A5V4d

Health economics
pathways for children with medical problems reduce invasive investigations, and lead to more
appropriate treatment and reduced time spent in accident and emergency (A&E) services. 246
GDG justification of the 2 hour waiting time for an urgent referral
An important feature of this clinical guideline on children with feverish illness is the introduction of a
‘traffic light’ system to identify children with varying degrees of risk of serious illness. The guideline
makes clear recommendations on which children are unlikely to require medical attention beyond
information and reassurance (children with ‘green’ features) and who can thus be confidently
managed at home. The guideline identifies children who require an urgent face-to-face consultation
with a healthcare professional (‘red’) and those who may require a face-to-face consultation or require
a healthcare ‘safety net’ to be put in place (‘amber’).
Because of the limited information that can be obtained from a remote assessment, the GDG
originally recommended that all children with ‘red’ or ‘amber’ features should be referred for urgent
face-to-face assessment. The GDG felt it was necessary to make a recommendation on the maximum
time a child should have to wait to be first assessed by a healthcare professional if they were
classified as requiring an urgent consultation during a remote assessment. The aim of this was to
recommend a time frame within which action taken will make a difference to the outcome for the child.
Despite an extensive search of the published and grey literature, no clinical data could be identified to
define this limit. The GDG debated the issue among themselves and decided that it was such an
important question that wider consensus was required. Accordingly, the question went out as part of
the Delphi consultation exercise as agreed in the guideline methods protocol. A high level of
agreement was reached for a maximum wait of 2 hours following referral for urgent face-to-face
assessment (83% agreement). 2 hours was chosen as one of the time periods for the Delphi exercise
because it is an existing Department of Health standard for urgent referrals for out-of-hours health
care. 247
It was recognised by the GDG that children with one or more ‘amber’ signs included children who may
not require an urgent referral. It was agreed to make a recommendation on specific waiting times only
for children with ‘red’ features, and to recommend that a child with one or more ‘amber’ features is
seen face-to-face by a healthcare professional, but that the timing of the consultation for these
children could be carried out within a longer time frame which could be based on the clinical
judgement of the person carrying out the initial remote assessment.
The GDG believes that a 2 hour maximum wait for an urgent consultation does not represent an uplift
in care and is a cost-effective use of NHS resources. The reasons for this conclusion are outlined
here. First, there is audit data to suggest that this is already accepted routine practice for children at a
high risk of SBI. Second, the GDG strongly believes that a wait longer than 2 hours could potentially
increase mortality and morbidity. Finally, the GDG believes that by using a traffic light system to
classify children according to their risk of having a serious illness, healthcare professionals will have a
clearer indication as to which children do genuinely require an assessment by a healthcare
professional within 2 hours. By excluding the children with ‘green’ features and most of the children
with ‘amber’ features from this urgent referral group, the GDG believes the number of children who
are referred for a face-to-face assessment by a healthcare professional within 2 hours will be
reduced.
Evidence was presented to the GDG to show that the Department of Health has already set a national
standard for response to urgent calls as part of the National Quality Requirements in the Delivery of
Out-of-Hours Services. 247 This specifies a maximum 2 hour wait for a face-to face urgent consultation
for out-of-hours care: ‘Face-to-face consultations (whether in a centre or in the patient’s place of
residence) must be started within the following timescales, after the definitive clinical assessment has
been completed:
Emergency: Within 1 hour.
Urgent: Within 2 hours.
Less urgent: Within 6 hours’.
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