Barr, Ben

Duncan, WH

Lai, Eric T

Taylor-Robinson, David C

Whitehead, Margaret

University of Liverpool Repository

Child health unravelling in the UK Addressing child poverty is paramount  David C Taylor-Robinson1, Margaret Whitehead1, Ben Barr1  Department of Public Health and Policy, The Farr Institute@HeRC, Waterhouse Building 2nd Floor Block F, Liverpool, L69 3GL  Corresponding author, Email: dctr@liv.ac.uk     Competing interest statement:  We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: David Taylor-Robinson is funded by the MRC on a Clinician Scientist Fellowship (MR/P008577/1).  Child health unravelling in the UK Addressing child poverty is paramount  Last week yet another report highlighted the poor state of child health in the UK. [1]  The analysis, focussing on adolescent health, shows we compare poorly with other countries in terms of childhood long-term conditions, obesity, asthma deaths and young people not in education, employment or training.   Other recent reports show we lag behind in terms of health for babies and younger children.[2][3] Mental health for children in the UK has been described as being “in crisis”.[4] The Nuffield Trust report further shows that 11% of young people aged 15–19 in the UK are living in severe material deprivation. This is the fourth highest relative to the European comparator countries, with a worsening trend over time. Material deprivation is judged on whether families can afford a decent meal every second day, go on holiday, and whether they can cope with sudden unexpected financial expenses.[1]  Not only do we compare poorly to other countries, the situation appears to be getting worse for many child health outcomes, with widening inequalities within the country. One of the most important indicators of population health, infant mortality, is rising in England. We highlighted this extremely concerning trend in two letters to the BMJ, [5,6] showing that this rise had occurred particularly amongst more disadvantaged children. The latest data show a marked reversal of the longterm favourable trend in infant mortality, particularly in the most income deprived local authority areas in England (figure 1).  Figure 1: Infant mortality trend in the most and least deprived quintiles of local authority districts in England, 2000-2017, with 95% binomial confidence intervals.     Over the same period, child poverty has been rising. Since 2010, there have been sustained reductions in the welfare benefits available to families with children, disproportionately affecting the most disadvantaged communities. [7][8] Current estimates suggest that 4.1 million children in the UK are living in poverty – about 30% of children after housing costs are taken into account - the majority in working households. Estimates from the Resolution Foundation suggest a further 6 percentage point rise over the next 5 years, pushing child poverty to its highest level on record. By 2023-24, the proportion of children living in relative poverty is on course to hit 37%, affecting an extra 1.1 million children.[9]   Child poverty is the one of the most potent “upstream” drivers of lifelong ill-health and health inequalities.  Child poverty causes poor child health.[10] It causes children’s deaths, deaths from asthma and infections and prematurity. It causes child mental health problems that blight children’s life chances.[11]  It is a common, modifiable exposure, that has a large scale influence on child development across the population, impacting on school readiness and generating the early inequalities that track through to influence chances in later life.[12,13]   Many solutions have been suggested to address poor health in the UK, but in the absence of addressing child poverty all are likely to fail. In public-health we often invoke the famous metaphor of individuals drowning in a river and highlight the relative futility of addressing “downstream” lifestyle factors in the absence of moving upstream and sorting out the causes pushing people into the river in the first place. In the UK we are actually seeing some improvements in downstream risk factors amongst adolescents such as alcohol, smoking and drug use. Yet their health is continuing to deteriorate for some important outcomes, potentially because we are not addressing the social causes of their poor health. [1]     The NHS long term plan laudably goes some way to elevating children and young people in policy discussions, and there is also a welcome focus on addressing health inequalities. [1] But the lack of joined up thinking across government sectors and agencies does not help. How does the NHS expect to address inequalities in child health, when at the same time local government services essential for child health are being cut most in the most disadvantaged areas [14][15], and the continued roll out of Universal Credit is widely predicted to further entrench child poverty?[16]  As political chaos and uncertainty swirl, the most vulnerable in society lose out. Various advocates (but not enough) have raised concerns about the ongoing deterioration in the social determinants of health – as the fabric and systems that provide a foundation for health and development are eroded. And now we are seeing a great unravelling of the health of children and adults alike.[17] These data are deeply troubling, but the way forward is clear.  To improve child health and reduce inequalities, agencies need to implement the recommendations in a plethora of inequalities reports internationally, from the Black report, the Marmot report, and our Due North Report.[12] First and foremost, the government needs to put child health at the centre of policy, and address child poverty. We have the fiscal tools to do this, as evidenced by the way that pensioners’ incomes have been protected over the tumultuous period since the Great Recession.    And in the rush to personalise responses to structural causes for poor health [18,19] let’s not forget that money is the ultimate personalised medicine. Mums tend to exchange it for goods and services such as better housing, clothes, food and school trips that improve life for their children.[10]  References    1  International comparisons of health and wellbeing in adolescence and early adulthood. The Nuffield Trust. 2019.https://www.nuffieldtrust.org.uk/research/international-comparisons-of-health-and-wellbeing-in-adolescence-and-early-adulthood (accessed 25 Feb 2019). 2  International comparisons of health and wellbeing in early childhood. The Nuffield Trust. 2018.https://www.nuffieldtrust.org.uk/research/international-comparisons-of-health-and-wellbeing-in-early-childhood (accessed 28 Sep 2018). 3  RCPCH. State of Child Health. RCPCH. https://www.rcpch.ac.uk/resources/state-child-health (accessed 6 Feb 2019). 4  Gunnell D, Kidger J, Elvidge H. Adolescent mental health in crisis. BMJ 2018;361:k2608. doi:10.1136/bmj.k2608 5  Taylor-Robinson D, Barr B. Death rate now rising in UK’s poorest infants. BMJ 2017;357:j2258. doi:10.1136/bmj.j2258 6  Taylor-Robinson D, Lai E, Wolfe I, Weeks A, Barr B, Whitehead M. Death rate continues to rise for poorest infants in England and Wales. The BMJ Published Online First: 13 September 2018.https://www.bmj.com/content/360/bmj.k1090/rr-2 (accessed 17 Sep 2018). 7  Beatty C, Fothergill S. The uneven impact of welfare reform : the financial losses to places and people. 2016. doi:10.7190/cresr.2017.5563239352 8  Hood A, Waters T, Institute for Fiscal Studies (Great Britain), et al. Living standards, poverty and inequality in the UK: 2016-17 to 2021-22. 2017.  9  The Living Standards Outlook 2019. Resolution Foundation. https://www.resolutionfoundation.org/publications/the-living-standards-outlook-2019/ (accessed 25 Feb 2019). 10  Cooper K, Stewart K. Money Matters: Does Money Affect Children’s Outcomes? A Systematic Review Update. http://sticerd.lse.ac.uk/case/_new/research/money_matters/default.asp 11  Wickham S, Anwar E, Barr B, et al. Poverty and child health in the UK: using evidence for action. Archives of disease in childhood Published Online First: 2016. doi:10.1136/archdischild-2014-306746 12  Whitehead M, McInroy N, Bambra C et al. Due North Report of the Inquiry on Health Equity for the North. UK: University of Liverpool and the Centre for Economic Strategies 2014. https://cles.org.uk/news/inquiry-publishes-due-north-report-on-health-equity/ (accessed 27 Mar 2017). 13  Pearce A, Dundas R, Whitehead M, et al. Pathways to inequalities in child health. Arch Dis Child Published Online First: 23 February 2019. doi:10.1136/archdischild-2018-314808 14  Better Health For All. Better Health For All. https://betterhealthforall.org/ (accessed 25 Feb 2019). 15  Bigger cuts to Sure Start children’s centres in more disadvantaged areas. The BMJ Published Online First: 17 September 2018.https://www.bmj.com/content/359/bmj.j5332/rr (accessed 17 Sep 2018). 16  Hood A, Waters T. Benefit cuts set to increase child poverty, with biggest rises likely in North East and Wales. 2017.https://www.ifs.org.uk/publications/10029 (accessed 25 Feb 2019). 17  Bennett JE, Li G, Foreman K, et al. The future of life expectancy and life expectancy inequalities in England and Wales: Bayesian spatiotemporal forecasting. The Lancet 2015;386:163–70. doi:10.1016/S0140-6736(15)60296-3 18  Predictive prevention and the drive for precision public health - Public health matters. https://publichealthmatters.blog.gov.uk/2018/11/20/predictive-prevention-and-the-drive-for-precision-public-health/ (accessed 25 Feb 2019). 19  Taylor-Robinson D, Kee F. Precision public health—the Emperor’s new clothes. Int J Epidemiol 2019;48:1–6. doi:10.1093/ije/dyy184      The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, a worldwide licence to the Publishers and its licensees in perpetuity, in all forms, formats and media (whether known now or created in the future), to i) publish, reproduce, distribute, display and store the Contribution, ii) translate the Contribution into other languages, create adaptations, reprints, include within collections and create summaries, extracts and/or, abstracts of the Contribution, iii) create any other derivative work(s) based on the Contribution, iv) to exploit all subsidiary rights in the Contribution, v) the inclusion of electronic links from the Contribution to third party material where-ever it may be located; and, vi) licence any third party to do any or all of the above.  

Child health unravelling in UK Poverty is a key driver of the UK's dismal performance on child health

http://livrepository.liverpool.ac.uk/3033856/1/unravelling_27feb_clean.pdf

Child health unravelling in UK Poverty is a key driver of the UK's dismal performance on child health

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