’s primary care.49 A picture is emerging whereby a hybrid model designed around patient preference is likely to replace traditional primary care.50 More work is needed to understand the optimal combination.51,52 The rebuild offers great opportunities to codesign primary care with CYP’s preferences.
The NHS Long Term Plan,53 published before the pandemic, has encouraged a shift towards integrated care systems to bring together NHS services, local authorities, and the voluntary sector for public health improvement.54 In addition to integration, the plan promises better prevention, workforce support, investment in digital infrastructure, and a better start to life for all CYP. It is essential that in this reorganisation, CYP are included in the plans for primary care reform.
In conclusion, during the first phases of the pandemic, CYP’s contact with GPs, particularly for face-to-face assessment, was lower than observed in adult populations.27 A major part of this shift may be ascribed to the change in prevalence of seasonal viral infections. Most contacts were held remotely but face-to-face consulting for infants was less disrupted and there was a major shift to remote contacts for primary care sensitive conditions mitigating overall falls. In reforming primary care services, the priority must be to consult stakeholders, including GPs and children and families, build safe digital and physical infrastructure, and support the primary care workforce to meet demand and to deliver better health outcomes for the whole population.
