There has been a clear decline in health outcomes for children across the UK. Journalist Anna Scott explores how we reached this point, and vitally, asks what can be done.
Children’s physical and mental health is declining and the UK governments, the NHS and local authorities must respond urgently to make improvements. This is the main message in Prioritising early childhood to promote the nation’s health, wellbeing and prosperity, an extensive report published by the Academy of Medical Sciences (AMS) earlier this year (AMS, 2024).
| UK CHILD HEALTH IN FIGURES |
| Infant mortality UK ranks 30th out of 49 ‘Organisation for Economic Co-operation and Development’ (OECD) countries |
| 1 in 5 children aged 2 to 2½ fall short of early learning goals |
| 1 in 5 five-year-olds are obese or overweight |
| 1 in 4 five-year-olds have tooth decay |
| 1 in 5 women will experience mental health problems during or after pregnancy |
| £16.13 billion The annual cost to society of addressing issues that might have been avoided through action in early childhood |
The biomedical and health research academy is on a mission to foster an ‘open and progressive research sector to improve the health of people everywhere’. And it has voiced concern that progress on child health (of those aged up to, and including, the age of five) in the UK has stalled. Infant survival rates are worse than in 60% of similar countries, the AMS report notes, while child vaccination rates have fallen below World Health Organization safety thresholds (AMS, 2024).
The report also outlines areas in which intervention could help to boost the health of young children. Examples include reducing obesity, preventing infections and cutting tooth decay. The AMS report lists five urgent action points for government to achieve this (see Priorities).
‘The most important message in the report is that intervening to support families in the first five years of life is important for life chances of that child that extend far beyond health, says Professor Sir Andrew Pollard, director of the Oxford Vaccine Group and co-chair on the report. ‘It also makes economic sense for governments because there is a huge return on investment.’
The report brings together research on child health in the early years, from pre-conception through pregnancy and up to (and including) the age of five. It has input from child health experts, researchers, charities, policymakers, as well from as parents and carers with lived experience.
WHAT’S BEHIND THE DECLINE?
Key factors cited in the AMS report include the Covid-19 pandemic, the increased cost of living and climate change, particularly when they compound the widespread inequalities impacting parts of the country.
Researchers have found that children living in communities with higher levels of socioeconomic deprivation face a range of poor outcomes compared to those living in the least deprived areas. These include a greater likelihood of obesity, low uptake rates of the measles, mumps and rubella (MMR) vaccine and exposure to higher levels of air pollution and the associated poor health outcomes (AMS, 2024). The report also shows how systemic differences in relation to people’s ethnicity intersect with health determinants (AMS, 2024).
‘Poverty and inequalities reduce life chances and are associated with greater hospitalisation rates, obesity, tooth decay, mental health problems, adverse behaviour, and so on – all of which are reduced by early years interventions,’ highlights Professor Pollard.
The extensive AMS publication is not alone its reporting of a decline in children’s health. Evidence from various sources has consistently shown that the health and wellbeing of children has deteriorated in the last 20 years. The situation is especially glaring when comparisons are made with countries with similar economies.
Alan Emond, emeritus professor of child health at Bristol Medical School’s Centre for Academic Child Health says: ‘The causes are multifactorial: primarily economic after over a decade of austerity, the effect of the pandemic, and a consequence – the increase in economic inequality.’
‘Secondly, poor health in the under-fives can also be attributed to lack of investment in health and social care, a reduction in the children’s workforce and preventive services such as dentistry.
‘Thirdly, societal changes in children’s lifestyles over recent decades have resulted in poorer diets, less exercise, less free unsupervised play with peers, and less support from other adults, such as grandparents, in the extended family,’ he adds.
LACK OF INVESTMENT
A person’s early years provide the foundation for health later on in life. Yet while poor health in the population is known to have an impact on the nation’s prosperity, this doesn’t often influence policies that emerge across government, the AMS report states. Crucially, the UK spends relatively little on child health research, and allocates a smaller proportion of public money on children aged up to five in comparison to similar countries (AMS, 2024).
‘IT IS VERY CLEAR FROM THE
EVIDENCE THAT INVESTMENT
IN COMMUNITY SERVICES
REVERSES DETERIORATING
OUTCOMES FOR CHILDREN’
This lack of investment is widely recognised, according to Katie Harron, professor of statistics and health data science at the UCL Great Ormond Street Institute of Child Health. She cites the 28% fall (in real terms) in the value of the public health grant in England since 2015/16 from which health visiting is commissioned (Health Foundation, 2024).
‘In the context of constrained resources, local areas are having to make decisions about how best to deliver their services, based on relatively little evidence of what works and for whom,’ says Katie. ‘This leads to high levels of variation in how health visiting is delivered’. Katie was involved in a study [currently in pre-press format] which showed that, from 2018 to 2022, the percentage of children receiving their mandated two to two-and-a-half year review ranged from 33% to 97% – depending on where in England they lived (Mengyun et al, 2024).
A complicating factor is that it’s hard to provide clear evidence to prove the value of health visiting when making a case for appropriate investment, she explains, in part of because it has such a wide remit. ‘The impacts of health visiting are therefore spread across many systems, and some outcomes are hard to measure (such as improved home learning environment, parental health and wellbeing or access to childcare),’ says Katie.
‘Where benefits are observed, they may be difficult to attribute to health visiting alone,’ but she adds: ‘Health visitors are uniquely placed to influence and work with the whole family in the interests of children on social, psychological and health choices.’
According to children’s commissioner for Wales Rocío Cifuentes, child health provision faces huge challenges at a time when NHS services across the board are experiencing unprecedented pressures. In Wales there was a 62.5% increase in the number of children waiting for a paediatric appointment from 2016 to 2023, she points out (Royal College of Paediatrics and Child Health, 2024).
‘Since then, there have been some more encouraging signs, but far too many children are waiting an unacceptably long time for assessment and treatment,’ she says. ‘It’s clear from conversations I have with professionals around Wales that we need to have more health professionals working with children and young people, because the current workforce is not sufficient in size to tackle the challenges we face.’
WHAT’S BEING DONE?
The Parent-Infant Foundation launched a Manifesto in March as part of the First 1001 Days Movement for babies (of which Unite-CPHVA is a member) to try and help politicians address the issues – particularly, the five-year decline in toddlers’ development (see Recommendations for UK policymakers). ‘We have also been alarmed to see in recent data from the Office for Health Improvement and Disparities (OHID), that one in five two-year-olds in England is now below expected levels of development,’ says Keith Reed, the foundation’s chief executive (OHID, 2023).
| PRIORITIES |
| The AMS (2024) report outlines five priorities that government must address urgently: |
| 1. Implement effective interventions and policies to improve the health and wellbeing of children and support future research. |
| 2. Establish a clear vision across government for the early years to overcome policy silos. |
| 3. Deliver effective services for children by improving the child and family health workforce and reducing fragmentation across sectors. |
| 4. Collect and use a broader range of data to enable research into interventions, policies and their effective implementation to improve child health and wellbeing. |
| 5. Involve diverse perspectives from children, parents and carers in developing and implementing new policies and interventions. |
‘As part of the manifesto, the First 1001 Days movement warns that an estimated 10% of babies in this country are living in fear and distress because of disturbed or unpredictable care, and OHID stats show one in five babies is missing the mandatory one-year old HV check where problems can be picked up,’ Keith adds. In addition, data shows that 2.5 hours of teacher time is lost every day because children are not ‘school-ready’, and one in four children starting reception are not toilet trained (Kindred², 2024).
‘We advocate for specialised parent-infant relationship teams to be mandated across the UK – multidisciplinary teams with expertise in supporting and strengthening the important relationships between babies and their parents or carers,’ Keith says. ‘These teams provide evidence-based interventions that can change the trajectory of a baby’s life.’
The decline in Sure Start centres – along with fewer resources for preventive health – have put more children and families at crisis level in the first 1001 days, according to Emma Carey, a HV in England and a Queen’s Nurse. ‘Although the introduction of family hubs is positive, this should be a service that all families across the UK can receive,’ she says.
‘Funding for specialist support in the family hubs, such as the perinatal infant mental health and breastfeeding support, should be sustained rather than only offered until April 2025,’ Emma adds.
CHALLENGES FOR CPs
Janet Taylor is a nurse manager for children’s services at South Eastern Health and Social Care Trust, in Belfast. She points out that the premise of Northern Ireland’s Healthy Child, Healthy Future framework is that investment starts with pregnant mothers and continues until the child goes to school (Department of Health, 2010). This means the child should have a healthy future. ‘A lot of it is self-explanatory and preventive work,’ she adds. ‘But HVs in England have huge caseloads, and there is high turnover of staff.
‘There’s always more to be done, but it’s also worth highlighting variations around different countries,’ adds Janet who also chairs the CPHVA Executive. ‘For example, in Northern Ireland we’re working really hard to try and increase the pre-school vaccinations for MMR, by making clinics [more] accessible to parents. Previously, we’ve generally been really good.’
‘CPS ARE IN THE FRONTLINE
OF THE HEALTH SYSTEM
AND THEIR WORK IS
ALREADY IMPACTING THE
HEALTH AND FUTURES OF
YOUNG CHILDREN’
In England, Emma says the number of visits HVs can offer every family as a minimum has ‘drastically’ reduced. She adds: ‘[This] means that families do not always have the time or opportunity to build up a trusting rapport with us and talk to us about when things are not going well.’
‘We will do more frequent visits when there are known and well-established health issues, or where there are safeguarding concerns and a child is at risk of or is already suffering significantly,’ Emma adds.
In Scotland, a Scottish Government Perinatal and Infant Mental Health Fund enables charities to deliver mental health services, allowing 77% of recipients to feel better able to meet the needs of their infants and children. In addition, 75% of parents show improvements in supporting infants at a higher risk of having a mental health problem, according to the AMS report (2024).
| RECOMMENDATIONS FOR UK POLICYMAKERS |
| The First 1001 Days Movement Manifesto for Babies recommends: |
| > A cross-government strategy to support babies’ healthy development, including a dedicated cabinet committee reporting directly to the prime minister to ensure cohesive action. |
| > Sustainable funding for preventive services and extending funding for the Start for Life programme – due to end by April 2025. |
| > A workforce plan for children’s social care and the early years incorporating adequate staffing levels. |
Community practitioners face a range of hurdles in supporting children and families to reverse poor health outcomes. ‘The increasing number of the “working poor” – with more families struggling to make ends meet – has an impact on health and, therefore, on CPs’ workloads,’ says Gavin Fergie, Unite (health) lead professional officer.
While increasing the numbers of CPs – in particular SCPHNs in the health visiting, school nursing and community nursery nurse spheres – will help, ‘recurrent funding needs to be part of the package’, he adds.
In response to the AMS report, a government spokesperson highlighted steps that have been taken including: reducing quantities of sugar in children’s foods, the Healthy Start programme to encourage healthy diets for lower income families, investing in sport for children, and an additional £2.3bn a year for mental health services (PA Media, 2024).
HOW CAN YOU HELP?
‘It is very clear from the evidence that investment in community services reverses deteriorating outcomes for children,’ says Professor Sir Andrew Pollard. ‘CPs are in the frontline of the health system and their work is already impacting the health and futures of young children. So much of the research shows that the work at the individual family and community level on improving physical and mental health through pregnancy and the first five years has long-term benefits.’
| THE CHILDREN’S ALLIANCE PLAN FOR PLAY REPORT RECOMMENDS: |
| > Statutory provision of play and creative arts therapy services in all primary schools as an early intervention/preventive measure for children’s mental health and wellbeing. |
| > Ring-fenced central government funding to enable local authorities in the UK to provide every child with the opportunity to play in a local, safe, high-quality playground. |
So, what can you do, especially with the current workforce challenges, and until the government takes the actions being called for? Janet recommends that CPs should ‘do their best to identify what they need to concentrate on with a particular family’. She adds: ‘There will be families that you visit that are on the ball with vaccines, but maybe need a bit of support with toilet training. Maximise every resource you have – both in your own sector, but also in other sectors that are available – and try and educate as best you can. But you can only do so much,’ she adds. ‘SCPHN nurses are the key to improving the health of our children and play a vital role in supporting families and children.’
Gavin, meanwhile, urges CPs to engage with their local Unite branches: ‘Read and reflect, engage in the political process, challenge those who will be seeking your vote at a local and national level within the next two years. Change is never affected by those who don’t engage. The profession are on their knees and politicians make decisions.’
Ultimately, as Rocío Cifuentes points out, CPs ‘have that contact with families that can and does make the biggest difference to tackling the wider determinants of poor health outcomes from an early age’.
CPs will continue to do what they have always done: play an essential role in children’s health. With a wider understanding of the national picture and key recommendations, CPs can enhance the part they play in reversing these outcomes.
| RESOURCES |
| > The Academy of Medical Sciences’ report: Prioritising early childhood to promote the nation’s health, wellbeing and prosperity |
| > Manifesto for Babies, the First 1001 Days Movement |
| > What is a parent-infant team? |
| > The Family hubs and Start for Life programme guide |
| > Start for Life guidance for practitioners |
WHAT’S YOUR VIEW?
Have you observed declining health in the under 5s you look after, and in what ways? How have you helped such families? What do you think is the answer and what actions do you think are needed? Contact editor Aviva Attias with your views and insight
aviva@communitypractitioner.co.uk
REFERENCES
AMS. (2024) Prioritising early childhood to promote the nation’s health, wellbeing and prosperity. See: acmedsci.ac.uk/file-download/96280233 (accessed 19 April 2024).
Children’s Alliance. (2023) A plan for play. See: childrensalliance.org.uk/wp-content/uploads/2023/09/A-PLAN-FOR-PLAY-FINAL-ILLUSTRATED.pdf (accessed 19 April 2024).
Department of Health. (2010) Healthy Child, Healthy Future. See: health-ni.gov.uk/publications/healthy-child-healthy-future (accessed 19 April 2024).
Kindred². (2024) School Readiness Survey. See: kindredsquared.org.uk/wp-content/uploads/2024/02/Kindred-Squared-School-Readiness-Report-Infographic-February-2024.pdf (accessed 19 April 2024).
Mengyun, L, Woodman, J, Mc Grath-Lone, L, Clery A at al. (2024) Variation in health visiting for the under 5s: A cross-sectional analysis of administrative data in England for 2018-2020. [Available as a preprint]. See: medrxiv.org/content/10.1101/2024.02.22.24303170v1 (accessed 19 April 2024).
Office for Health Improvement and Disparities. (2023). Child development outcomes at 2 to 2 and a half years: annual data April 2022 to March 2023. See: gov.uk/government/statistics/child-development-outcomes-at-2-to-2-and-a-half-years-annual-data-april-2022-to-march-2023 (accessed 19 April 2024).
PA Media. (2024) Experts lament ‘appalling decline’ in health of under-fives in UK. See: theguardian.com/society/2024/feb/05/experts-lament-appalling-decline-in-health-of-under-fives-in-uk (accessed 19 April 2024).
Parent-Infant Foundation. (2024). Manifesto for Babies. See: parentinfantfoundation.org.uk/1001-days/manifesto/ (accessed 19 April 2024).
Royal College of Paediatrics and Child Health. (2024). Worried and waiting: A review of paediatric waiting times in Wales. See: rcpch.ac.uk/sites/default/files/2024-02/Worried-and-waiting-Wales-English.pdf (accessed 19 April 2024).
The Health Foundation. (2024) Investing in the public health grant. See: health.org.uk/news-and-comment/charts-and-infographics/public-health-grant-what-it-is-and-why-greater-investment-is-needed (accessed 19 April 2024).
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