Winter pressures in children’s emergency care settings - position statement

We are familiar with the stresses on emergency departments  (EDs) each winter. Each child and young person who needs unscheduled care should have access to services that are high-quality, safe and effective. 

In this joint position statement from RCPCH, RCEM and RCN, we recommend a whole system approach to healthcare planning that treats children equally to adults to help tackle winter pressures in EDs.

November 2019


Pressures on emergency departments (EDs) are a familiar sight during the winter. Increased incidence of respiratory infections, alongside an increased acuity of illness and demands on primary care leads to a rise in ED attendances.

Within hospitals, bed closures and higher acuity illness on inpatient wards hampers patient flow through the ED. This results in overcrowding and challenges the delivery of safe and effective care.

These factors pose specific risks to the delivery of healthcare to children and young people. In EDs, paediatric space and resources can be reallocated to deliver care for adults. Across health systems, children’s needs for urgent and emergency care are not treated equally in planning and delivering services.  

Pressures felt in children’s emergency care settings are not just confined to children’s EDs; they are part of a whole system problem reaching downstream into community settings.

These risks need to be better managed, not least because many EDs are experiencing an increase in attendance and acuity of patients beyond traditional winter pressures, so the consequences for children’s emergency care can be felt across the year. 

What we want

Every child should have timely access to high-quality unscheduled care services that:

  • are high-quality, safe and effective,
  • promote good health and wellbeing, and
  • reduce the impact of illness on the child and their parents and carers.

No child should be in hospital when care can be provided to an equivalent or better standard outside hospital in their locality and closer to home if appropriate because: 

  • children and young people account for 25% of ED attendances and they are the most likely age group to attend EDs when they could be managed more effectively in primary care or community settings1   
  • general practices whose patients report better access also have 10% fewer visits to EDs out of hours2 .

There is a need for a system-wide approach that focuses on the specific and particular needs of children and young people and does not allow their healthcare to be overlooked. Children’s care in EDs must not be jeopardised by escalation plans and surge policies when pressure builds. 

Service providers, planners, commissioners and users must work together across hospital and community services, primary and secondary care, and paediatrics and general practice to design and deliver efficient and effective unscheduled care in a geographical network which is responsive to the needs of local children and their parents and carers.

The future of urgent and emergency care for children depends on building networks that harness expertise within the subspecialty of paediatric emergency medicine across all urgent care and community settings. 

Policy recommendations

  1. Trusts and health boards must ensure that resources within children’s EDs are excluded from adult surge policies and other processes.
  2. Service planners and health organisations must have a dedicated lead for children at executive or board level so that the needs of children are included in strategic decision making.
  3. Trusts and health boards must ensure children are explicitly considered and included in hospital and community winter pressures plans.
  4. Commissioners and service planners must increase resources (including workforce) throughout community and primary care services as well as in children’s emergency care settings and paediatric inpatient services.

What we are doing

We continue to lobby key decision makers across the UK so that children are treated equally in healthcare planning and service delivery.

RCPCH’s Facing the Future standards for emergency care settings aim to ensure that urgent and emergency care is fully integrated to ensure children are seen by the right people, at the right place and in the right setting. The RCPCH audit toolkit supports clinicians and providers to monitor and improve local services. 

RCEM’s annual winter flow project will highlight the challenges around resource pressures difficulties. Over 50 NHS trusts and health boards submit anonymised data on system pressures and patient flow. The winter flow project is used to support understanding of system pressures and patient flow, informing the wider debate around emergency medicine and focusing attention in the media and in governments on the practical challenges faced by providers as they make every effort provide excellent care for patients.

RCN’s safe and effective staffing campaign is calling for safe and effective care to be enshrined in law in each UK country. Safe staffing means having enough nursing staff with the right skills and knowledge, in the right place, at the right time. Without safe staffing levels in place, nursing staff are struggling to provide patients with the safe and effective care they would like to, and which patients deserve. 

We signpost members to good practice examples, quality improvement initiatives and resources to help tackle pressures in EDs, for example through the RCPCH winter pressures resources and RCEM winter planning resources.

  • 1NHS England. 2019. NHS Long Term Plan
  • 2Cecil E., Bottle A., Cowling T. et al. Primary care access. Emergency department visits and unplanned short hospitalizations in the UK. Paediatrics 2016: peds. 2015-1491