- 1. Implement in full; A Strategy for Paediatric Healthcare Services Provided in Hospitals and in the Community (2016 – 2026)
- 2. Reduce the number of child deaths
- 3. Develop integrated health and care statistics
- 4. Develop research capacity to drive improvements in children’s health
- 5. Reduce child poverty and inequality
- 6. Maximise women’s health before, during and after pregnancy
- 7. Deliver high quality, evidence-based, meaningful and consistent, health and social well-being improvement programmes to all primary and post primary pupils
- 8. Strengthen tobacco and alcohol control
- 9. Tackle childhood obesity effectively
- 10. Maximise mental health and wellbeing throughout childhood
- 11. Tailor the health system to meet the needs of children, young people, their parents and carers
- 12. Implementing guidance and standards
Child health in Northern Ireland is amongst the poorest in Western Europe and important indicators continue to demonstrate real inequality in health outcomes. 23% of children in Northern Ireland live in poverty, 28% are overweight or obese and child mortality rates remain worryingly high in Northern Ireland.
The challenges facing the health and social care system in Northern Ireland are well documented and, while the newly published A Strategy for Paediatric Healthcare Services Provided in Hospitals and in the Community (2016 – 2026) provides a strong step in the right direction, there is much more that the Northern Ireland Executive could and should be doing to ensure we give every infant, child and young person the best start in life.
Early intervention and prevention can reduce and resolve issues before they become more difficult and expensive to treat later in life. The infants, children and young people of today are the productive future workers of the nation, and the parents of the next generation. They have the right to achieve their potential, and for this their health and productivity must prosper.
These recommendations reflect the importance of seeing the whole child, their specific condition, their wider health, their family and the environment in which they are growing up. More cohesive and robust action is needed, with better data and active monitoring of the impact. We welcome the opportunity to work with the Northern Ireland Executive and stakeholders to implement and monitor these recommendations.
Dr Karl McKeever
RCPCH Officer for Ireland
1. Implement in full; A Strategy for Paediatric Healthcare Services Provided in Hospitals and in the Community (2016 – 2026)
To ensure the health of infants, children and young people in Northern Ireland improves to match the best in Europe, co-ordinated government action across several departments is required. Achieving the best child health outcomes has to be a priority right across government.
The Donaldson Review in 2015 provided a timely review of the current health and social care system in Northern Ireland, and identified a number of challenges, including rising demand and a pressurised workforce. The recent Systems, Not Structures: Changing Health and Social Care report noted similar challenges, and indeed set out the case for change to outcome based healthcare.
The RCPCH welcomes the recent publication of A Strategy for Paediatric Healthcare Services Provided in Hospitals and in the Community (2016–2026), which recognises the importance of commissioning and delivering high quality services for infants, children and young people through a networked approach. We are pleased that the Strategy refers to the wider priorities as set out in Health and Wellbeing 2026: Delivering Together and the Healthy Child, Healthy Future framework and continues to highlight the importance of prevention and early intervention. The Strategy must be implemented in full, alongside a comprehensive, digital approach to capturing child health information and data (see recommendation three).
- 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 Health should establish a Northern Ireland paediatric network, headed by a children’s clinical lead, to drive the implementation of A Strategy for Paediatric Healthcare Services Provided in Hospitals and in the Community (2016-2026) across Northern Ireland.
2. Reduce the number of child deaths
The child mortality rate in Northern Ireland provides worrying reading; Northern Ireland has the highest child mortality rate in the UK across all age groups. After the first year of life, adolescence is the life stage where most deaths occur. Many of these deaths are potentially avoidable and occur due to external factors such as assault, road traffic accidents, suicide and other injuries.
We welcome the Department of Health’s recent consultation on an updated suicide prevention strategy (Protect Life 2: A Strategy for Suicide Prevention in the North of Ireland) and particularly the continued focus on reducing the differential in suicide rate between the most and least deprived areas. Adolescent suicide rates in Northern Ireland have remained higher than all other UK countries since 2006 and we would encourage the Department to ensure there is a greater focus on children and young people (including implementing a multifactorial outcome based approach).
Child pedestrians have been identified as particularly vulnerable road users and higher incidences of death and serious injury have also been found amongst young drivers. We welcome the targets set out in Northern Ireland’s Road Safety Strategy to 2020 and encourage the Northern Ireland Executive to deliver on subsequent commitments to lower the speed limits in built-up areas and strengthen graduated licensing schemes.
Many other injuries and poisonings during childhood are preventable. Parents and carers need to be supported to make safety a priority, ensuring they are equipped with the knowledge, skills and resources for creating safe environments. The Home Accident Prevention Strategy (2015- 2025) makes clear recommendations that require cross-departmental action.
The reasons why infants, children and young people die are complex and require a range of interventions and policy solutions to reduce avoidable mortality but we believe that specific interventions undertaken by the Northern Ireland Executive could succeed in lowering the child mortality rate.
- The Northern Ireland Executive should fully implement a child deaths overview panel to ensure that learning from child deaths in Northern Ireland is implemented comprehensively across all sectors.
- The Department of Health should ensure there is a greater focus on children and young people in Protect Life 2: A Strategy for Suicide Prevention in the North of Ireland and engage with stakeholders to ensure that the recommendations are implemented in full.
- The Northern Ireland Executive should introduce graduated licensing schemes for novice drivers.
- The Northern Ireland Executive should introduce 20mph speed limits in residential areas and other urban areas where there is a significant presence of vulnerable road users to create safer environments for children to walk, cycle and play.
- The Department of Health, the Public Health Agency, health and social care trusts and the Health and Social Care Board should prioritise children’s safety, and 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.
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. The amount and quality of data readily available from Northern Ireland was significantly less than the other UK nations. There is an urgent need to measure health metrics, services, processes and outcomes more reliably and consistently.
Investment is needed to better collect and manage clinical information for population health management and to plan and implement an outcome based commissioning system which results in health and social care services that are responsive to service delivery challenges, share information appropriately, and learn from previous experiences.
- The Northern Ireland Executive should work with the other UK nations to develop standards to ensure child health data are of high quality, captured to pre-specified definitions and can be analysed consistently with England, Scotland and Wales.
- 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.
4. Develop research capacity to drive improvements in children’s health
Infants, children and young people need biomedical and health services research that takes account of their changing physiology, and addresses their problems directly, generating 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. However, the fraction of research funding devoted to paediatrics and child health by the major research funders with a broad health research mission is relatively small, and clinicians are often unable to take part in research owing to time pressures. There is a need to support the expansion of research into many conditions that affect infants, children and young people in order to improve health outcomes.
- The Northern Ireland Executive should encourage increased investment in research relating to child health, across the pharmaceutical, medical, social sciences, youth justice and education domains.
- The Health and Social Care Board and health and social care trusts should ensure protected time in job plans for clinicians to contribute to and support child health research.
5. Reduce child poverty and inequality
The link between poverty and poor health is highlighted throughout this report. With 23% of children in Northern Ireland reported to live in relative poverty, more must be done to reduce this number and to minimise the impact of deprivation on health outcomes. We welcome the new Child Poverty Strategy for Northern Ireland. It is essential that it is implemented with urgency and that departments work together to closely monitor children’s outcomes across a range of health, social, educational and economic indicators.
Equal access to health services from pre-conception is an important leveller. In particular health visitors and school nurses play a vital role in early identification and intervention, preventing accident and injury and more serious problems later in life. These services must be preserved and properly resourced.
- The Northern Ireland Executive should implement the new Child Poverty Strategy for Northern Ireland with urgency.
- The Department of Health and Public Health Agency should ensure public health and prevention services, including health visitors, school nurses and the Family Nurse Partnership, are prioritised and supported ensuring equitable access to services across Northern Ireland. This should include a focus on primary care in order to mediate the adverse health effects of 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 all improve health outcomes for both mothers and infants.
The Strategy for Maternity Care in Northern Ireland recognised the impact of wider health determinants and health behaviours in giving every baby the best start in life. We welcomed the increased effort through Breastfeeding - a great start: a strategy for Northern Ireland 2013- 2023. However, Northern Ireland continues to have the lowest levels of breastfeeding in the UK (with less than 28 percent of infants at six weeks receiving any breast milk) and this trend is particularly prominent for young mothers and those living in areas of deprivation. Progress against the strategy needs to be carefully monitored and greater action is needed across all agencies to ensure the strategy is implemented in full.
- The Department of Health should monitor progress against Breastfeeding - a great start: a strategy for Northern Ireland 2013-2023 and publish an annual report.
- The Public Health Agency, Health and Social Care Board and health and social care trusts should provide consistent, targeted breastfeeding support and education, in particular for young mothers and those living in areas of higher deprivation.
- The Public Health Agency, working through local champions and peer supporters, should work with local communities to identify barriers to breastfeeding and develop measures to overcome these.
7. Deliver high quality, evidence-based, meaningful and consistent, health and social well-being improvement programmes to all primary and post primary pupils
There is good evidence that high quality personal, social and health education gives children and young people the knowledge and skills to make positive, healthy decisions. Effective health education should be embedded within a whole-school approach for promoting the health and wellbeing of students. This has been reinforced time and time again by children and young people who have spoken to us, consistently saying that they want more personal, social and health education as well as more sex and relationships education at school, delivered by experienced, credible, influential and relatable people, starting as early as seven to eleven years of age.
Despite embedding personal, social and health education and relationships and sexuality education as a statutory element of the school curriculum in Northern Ireland, there is no uniform pattern to the provision in schools.
- The Department for Education and the Department for Health should introduce standardised (high quality, evidence-based, meaningful and consistent) personal, social and health education programmes, which specifically tackle issues around mental health, nutrition, sex and relationships, bullying and social inclusion and drugs and alcohol, across all primary and post primary schools.
- The delivery of these programmes should be included in robust Education Training Inspectorate inspections to ensure consistency.
8. Strengthen tobacco and alcohol control
Smoking is the single biggest cause of preventable illness and premature death in Northern Ireland, killing round 2,300 people each year. Adolescence is the time young people start smoking, and exposure to tobacco in early life has major consequences across our lives. Progress has been made but we must push onward towards ensuring our children have a tobacco-free childhood.
The Ten Year Tobacco Control Strategy for Northern Ireland sets clear aims to reduce smoking rates and provide protection from second hand smoke with a focus on children and young people and pregnancy. Strategies outlined in Smoking cessation in pregnancy: a call to action will be important in achieving this goal. Routine reporting mechanisms are essential to measure progress against this.
Another common vice, alcohol abuse remains a concern for young people in Northern Ireland, with drug and alcohol use also identified as an important risk factor for suicide in children and young people. The Scottish Government is leading the way in tackling alcohol abuse with the introduction of minimum unit pricing. We would like to see the Northern Ireland Executive follow suit.
- The Department of Health should implement the recommendations outlined in Smoking cessation in pregnancy: a call to action focussing on the provision of carbon monoxide screening in routine pregnancy care, alongside sustained and intensive reinforcement of public health messages related to smoking cessation.
- The Northern Ireland Executive should commence the necessary subordinate legislation to ban smoking in cars when children are present and to ensure adequate enforcement of that ban.
- The Northern Ireland Executive should extend bans on smoking in public places to school grounds, sports fields and playgrounds, coupled with sustained public health campaigns about the dangers of second hand smoke.
- The Northern Ireland Executive should restrict access to alcohol by children and young people by introducing minimum unit pricing for alcohol.
9. Tackle childhood obesity effectively
Obesity is the biggest human generated burden on the economy after smoking. In Northern Ireland, 28% of children are overweight or obese. This report illustrates the need for continued efforts by government and partners to reduce childhood obesity, starting with maternal health and wellbeing and continuing once children are born and grow into adulthood.
There is no silver bullet for tackling childhood obesity, which is why we are calling for a comprehensive package of measures from the Northern Ireland Executive. Many of the key policy initiatives which will go furthest to reverse current trends (advertising bans and fiscal measures, for example) are the responsibility of Westminster Government, but we believe that there are some key areas where the Northern Ireland Executive can take action. Prevention and early intervention are crucial and children and young people who are already overweight or obese must be able to access the support and treatment they need to reduce their weight.
- The Public Health Agency should expand its national programmes to measure children after birth, before school and in adolescence.
- The Health and Social Care Board should commission services for children who are overweight or obese to help them lose weight. This should include incentives for GPs to refer patients to such services in the Quality and Outcomes Framework for Northern Ireland.
- Health and social care trusts and professional bodies should ensure that all health care professionals can make every contact count by having that difficult conversation with their patients (whatever their age) who are overweight.
- The Northern Ireland Executive should continue to encourage physical activity for all children and young people and support parents and families to adopt healthy lifestyles. It can do this by improving social and physical environments by ensuring local authorities planning decisions include a public health impact assessment. It can introduce 20 mph speed limits in built up areas to create safe places for children to walk, cycle and play.
- The Northern Ireland Executive should undertake an audit of local 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.
10. Maximise mental health and wellbeing throughout childhood
Half of adult mental health problems are estimated to start before the age of 14 and 75 percent start before the age of 24 years. Early identification and early intervention are essential in ensuring that children and young people can access the services and support they need to offset the effects of mental health problems.
All clinicians and practitioners caring for vulnerable children and young people should be appropriately trained to identify mental health problems, and know what to do to intervene early. Paediatricians must also be better prepared to identify and support vulnerable children and young people with mental health problems. Considering emergency care settings are the first point of care for many of these young people, there is a real need to make every contact count.
An important step in promoting the mental health and wellbeing of children and young people is to understand the scale of the problem. We need clear and robust data to identify areas of need so that services can be most appropriately targeted. As highlighted by the 2006 Bamford Review of Mental Health and Learning Disability there is a lack of data on the prevalence of mental health problems in children and young people in Northern Ireland.
- The Northern Ireland Executive should commission a regular survey to identify the prevalence of mental health problems among children and young people in order to aid the planning of mental health care services.
- The Department for Education should ensure that appropriate mental health support is offered in all primary and post primary schools in Northern Ireland.
- The Health and Social Care Board 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.
- 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.
11. Tailor the health system to meet the needs of children, young people, their parents and carers
Interventions for all children throughout their life, and particularly the vulnerable and hard-to-reach groups, require a joined-up approach by health services and other agencies. For example, children and young people with long-term or complex conditions often need care from a variety of health professionals and navigating that system can be daunting and confusing. Integration of care services can prevent duplication and waste as well as making the system more user friendly for children, young people and their families. Education also plays a key role, by giving children and young people and their families the information they need to manage their condition, by educating all young people to reduce the stigma associated with long term conditions and by ensuring schools meet their obligations to provide support.
- The Belfast Health and Social Care Trust should ensure children and young people and their carers contribute meaningfully to the planning and design of the new children’s hospital in Belfast, and to the ongoing evaluation of the environment and services provided.
- The Regulation and Quality Improvement Authority should introduce a regular patient survey of children and young people to measure their experiences of healthcare in all settings.
- Health and Social Care Trusts should ensure better transitions from child to adult services, involving children and young people and, where appropriate social care, education and youth justice, in planning the transfer, and promoting the many examples of best practice that exist.
- Health and Social Care Trusts should provide every child and young person with a long term condition with a named doctor or health professional.
- Health and Social Care Trusts should ensure that clinical teams looking after children and young people with known medical conditions make maximum use of up-to-date tools, including digital portals or online health records, to support improved communication and clarity around ongoing management, for example the use of epilepsy passports or asthma management plans where appropriate.
- The Department for Education in collaboration with Department of Health should undertake a review of existing guidance and procedures in Northern Ireland schools relating to students with medical conditions and following this, consider the introduction of a legislative duty to support pupils with medical conditions in schools.
- The Northern Ireland Executive should fund mandatory child health training for all GP trainees.
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 guidance, guidelines and standards. This creates a very clear case for the consideration of greater regulation and enforcement. With the healthcare service under increasing financial and workforce pressure, what is measured is what matters when it comes to selecting from competing priorities.
- The Department of Health, Health and Social Care Board and Health and Social Care Trusts should identify the barriers to implementing guidelines and standards then create an action plan to overcome them.
- The Department of Health should ensure that children’s healthcare services are included in the Regulation and Quality Improvement Authority’s inspection programmes for acute hospitals and community health services.