A policy response for England to the State of Child Health report

The groundbreaking State of Child Health report in January 2017 drew together a range of data across 25 key indicators of child physical and mental health creating a snapshot of infant, children and young people’s health. We highlight our recommendations for England.
Last modified
11 September 2018

Introduction

Despite having a health system which is the envy of the world, the health of children in the UK lags behind the rest of Western Europe. Nearly one in five children live in poverty, one third of 11-year-olds are overweight or obese and, most devastatingly, over 4,000 infants, children and young people died in the UK in 2014, with a significant number of these deaths potentially avoidable.

Government has taken steps in recent years to improve child health. Innovative new policies such as the proposed soft drinks industry levy to tackle childhood obesity, standardised packaging of cigarettes to cut smoking rates, and a commitment to investing in child and adolescent mental health services all mark a step in the right direction, but the approach so far has been piecemeal. More cohesive and robust action is needed to secure better health for all children.  

The Prime Minister’s assertion that the UK should be a country that works for everyone, not just the privileged few, is welcome. The findings of our report show that this pledge to tackle inequalities must stretch to health. Without bold and brave action to prevent illness from the very start of life and promote well-being across all sections of society, we will fail our country’s most vulnerable citizens for generations to come.

Professor Neena Modi, RCPCH President (2015-2018)
Professor Russell Viner, RCPCH Officer for Health Promotion

1. Develop and implement a cross-departmental child health strategy

We want to see child health at the top of the political agenda for the Prime Minister and the UK Government. To achieve this and ensure the health of infants, children and young people in the UK matches the best in Europe, co-ordinated Government action across several departments is required. Responsibility for improving child health and reducing mortality is held by several Government departments, not just the Department of Health. Achieving the best child health outcomes has to be a priority at the highest levels across Government, which is why a dedicated Cabinet Sub-Committee should be established to develop and implement a clear strategy. 

Recommendation

  • The Prime Minister should establish a Cabinet Sub-Committee on Child Health to develop and implement a robust and comprehensive cross-departmental child health strategy.

2. Reduce the number of child deaths

Over 4,000 infants, children and young people across the UK died in 2014. After the first year of life, adolescence is the period when children are most likely to die. Many of these adolescent deaths are potentially avoidable and occur due to external factors such as road traffic accidents and other injuries. With road traffic accidents in particular, it is significant that young drivers make up 2 percent of licence holders but are involved in 12 percent of accidents. Specific interventions by Government are likely to lower the UK child mortality rate.

Recommendations

  • Government should fund local authorities to deliver health visiting services and home safety equipment schemes which educate and equip parents and carers to keep their children safe, with a focus on water safety, blind cord safety and safe sleeping.
  • Government should introduce graduated driving licences in Great Britain for novice drivers. 
  • All local authorities should introduce 20mph speed limits in built-up areas to create safer environments for children to walk, cycle and play.

3. Develop integrated health and care statistics

This report makes repeated calls for richer and more consistent data capture so that information is comparable across the UK. There is a need to measure health metrics, services, processes, and outcomes more reliably and consistently. This means adopting a national approach.

This is a pivotal time for the UK Government. The relationship between the UK and Europe is changing which will inevitably impact upon the relationship between the four nations and how well they can work together. Change will bring about challenges but will also open the door to new opportunities. Government has a unique opportunity to develop integrated health and care statistics across England, Wales, Scotland and Northern Ireland and ensure that all data are captured to pre-defined criteria, and coded and analysed consistently. An integrated approach will result in more reliable, comparable information on trends and variation, and provide an essential evidence base to inform the use of resources in the medium and long term, and the success of national health and social care policies.

A National Neonatal Data Set that is an NHS Information Standard already exists (SCCI1595) and the establishment of the Maternity and Children's Data Sets project (MCDS) is a further step in the right direction. The MCDS includes the Maternity Services Data Set, Children and Young People's Health Services Data Set and the Child and Adolescent Mental Health Services Data Set and comprises mother and child data that will be used to improve quality and support better commissioning of services. We want to see these data fulfil their potential in a timely and reliable manner. 

Recommendations

  • Government should direct NHS Digital to develop standards to ensure child health data are of high quality, captured to pre-specified definitions, and analysed consistently across the UK. 
  • NHS England should support local authorities and Trusts to submit data to the Maternity and Children’s Data Sets and Neonatal Data Set in a timely manner.
  • NHS Digital should continue to work with health care professionals to develop the Maternity and Children’s Data Sets, so that outcomes and metrics that are important for child health and wellbeing can be progressively extended and improved.

4. Develop research capacity to drive improvements in children's health

Children are not small adults and adolescents are not large children. They both need biomedical and health services research that takes account of their changing physiology and addresses their problems directly. This would generate evidence to improve the quality of the treatments and healthcare they receive, and the policies that affect their wellbeing and the wellbeing of future generations. Government must therefore support the expansion of research into conditions that affect infants, children and young people in order to improve their health.

However, the fraction of research funding awarded to paediatrics and child health by the major research funders and industry investment in child health research are both relatively small compared with population and disease burden. Lack of research leaders in children's health potentially contributes to the problem. We applaud innovations such as the European Paediatric Medicines regulations that have provided much needed incentive to industry to develop medicines for children. We urge Government to support the expansion of research into rare as well as common conditions that affect infants, children and young people across physical and mental health. 

Recommendations

  • Government should encourage increased investment in research relating to child health, across the pharmaceutical, medical, social sciences, youth justice and education domains.
  • Government should introduce incentives for industry to develop medicines, technologies, products, and devices for children.
  • Health Education England and NHS Trusts should take steps to allocate time to allow trainees and clinicians to contribute to and support child health research.
  • Higher educational institutions (HEIs) should ensure that faculty structures and career opportunities support careers and capacity development in child health research. 
  • The National Institute for Health Research should expand existing support for child health research training.

5. Reduce child poverty and inequality

The link between poverty and poor health is highlighted throughout this report. More must be done to reduce the number of children living in poverty and minimise deprivation if child health is to be improved. Children deserve equal opportunities from the very early years. Government should prioritise the development of levelling policies to ensure that, in the words of the Prime Minister, “the UK is a country that works for everyone”. The “health in all policies” approach is aimed at ensuring that all public policy, including economic policy, is scrutinised in relation to the potential impact on health across the UK population. We want Government to adopt a “child health in all policies” approach. 

Equal access to health services from pre-conception is another important leveller. Health Visitors and School Nurses are pivotal to early identification and intervention, preventing accident, injury and more serious problems later in life. We fear that the Government decision to cut local authorities’ public health funding will prevent infants, children and young people from accessing these crucial services, and this will most impact upon low-income families.

Recommendations

  • Government should adopt a “child health in all policies” approach to decision-making and policy development, with Her Majesty’s Treasury disclosing information about the impact of the Chancellor’s annual budget statement on child poverty and inequality.
  • Government should place a moratorium on further public health funding cuts until a clear impact assessment of the effects of the most recent cuts is undertaken.
  • Government should ensure universal early years public health services, including health visiting and school nursing, are prioritised and supported financially, with targeted help for children and families experiencing poverty.

6. Maximise women’s health before, during and after pregnancy

Maternal health and wellbeing has a profound impact on the health of children. This report demonstrates how being a healthy weight, breastfeeding and stopping smoking improve the health of both mothers and infants, once again illustrating the importance of adequately funded public health services. 

Breastfeeding rates in the UK are among the lowest in the world, yet recent data are unavailable due to the Government decision to cancel the 2015 Infant Feeding Survey. In the longer term NHS Digital hopes to obtain data on breastfeeding and other important public health information for 0-5 year olds as part of the Maternity and Children’s Data Set. However, these data will be for England only. Robust data from across the four nations are needed to see the full picture for breastfeeding in the UK and identify particular areas of need for targeted support services. 

Hospitals must also play their part in promoting breastfeeding and provide clear and consistent advice to new mothers.  Government, too, has a role in supporting women to breastfeed and should take a cross-departmental approach to developing new initiatives to increase uptake.

Recommendations

  • The Department of Health should reinstate the UK-wide Infant Feeding Survey. 
  • Government should develop a cross-departmental initiative to support breastfeeding. This should include a national public health campaign that promotes breastfeeding and a sector wide approach to support women to breastfeed, including in the workplace. 
  • Government should protect funding for public health services so that health visiting, smoking cessation programmes and breastfeeding support are accessible to all pregnant women and new mothers.
  • NHS England should mandate that all maternity services in England achieve and maintain UNICEF UK Baby Friendly Initiative Accreditation by January 2019.

7. Provide statutory comprehensive personal, social and health education, including sex and relationships education, in all schools

The national curriculum states that ‘all schools should make provision for personal, social, health and economic education (PSHE)’. However, it remains a non-statutory subject for schools in England. There is good evidence that high quality PSHE gives children and young people the knowledge and skills to make positive, healthy decisions, and this report shows that young people themselves want greater access to PSHE, including sex and relationships education (SRE). Parliamentarians agree, with the Education Select Committee recommending in a 2015 report that ‘(the Department for Education) develop a work plan for introducing age-appropriate PSHE and SRE as statutory subjects in primary and secondary schools, setting out its strategy for improving the supply of teachers able to deliver this subject and a timetable for achieving this’. This call has been echoed across the health and education sector, and by the Chairs of the Health, Home Affairs, and Business, Innovation, and Skills Committees in the House of Commons.

Recommendations

The Department for Education should introduce statutory and comprehensive personal, social and health education programmes, comprising sex and relationship education, across all primary and secondary schools, including free schools and academies. 

  • The delivery of these programmes should be included in robust Ofsted inspections.

8. Strengthen tobacco and alcohol control

Smoking is the single biggest cause of avoidable deaths in the UK. Although passive smoking is currently the biggest risk to children and young people, 6 percent of adolescents still smoke regularly in England. Smoking rates in more disadvantaged areas of England are higher than in the least disadvantaged areas, in keeping with most of the adverse health indicators in this report. The rise in the popularity of electronic cigarettes presents another temptation for young people. 

The Government commitment to tackling harm caused by tobacco through policies such as banning smoking in cars with children and introducing plain packaging is admirable, but more needs to be done to ensure that infants, children and young people are better protected from the adverse effects of smoking and marketing of tobacco and tobacco-related products. The new Tobacco Control Plan was due for publication in 2016, but is yet to be released at the time of going to print.  

Other common forms of substance use, like alcohol misuse, remain a concern for young people in England. Young people between the ages of 15 and 17 years are more likely to binge drink (drinking multiple drinks in a row), which is linked with other health risk behaviours such as unprotected or regretted sexual activity, antisocial and criminal behaviour, and self-harm and thoughts of suicide. The Scottish Government are leading the way in tackling alcohol abuse with the introduction of minimum unit pricing, and we would like to see the Westminster Government follow suit.

Recommendations

  • Government should publish a new Tobacco Control Plan for England, with a focus on implementing measures to reduce smoking uptake in children.
  • Government should extend bans on smoking in public places and cars to schools, sports fields, playgrounds and on NHS premises.
  • Public Health England should support Government measures through sustained public health campaigns about the dangers of second hand smoke.
  • Government should prohibit all forms of marketing of e-cigarettes for non-medicinal use.
  • Government should introduce a minimum unit price for alcohol.

9. Tackle childhood obesity effectively

The Westminster Government has already committed to tackling the national scourge of childhood obesity through the implementation of its Childhood Obesity Plan published in summer 2016. Measures such as the proposed soft drinks industry levy and the Public Health England-led reformulation programme for unhealthy food and drink are welcome. However, this report reveals that the prevalence of child overweight and obesity is not falling, and in fact appears to be rising in England’s most disadvantaged areas. We believe that far stronger action is required to tackle this public health crisis. 

Recommendations

  • Her Majesty’s Treasury should commission an independent and ongoing evaluation of the soft drinks industry levy.  
  • Public Health England should outline its plans for a regulatory framework for reformulation if the current voluntary programme does not achieve the targets set. Clear guidance on evaluation of industry reformulation and a specific timetable for implementation should also be published.
  • Government should ban the advertising of foods high in saturated fat, sugar and salt in all broadcast media before 9pm.
  • Government should undertake an audit of local authority licensing and catering arrangements with the intention of developing formal recommendations on reducing the proximity of fast food outlets to schools, colleges, leisure centres and other places where children gather.
  • Government should extend the mandatory school food standards to all free schools and academies, and to early years settings. Compliance with these standards should be monitored through Ofsted inspections.
  • NHS England and professional bodies should ensure that all health care professionals make every contact count by empowering them to have the often difficult conversation with patients about their weight.
  • Government should extend the National Child Measurement Programme to measure children after birth, before school and during adolescence. 

10. Maximise mental health and wellbeing throughout childhood

Half of adult mental health problems start before the age of 14 and 75 percent start before the age of 24 years. Early identification and intervention are essential to ensure that children and young people can access the services and support they need to offset the effects of mental health problems. All professionals working with children should be signposted to educational resources such as MindEd, a Government funded e-portal which offers free, simple guidance on children and young people's mental health, wellbeing and development.

All clinicians and practitioners caring for vulnerable children and young people should be trained to identify mental health problems, and know what to do to intervene early. Paediatricians must be better prepared to identify and support vulnerable children and young people with mental health problems. Emergency care settings are the first point of care for many of these young people, illustrating the need for earlier recognition.   

The CAMHS crisis in the UK is well-documented, and Government commitment to tackling this through additional investment is welcome. However, anecdotal evidence suggests that extra funding is not necessarily reaching the frontline. Clear, robust data are required to identify areas of need so that services can be most appropriately targeted.

Recommendations

  • Government should carry out the National Mental Health survey every three years to identify the prevalence of mental health problems among children and young people in order to aid the planning of health care services.
  • NHS England should commission child and adolescent mental health services so that they are structured around the child or young person, delivered as close as possible to their home and supported by a family centred approach to care planning and information sharing. 
  • The Department for Education should ensure that appropriate mental health support is offered in all primary and secondary schools in England, including free schools and academies.
  • Professional bodies representing all those working with infants, children and young people in health, social care, education, criminal justice and community settings should equip their members with the necessary tools to identify mental health issues through the promotion of resources such as the MindEd portal.
  • NHS England should ensure that funding designated for expanding child and adolescent mental health services reach frontline services in Clinical Commissioning Groups.

11. Tailor the health system to meet the needs of children, young people, their parents and carers

This report makes clear that the integration of care around the needs of children, young people and their families is crucial to improving their health services and outcomes. Navigating the health system can be daunting for anyone, but especially so for unwell children and their families. The difficult transition period between child and adult services can be particularly traumatic, with young people often feeling as though their voices aren’t heard. The health and care system must be tailored to the specific needs of children, young people and their families and they must be supported to navigate the system. 

In view of the major ongoing reorganisations of health services, NHS England must ensure the health and care needs of infants, children and young people are appropriately considered in all Sustainability and Transformation Plans.

Greater integration will require better communication and sharing of information between health and social care professionals. NHS England’s new Healthy Children: Transforming Child Health Information sets out an ambitious strategy for how information and technology will be used to improve children’s health and wellbeing. A child health data hub is envisaged which will bring together information from multiple sources. The strategy has the potential to capture where children are, how healthy they are and if they are accessing preventative programmes of care. 

Recommendations

  • NHS England should ensure that the health and care needs of infants, children and young people are prioritised in the implementation of all Sustainability and Transformation Plans. Child health professionals and children and young people should be consulted in this implementation.
  • NHS England should ensure better transitions from child to adult services, involving children and young people in planning the transfer, and promoting the many examples of best practice that exist.
  • Health Education England should fund mandatory child health training for all GP trainees.
  • NHS England should ensure every child and young person with a long term condition has a named doctor or health professional.
  • The Care Quality Commission should extend the patient survey of young people in inpatient settings to cover outpatient and community settings.
  • NHS England should ensure parents and carers are engaged and equipped with the appropriate skills and knowledge to navigate the planned digital health and care system.
  • NHS England should provide information to all Trusts through its Clinical Reference Groups, commissioning structures and assurance processes to ensure that clinical teams looking after children and young people with known medical conditions make maximum use of tools to support improved communication and clarity around ongoing management, for example the use of epilepsy passports or asthma management plans where appropriate.

12. Implementing guidance and standards

There are many areas of infant, children and young people’s health that already have a strong evidence base that should guide practice but this report makes frequent mention of the importance of implementing existing guidelines and standards. Through existing monitoring and assurance processes, NHS England should ensure care is provided according to evidence-based standards.  

Recommendations

  • NHS England should support clinical commissioning groups to commission quality health and care services against evidence-based standards and support all Trusts to implement guidelines and standards.
  • Public Health England should support local authorities to deliver quality public health services against evidence-based standards.