Policy response for Scotland to the State of Child Health report 2017

Child health in Scotland is among the poorest in Western Europe. Over 210,000 children live in poverty, 28 percent are overweight or obese and about 400 infants, children and young people die each year, with a significant number of these deaths potentially avoidable.

The State of Child Health report provides a comprehensive list of 25 measures of the health of UK children, including specific conditions, risk factors for poor health and child deaths. These are our recommendations for Scotland.
Last modified
11 April 2019

A message from Dr Steve Turner, RCPCH Officer for Scotland

The Children and Young People (Scotland) Act 2014 provides a strong foundation for putting children and young people at the centre of service planning, ensuring their needs and rights are respected across health, social care and education sectors. Through the Getting It Right For Every Child (GIRFEC) approach there are clear opportunities to strengthen the health system in order to maximise outcomes for children and young people.

There have been notable improvements in health indicators for children over recent years but the rate of improvement is slower than it should be. There is much that the Scottish Government is doing to reduce the impact of poverty and inequality and there is much in Scotland that can be celebrated and learned from. However, more is required and we cannot be complacent when it comes to improving infants, children and young people’s health.

We know that the 1000 days between conception and the second birthday shape the lifecourse of an individual and the Scottish Government needs to optimise the early environment. Children of all ages need to be protected from adverse childhood experiences and given a support structure to develop the resilience to thrive in today and tomorrow’s society.

The Scottish Government has the confidence and ambition to set targets for child health, and this year achieved its goal of reducing the proportion of children exposed to second hand smoke to six percent ahead of schedule. I would welcome target setting in other areas including the proportion of children living in poverty and the proportion who are obese.

We all have an important role in nurturing our children to ensure that they achieve health in body and mind and the State of Child Health report is an excellent platform to develop a strategy which will deliver good health to the children of today and tomorrow.

1. Publish and implement the Child and Adolescent Health and Wellbeing Strategy

To ensure the health of infants, children and young people in Scotland matches the best in Europe, co-ordinated action across several Scottish Government departments is required. Scotland has much to be proud of in terms of improving outcomes for infants, children and young people. The Getting it Right for Every Child programme, the cornerstone of child health policies, is designed to improve outcomes for infants, children and young people by offering the right help at the right time from the right people. We welcome the development of the Child and Adolescent Health and Wellbeing Strategy.

The Scottish Government have an opportunity to address the stark inequalities faced by our infants, children and young people and truly make Scotland the best place in the world to grow up in.


  • The Scottish Government should publish and implement the Child and Adolescent Health and Wellbeing Strategy. The Strategy should include a clear accountability framework setting out responsibilities for professionals, the public and civil society as well as details about resources and funding to implement it.
  • The Scottish Government should adopt a ‘child health in all policies’ approach to decision making, policy development and service design. This is based on the recognition that challenges facing child health are highly complex and often linked through the social determinants of health. Just one government sector will not have all the tools, knowledge and capacity, let alone the budget to address this complexity.

2. Reduce the number of child deaths

Each year between 350 and 450 infants, children and young people die in Scotland.

The majority of these deaths occur in children under one year of age, preterm birth and low birth weight are crucial risk factors for premature death during infancy. The second largest number of deaths occurs in the 15 to 18 year old age group and is often the result of alcohol abuse or road traffic accidents.

The reasons why children die are complex and will require a range of interventions and policy solutions to reduce avoidable mortality.


  • The Scottish Government should implement a robust, consistent child death review system for Scotland by 2018.
  • The Scottish Government should urge the UK Government to introduce graduated licensing schemes for novice drivers.
  • Local authorities and health boards should prioritise children’s safety and, through utilising resources such as health visitors, the family nurse partnership and home safety equipment schemes, 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

The State of Child Health makes repeated calls for better data capture so that data are available and comparable across the UK. This will provide an essential evidence base to inform the use of resources in the medium and long term. Scotland is ideally placed to lead on this since it is the only nation where each individual has a unique health identifier that is used across the NHS in Scotland.


  • The Scottish Government should develop standards to ensure child health data are of high quality, captured to pre-specified definitions, and can be analysed consistently with England, Northern Ireland and Wales.
  • The Scottish Government should commit to funding the longitudinal study Growing Up in Scotland for at least another five years and ensure that its findings are used to develop policies and services for children and their families.

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

There is a need to support the sustained expansion of applied research into many conditions that affect infants, children and young people. In order to improve health outcomes there needs to be evaluation of therapy and practice by clinical trials and greater understanding of the factors that influence behaviour.


  • NHS Scotland and local health boards must ensure protected time in job plans for NHS clinicians to contribute to and support child health research.
  • NHS Scotland should place the 20 percent ring fenced time for young clinicians participating in the Scottish Clinical Research Excellence Development Scheme into dedicated three to four month “research only” blocks where there are no clinical duties.
  • The Scottish Government should encourage increased investment in research relating to child health, across the pharmaceutical, medical, social sciences, youth justice and education domains.
  • Higher educational institutions should ensure that faculty structures and career opportunities support careers and capacity development in child health research.

5. Reduce child poverty and inequality

The link between poverty and poor health is highlighted throughout this report. It is estimated that more than 210,000 of Scotland’s children live in poverty. These children are more likely to have negative health outcomes, to be born with low birth weight or fail to thrive and be exposed to risks that perpetuate ill health such as poor diet, lack of physical activity, parental drug or alcohol misuse and being in care.

More must be done to reduce the number of children living in poverty in Scotland and to minimise the impact of deprivation on health outcomes. Robust monitoring of child poverty is vital and we urge the Scottish Government to publish its proposals for a Child Poverty Bill for Scotland as soon as possible.


  • The Scottish Government should continue recording income-based measures of poverty so that trends and impacts of service provision can be meaningfully assessed, with a focus on achieving a target of less than 10 percent of children experiencing relative low income poverty.
  • The Scottish Government should support parents and families through targeted programmes such as the Family Nurse Partnership and financial inclusion services.
  • The Scottish Government should ensure universal early years public health services, such as health visitors, are prioritised, supported and properly funded, with targeted help for children and families experiencing poverty.
  • NHS Scotland should provide good quality, safe and effective prevention and care throughout the healthcare service with a particular 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. Mental health support is also vital. Breastfeeding is an important protective factor for infant survival and it is therefore encouraging that all hospitals in Scotland are either accredited or working towards UNICEF Baby Friendly accreditation.

The Scottish Government must continue to promote sustained breastfeeding by building on the progress made in recent years and by revising and updating the Improving Maternal and Infant Nutrition: A Framework for Action and the 2010/11 HEAT Target, Exclusively Breastfeed.


  • The Scottish Government should raise awareness of the benefits of breastfeeding, particularly in areas where rates are low by increasing the visibility of national public health campaigns that promote good nutrition and exercise before and during pregnancy.
  • The Scottish Government should develop targets to improve rates of mothers exclusively breastfeeding after six to eight weeks. These should be regularly monitored to assess improvements.
  • The Scottish Government should ensure neonatal services recruit staff or train existing staff to deliver specialist breastfeeding advice and support.

7. Introduce statutory sex and relationships education in all schools

Despite embedding relationships, sexual health and parenthood (RSHP) education within the Scottish health and wellbeing curriculum, unlike the rest of the UK and many other European nations, there is no statutory requirement in Scotland for schools to teach sex and relationships education.

Children and young people who have spoken to us, have consistently said that they want more sex and relationships education at school, delivered by experienced, credible, influential and relatable people, starting as early as seven to 11 years of age. Annual topic-specific forums are not enough as messages need to be consistent and repeated throughout a child’s education. There is good evidence that various whole school health interventions are effective in preventing teenage pregnancy, smoking and bullying.

In June 2016, the UN Committee on the Rights of the Child recommended that meaningful sexual and reproductive health education is part of the mandatory school curriculum for all state schools, including special schools and youth detention centres.


  • The Scottish Government should introduce a statutory requirement for all schools to deliver comprehensive, evidence based, sex and relationships education across all primary and secondary schools.
  • The Scottish Government should ensure that compulsory evidence based health and wellbeing programmes are embedded in all primary and secondary schools which foster social and emotional health and wellbeing, through building resilience, and specifically tackling issues around social inclusion, bullying, drug and alcohol use and mental health.

8. Strengthen tobacco control

There are clear links between tobacco use and health inequalities. In Scotland, 34 percent of adults in the most deprived areas smoke cigarettes, significantly higher than nine percent of those in the least deprived areas. 29.3 percent of pregnant women in the most deprived areas are smokers at their first antenatal appointment, compared to 4.5 percent in the least deprived areas. There are approximately 65 smokers to each retail outlet selling tobacco in Scotland.

A child born in a more socially deprived area of Scotland is more likely to:

  • be growing up around smokers
  • be born into a family that smokes
  • have a mother who smoked during her pregnancy.Children of smokers are more likely to start smoking themselves and continue to repeat the cycle of their own experience. Adolescence is the time young people start smoking and exposure to tobacco in early life has major consequences across our lives. Smoking creates the greatest human generated cost to the economy. It costs society more than war, armed violence and terrorism. Progress has been made but we must push onward towards ensuring our children have a tobacco-free childhood.


  • The Scottish Government should extend bans on smoking in public places to school grounds and all sports fields and playgrounds.
  • The Scottish Government should continue to implement actions set out in Creating a tobacco-free generation: a tobacco control strategy for Scotland focussing on tobacco control plans and implementing measures to reduce smoking uptake in children.
  • The Scottish Government and NHS Scotland through Workstream 1 of the Early Year Collaborative and through the Scottish Patient Safety Programme should continue to work towards achieving the aims set out to reduce the avoidable harm associated with smoking during pregnancy.

9. Tackle childhood obesity effectively

Obesity is the biggest human generated burden on the economy after smoking. Worryingly 28 percent of Scottish 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 as they grow into adulthood.

Prevention and early intervention are crucial to tackle the impact of obesity. 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.

There is no silver bullet for tackling childhood obesity, which is why we are calling for a comprehensive package of measures from the Scottish Government. 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 Scottish Government, NHS Scotland and Education Scotland can take action.


  • The Scottish government should set challenging targets to reduce the proportion of children who are overweight or obese.
  • NHS Scotland should expand its national programme to measure children after birth, before school and in adolescence.
  • NHS Scotland 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 Scottish 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.
  • The Scottish Government should encourage physical activity for all children and young people and support parents and families to adopt healthy lifestyles by improving social and physical environments. Local authorities should ensure planning decisions include a public health impact assessment and should introduce 20 mph speed limits in built up areas to create safe places for children to walk, cycle and play.

10. Maximise mental health and wellbeing throughout childhood

In Scotland, one in 10 children starting school have social, emotional or behavioural difficulties and as many as five children in every class have additional support needs, all of which puts pressure on other services.

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 early intervention are essential in ensuring that young people can achieve their potential. All those caring for these groups require the skills to identify mental health problems and to know what to do to intervene early. Paediatricians must also be better prepared to handle these issues.

Good mental health is an essential part of our vision for children and young people. Mental wellbeing affects their behaviour, their ability to learn and achieve, and their physical health. And just as importantly, it impacts on their ability to enjoy their childhood and teenage years to the full.


  • The Scottish Government should publish the new strategy Mental Health in Scotland – a 10 year vision and ensure that it focuses on prevention, early intervention and early years approaches and is properly resourced, funded and implemented. The new strategy should also contain a commitment to equal parity of esteem between physical and mental health needs.
  • 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 identity mental health issues through the promotion of resources such as the MindEd portal.

11. Tailor the health system to meet the needs of children and young people

Interventions for all children throughout their life course, and particularly the vulnerable and hard to reach groups, require a joined-up approach by health 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 legal obligations to provide support.


  • The Scottish Government should include the views of children and young people in the patient surveys of GP services and inpatient settings. The Scottish Government should also extend the surveys to cover outpatient and community settings and include the views of children and young people.
  • The Scottish Government should fund mandatory child health training for all general practice trainees.
  • NHS Scotland should ensure better transitions from child to adult services, involving children and young people in planning the transfer.
  • NHS Scotland should provide every child and young person with a long term condition with a named doctor or health professional.
  • Health Boards should 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 Scotland should ensure care is provided according to evidence-based standards.


  • The Scottish Government and NHS Scotland should identify the barriers to implementing guidelines and standards and then create an action plan to overcome them.