Growing up in the UK: can we deliver a healthy future for our children?BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3713 (Published 12 June 2013) Cite this as: BMJ 2013;346:f3713
- Janis Baird, senior lecturer in public health1,
- Andrew Mortimore, director of public health2,
- Patricia Lucas, senior lecturer in early childhood3
- 1MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK
- 2Public Health, Southampton City Council, Southampton, UK
- 3School for Policy Studies, University of Bristol, Bristol, UK
The health and wellbeing of children growing up in the United Kingdom are worse than is seen for children in most of the UK’s European counterparts.1 In May 2013, the BMA report Growing up in the UK: Ensuring a Healthy Future for our Children set out an ambitious agenda for improving child health and reducing inequalities.2 Central to its message is greater advocacy on behalf of children from all people involved in their care and better representation of the views of children and families.
The report argues powerfully for prevention—a public health approach that acts on risk factors at all levels to deliver a whole population shift. It cites many examples of where this makes compelling economic sense, with early intervention preventing high costs later on. Local authorities, which now have responsibilities for public health leadership, currently face the most challenging budget reductions in living memory. Services are being severely cut back, and all authorities are searching for a sustainable delivery model that protects essential services such as child protection, while allowing for the promotion of health and wellbeing. Clinical commissioning groups and public health teams must lead the way in making the case to preserve and build on successful early years programmes by working in genuine partnership with the communities they serve. Implementing the report’s recommendations will be challenging in many ways.
There have been only modest improvements in child health since the last BMA report on child health in 1999,3 despite a succession of initiatives. This relative lack of progress can, in part, be attributed to high persisting rates of child poverty: one in four children in the UK lives in poverty.4 Rates of child poverty in the UK fell slightly between 2007 and 2010 owing to a tax benefit system that favoured families with children. But this system is currently undergoing major restructuring, and families will be affected by the introduction of universal credit and changes to child benefit, disability living allowance, and council tax benefit. These changes will restrict, reduce, or remove benefits from many families, and forecasts from the Institute of Fiscal Studies suggest that child poverty will rise slightly in 2013-14.5 Many vulnerable families will probably do badly under these changes—those with one resident parent, families headed by vulnerable adults (for example, people with mental health difficulties), larger families, and those where anyone has a disability. The report calls for professional bodies to lobby for action to reduce the impact of benefit reform on children, and for the introduction of a minimum income for healthy living. This assumes that doctors will observe and report the impact of poverty on families in their care and advocate on behalf of children.
Maintaining a focus on early intervention, the report recommends a life course approach to improving child health. It is well established that the nutrition of mothers influences the lifelong health of their children.6 The health behaviours of parents also have a major influence on the health and development of their children. Mothers’ diet is a strong predictor of infant diet, and growth during infancy predicts later risk of obesity.7 8 The government response to the current epidemic of obesity and chronic disease emphasises the need for people to make healthy choices and calls for action at community level to bring about population improvements in diet and physical activity.9 But although government initiatives, such as Change4Life, have led to a decrease in unhealthy behaviours, recent evidence shows that reductions have mainly been among more advantaged groups and unhealthy behaviours continue to cluster in disadvantaged groups.10 The latest BMA report calls for upstream action to tackle societal and environmental constraints on health behaviour. Such actions would include making outdoor spaces more accessible and safe; discouraging car use; and changing the food environment. Everybody has a duty to promote the wellbeing of children, and communities should be encouraged to provide networks of support for children and the adults who care for them.
Improving the health of children with complex needs—including those with disabilities, emotional and behavioural problems, and those who are maltreated—will require integrated and coordinated working from health and social care agencies, according to the report. Implementation of the Health and Social Care Act 2012 will lead to greater competition for the provision of services and increased numbers of providers. Delivering integrated and coordinated care will be more challenging as a result.
Few current services and interventions for children are informed by evidence of effectiveness. The report calls for urgent action to improve the evidence base. A shift away from universal services to targeted ones potentially threatens early interventions, such as parenting support. Healthy Start provides a mechanism for vitamin supplementation among pregnant women and young children in low income families, yet evidence on the ground shows that after seven years less than 10% of the target population are taking vitamins; this suggests that the targeted approach has failed. A universal offer of vitamin D supplements is relatively cheap and has improved health in some areas,11 but procurement and distribution obstacles are considerable and increasing.12 Sure Start, a key setting for delivery of early interventions,13 is already experiencing loss of staff and services. Effective measures such as these should not be allowed to fall by the wayside.
Most interventions that can improve child health involve collaboration between a range of agencies and settings. Assessing their effectiveness will require studies that are complex in design and costly to conduct. Commissioners need evidence of long term outcomes but also of process—what works for whom, under what circumstances, and at what cost to families and health services. This is a challenging research agenda, particularly given recent cuts to public spending.
We welcome the BMA’s report, its scope and ambition, and its focus on putting children first in services and policies. We fear that the climate for adopting its recommendations may not be favourable, but the medical profession must rise to the challenge.
Cite this as: BMJ 2013;346:f3713
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.
Provenance and peer review: Commissioned; not externally peer reviewed.