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Child health inequalities driven by child poverty in the UK - position statement

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Health inequalities are the avoidable, unfair and systematic differences in health outcomes between different groups of babies, children and young people. The drivers of health inequalities are the social, economic and environmental factors in which individuals live that have an impact on their health outcomes. This includes ethnicity, income, housing, climate change and being looked after by local authorities.

This position statement focuses on poverty as a driver of health inequalities.
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Last modified
21 September 2022
Post date
21 September 2022
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Everyone deserves the world. This is important because everyone is entitled to being healthy, happy and well, to be loved, not be hungry and be looked after.

RCPCH &Us1

Introduction

Health inequalities are the avoidable, unfair and systematic differences in health outcomes between different groups of babies, children and young people. The drivers of health inequalities are the social, economic and environmental factors in which individuals live that have an impact on their health outcomes. This includes ethnicity, income, housing, climate change and being looked after by local authorities. 

This position statement focuses on poverty as a driver of health inequalities. The influence of poverty on children’s health and wellbeing is undeniable. Children living in poverty are more likely to have poorer health outcomes including low birth weight, poor physical health, and mental health problems. The health impacts of growing up in poverty are significant and follow children across their life. The current cost of living crisis will only exacerbate this by pushing more families into poverty. It is essential that health inequalities driven by poverty are addressed to improve child health outcomes, as well as reduce costs to the NHS in the long term2 .

Spotlight from RCPCH &Us and partners

Last year [2021] we had the chance to question different people from health, education, the police, charities and the government on child poverty. We wanted to know how professionals notice that someone is living in poverty if the appointments are done on the phone or through a webcam. We also asked what they thought was the impact of child poverty on children and young people with disabilities, physical health or mental health conditions. We asked paediatricians about how to tackle the issues that are caused by poverty like stress or poor diet, and how can families get the help they need if they can’t afford to pay for medicines or event data or phone calls with virtual appointments. 

It is evident that child poverty is an issue that requires teamwork from different services in order to eradicate it and it is clear that it is a long-standing problem that plagues all of the UK. This plague affects a ludicrous amount of our children and can bring about dire consequences. It is time we bite the bullet and face the truth that we that we need to do better and that we should all come together as one fight and end it so no more children are living without adequate necessities and can instead focus on being bright and cared for members of our society.3

RCPCH &Us, YoMo Glasgow, Fitzrovia Youth in Action, Caerphilly Youth Forum

Child poverty in the UK

  • One in four (27%) children live in poverty in the UK, defined as living in a household with an income less than 60% of the median household income4 .
  • The main drivers for child poverty are insufficient income and high living costs associated with raising children5 . However, employment does not necessarily provide a solution out of poverty; 75% of children in poverty have at least one parent working in at least one job6 .
  • Children in specific family types are at higher risk of poverty. For example, lone parent families, the majority of which are headed by women, and having someone with long-term illness in the household increases the risk due to barriers to employment7 . 
  • There are stark ethnic differences in the rates of child poverty, and poverty is higher among certain ethnic minority groups. In England, 46% are living in poverty compared to 26% of children from white British families8 . 
  • The causes of poverty and how it affects child health and well-being will differ by geographical location. Of the UK nations, Wales has the highest rate of children in living poverty (31%), compared to England (30%), then Scotland and Northern Ireland (24%)9 . There are regional variations within each nation and disparities between rural and urban areas too10 . While rural Cornwall, Derry, Glasgow and inner-city London all have high rates of child poverty, the challenges, opportunities and strategies required to address problems in these areas will vary. 
  • No recourse to public funds (NRPF) is a condition applied to those staying in the UK with any form of temporary immigration status. This prohibits migrant families from accessing most benefits, such as Universal Credit and free school meals, placing migrant children at increased risk of destitution11 .

Evidence of how poverty drives health inequalities in the UK

Mortality in childhood
  • The UK has high rates of infant and child mortality when compared with other developed countries12 .
  • The index of multiple deprivation (IMD) is an overall measure of deprivation based on factors such as income, employment, health, education, crime, the living environment and access to housing within an area. Infants in the 10% most deprived areas are twice as likely to die in infancy as those in the 10% least deprived13 . For each increase in decile of deprivation, the relative risk of mortality increases by 10%14 .
  • There is a clear association between the risk of death and the level of deprivation for children who died in England between April 2019 and March 2020. Over a fifth of the 3,200 child deaths in the period examined might have been avoided if children living in the most deprived areas had the same mortality risk as those living in the least deprived15 . Between 2011 and 2020, the child death rate was 70% higher in the most deprived areas of Wales compared with the least deprived areas16 . 
Acute and long-term illness
  • Children living in poverty are significantly more likely to suffer from acute and long-term illness. They are significantly more likely to require hospital admission17  and were 72% more likely than other children to be diagnosed with a long-term illness.18
  • Rates of obesity and severe obesity in children living in the most income deprived areas entering Reception and Year 6 are rising, while the rates are decreasing in the least income deprived areas in England19 .  In Wales, the gap between obesity prevalence in the most and least income deprived quintiles has increased from 5.9% in 2017/18 to 6.9% in 2018/19.20
  • In Scotland, marked socioeconomic inequalities in child unhealthy weight have developed over the past 20 years. Children living in the most income deprived areas saw an 8.4 percentage point increase between 2019/20 and 2020/21, to 35.7% at risk of being overweight or obese, compared to a 3.6 percentage point increase, to 20.8%, in the least deprived areas21 . 
  • In NI the most recent data indicates a 1.1% difference in year one obesity between the most income deprived 20% areas.22
  • Children living in poverty are more likely to be at risk of tooth decay, in prevalence and severity. In England, children from the most income deprived areas having more than twice the level of decay compared with those from the least income deprived23 .In Wales, 42.2% of five-year olds in the most income deprived areas have tooth decay, compared to just 22.3% in the least income deprived areas24 . There has been a general improvement in the number of patients aged 0-17yrs who had at least 1 treatment for dental caries. This rate has fallen over time for NI overall and for those living in the 20% most deprived wards. However, the rate remains higher for the most deprived areas than the NI average25 . 
  • Children living in the poorest 20% of households in the UK are four times more likely to develop a mental disorder as those from the wealthiest 20%26 .
Indoor and outdoor air quality
  • Air pollution exposure is highest in the most income deprived areas27 , and children are disproportionally exposed to the highest levels of pollution28 .   
  • Children in more income deprived families are three times more likely to be exposed to second-hand smoke29 .  
  • Children in income deprived areas are more likely to live in housing with poor ventilation30  and other features of substandard housing. Families in poverty may ventilate their house less because of problems such as fuel poverty.

How poverty affects child health outcomes

Paediatricians have told us how poverty has affected their patients, including the following:  

  • Parents in poverty are less able to afford healthy foods and offer their children a healthy lifestyle. Healthy foods are nearly three times more expensive than less healthy foods per calorie, which means families may be more likely to eat food that is cheap but nutritionally poor, leading to obesity and malnutrition in children31 .
  • Recent increases in household energy costs comes on top of food insecurity, which may mean families face a choice between paying energy bills and food. Living in a cold home has a negative impact on physical health by, for example, exacerbating respiratory illnesses32 .
  • Low-income families may be unable to afford basic hygiene products due to financial constraints. For example, period poverty is the lack of access to sanitary products and 1 in 10 young people who menstruate are unable to afford period products, which can lead to missed school days or improvising menstrual products33 .
  • Adverse childhood experiences, which are usually multiple, have a cumulative negative effect on physical and mental health in later life and are three times more common in the context of poverty than in affluence34 . The foundations for healthy development of a robust respiratory system are built during infancy – those babies living in cold housing during their first winter will be expending calories on maintaining body temperature and avoiding low blood sugar levels, rather than organ development.
  • Children in low-income families have less access to the medical care they need35 . The average cost of attending a clinic appointment is £3535 . Families have reported missing paediatric appointments because of the financial costs of attending one due to travel, parking, food, childcare costs and potential loss in earnings, reported to be an average of £5036 . Low-income families may also be experiencing digital exclusion, where households may not have a smartphone or internet access and are unable to benefit from digital health technologies as a result37 .

Children and young people have told us how poverty affects them, including the following:

  • Not enough money for healthy nourishing food, leading to a poor diet and unhealthy eating. It would be easier to get disease and get sick because of poor diet and poor hygiene. It would also be hard to sleep, which would also affect your mental health. 
  • Not able to afford to go to social events or sports clubs, go on holiday, or go on school trips. You might be left out. 
  • Can’t afford good housing, could be homeless. You would be lacking basic things like electricity, or hot, clean water – leading to poor hygiene (dirty clothes, hair etc). 
  • You may end up being bullied, or possibly becoming a bully. People might make fun of you, and you might be bullied because you can’t afford clothes, or have a dirty uniform. 
  • Poverty would result in poor mental health and could lead to depression or anxiety. You could feel angry and frustrated, and might lash out at people. 
  • You would become vulnerable and might be exposed to ‘dodgy’ people and drugs. You could be forced to make bad choices and get up to trouble38 .

RCPCH recommendations to reduce health inequalities as a result of child poverty

England

Reduce health inequalities
  • We welcome the UK Government’s commitment to levelling up and addressing inequalities. The Health Disparities White Paper should be published without delay. The RCPCH recommends that the White Paper should: 
    • Include an explicit focus on reducing child poverty and health inequalities by reintroducing national targets to end child poverty. The Department for Work and Pensions, the Department for Education and the Treasury in particular should undertake a review into the impact of recent welfare changes on child poverty and inequality. 
    • Recognise children and young people as a distinct group to ensure they are provided with a universal health service that works for them, with extra focus, support and capacity for the most vulnerable.
    • Restore the public health grant for Local Authorities with investment in public health provision allocated based on children and young people’s health needs. 
Data and digital
  • NHSE should set out without delay how they will collect, analyse and publish data relating to health inequalities for children and young people across the health service, as outlined in the Health and Care Act 2022, and use these to improve design and delivery of care to support better health outcomes.
  • The Government should develop plans for use of the NHS number as single unique identifier for children and young people in England to enable professionals to share information more easily between agencies and services in order to provide better care for their needs. 
Workforce
  • NHS England should publish its longer term People Plan for 2022/23, which should set out how to deliver an appropriately trained paediatric and child health workforce, including health visitors and school nurses, that is properly resourced and based on robust workforce data and modelling. Tackling inequalities should be a key objective and will ensure all children and young people receive the best possible care. 

Scotland

Reduce health inequalities

We welcome existing commitments by the Scottish Government to reduce child poverty and health inequalities such as the introduction of the Scottish Child Payment, the Young Patients Family Fund and the expansion of free school meals. To expand on these, the RCPCH recommends that the Scottish Government should ensure:   

  • Action all measures contained in the Child Poverty (Scotland) Act and ensure these actions are appropriately resourced and funded, enabling the interim (2023/24) and 2030/31 targets to be met on time.
  • Provide greater detail on how the Tackling Child Poverty Delivery Plan 2022-26 will contribute to improving the health and wellbeing of children and young people living in poverty.
  • Provide long-term, stable funding for community-based services to support children, young people and their families and provide early intervention services.
Data and digital
  • The emerging Scottish Government Health and Social Care Data Strategy should consider how it can embed tackling child health inequalities as a core aim. In doing so, they should ensure collection, analysis and timely publication of data relating to health inequalities for children and young people across the health service and use these to improve design and delivery of care to support better health outcomes.
  • The Scottish Government should consider how the CHI number could be developed as a consistent identifier for children and young people to enable professionals to share more easily between agencies and services in order to provide better care for their needs. 
Workforce
  • The Scottish Government should clearly detail in the National Workforce Strategy for Health and Social Care how it will deliver an appropriately trained paediatric and child health workforce that is properly resourced and enables proactive planning and modelling based on robust workforce data, in order to tackle health inequalities to ensure all children and young people receive the best possible care.

Wales

Reduce health inequalities
  • The Welsh Government has made a number of commitments that we welcome, including that of rolling out free school meals to all primary school children by 2024. We also note that reducing health inequalities is a core feature of Welsh Government policy across a range of policy areas, including its obesity strategy and plans for health and social care services. However, we lack a focussed and prominent strategy setting specific targets to reduce child poverty and unequal health outcomes. We therefore recommend that:  
    • The Welsh Government should acknowledge high child poverty rates, review existing programmes and publish a revised strategy to reduce child poverty.
    • The Strategy should provide national targets to reduce child poverty rates, with clear accountability across Government.
    • The Welsh Government should expand the Children and Young People Plan so that future iterations form a comprehensive cross-departmental child health and wellbeing strategy that will address health inequalities and the impact of child poverty, which outlines the role each department has in contributing to solutions.
Data and digital
  • Welsh Government and Digital Health and Care Wales should embed tackling child health inequalities as a core aim for digital health strategy. In doing so, they should ensure collection, analysis and timely publication of data relating to health inequalities for children and young people across the health service and use these to improve design and delivery of care to support better health outcomes.
  • The Welsh Government should consider whether the NHS number could be used as single unique identifier for children and young people in Wales to enable professionals to share information more easily between agencies and services in order to provide better care for their needs. 
Workforce
  • The Welsh Government and Health Education and Improvement Wales should publish a comprehensive plan with a clear delivery framework to deliver an appropriately trained paediatric and child health heath workforce that has tackling inequalities as a key objective and ensures all children and young people receive the best possible care.
  • This plan would need to be properly resourced and funded; and enable proactive planning and modelling based on robust workforce data, in line with commitments made in ‘Healthier Wales: Our Workforce Strategy for Health and Social Care’ and ‘Our Programme for Transforming and Modernising Planned Care and Reducing Waiting Lists in Wales’.

Northern Ireland

Reduce health inequalities

The ten-year public health strategy Making Life Better - A Whole System Framework for Public Health 2013-2023 aims to achieve better health and wellbeing for everyone and reduce inequalities in health. Monitoring reports are published annually and in terms of policy, there are numerous associated strategies that can contribute to reducing health inequalities.

Health and Social Care reform is high on the agenda, yet progress is slow and the focus is often not on children. The collapse of the Northern Ireland Executive between 2017 and 2020, and more recently in 2022 causes concern that strategies intended to be cross cutting are working in relative isolation.

Therefore, we recommend that: 

  • The Northern Ireland Executive should adopt a ‘child health in all policies’ approach to decision making, policy development and service design. This is based on the recognition that the challenges facing child health are highly complex and often linked through the social determinants of health. 
  • The Department of Communities should expedite the production of an anti-poverty strategy that includes bespoke children and young people outcomes and indicators. Monitor, and report on, the health impact of poverty on children, young people and their families and target intervention to where it is needed most.
  • The Northern Ireland Executive should achieve the outcomes in the Children and Young People’s Strategy (2020-2030) and maintain a focus on those outcomes that will help to reduce health inequalities.
  • The Department of Health should ensure the shift towards the new Integrated Care System for Northern Ireland is designed and commissioned in such a way that structural barriers to achieving equitable health and wellbeing outcomes for children are be removed. 
Data and digital
  • The Department of Health should ensure that accurate and timely data and surveillance is collected to support research, monitoring and intervention evaluation to improve child health outcomes.
  • The Department of Health and Health and Social Care Trusts should invest in integrated electronic systems to collect and manage child health information with a clear focus on outcomes. 
  • The Northern Ireland Executive should consider the use of a single unique identifier for children and young people in Northern Ireland, expanding the use of the Health and Social Care Number across multiple public services would enable professionals to share information more easily between agencies and services in order to plan for and adequately provide for individual children’s needs. 
Workforce
  • The Department of Health should publish a comprehensive strategy to deliver an appropriately trained paediatric and child health heath workforce that is properly resourced and based on robust workforce data and modelling that has tackling inequalities as a key objective and ensures all children and young people receive the best possible care.

RCPCH &Us

From RCPCH &Us 39 .

Reduce health inequalities
  • We need more help for children, young people and families who are struggling to eat well, sleep well and live well.
  • As well as staying physically healthy, we need more services to support our emotional wellbeing as children, young people and our families.
  • We need the spaces and places around us (health services, schools, communities) to make us feel valued and help to break the cycle of feeling sad and alone.
Data and digital
  • We need services to provide accessible information to children, young people and families about where we need to go to get the support we need.
  • We need a voice in decision making.
  • We need to have coordinated help so that we only have to tell one service once about what is going on for us, but with our permission, they can tell others to make sure we get the best help.
Workforce
  • We need staff who know about different people and places that can help us. We need staff who are good at talking to us about what is going on in all areas of our lives.
  • There needs to be more investment in services and support for children, young people and families facing inequalities that will affect our health.

The role of the RCPCH 

  • In its 2021-24 strategy, the RCPCH has committed to continue to shape policy around health inequalities in childhood to drive better outcomes in children and young people’s health.
  • The RCPCH has published ‘Child poverty and health inequalities in the UK - a toolkit for paediatricians’ to support members in working to reduce health inequalities in childhood locally.
  • We will continue to advocate on the issues that matter most to our members, and to children, young people and their families. With the cost of living crisis having a detrimental impact to families, child poverty will be a key campaigning issue for RCPCH.
  • RCPCH &Us, the children, young people and families network for RCPCH will continue to inform, influence and shape our thinking on issues that matter to them, including child poverty and health inequalities.

Thank you to the 500+ children and young people, parents and carers plus supporting paediatricians from London, Warrington, Belfast, Edinburgh, Warwick, Peterborough, Essex, Oxford, Rhyl, Belfast, Hartlepool, Liverpool, Glasgow and Caerphilly who joined RCPCH &Us in sharing the voices, views and ideas on child health inequalities in 2022.