UK children have “alarming gap” in health between rich and poor, report finds

BMJ 2017; 356 doi: (Published 26 January 2017) Cite this as: BMJ 2017;356:j377

Re: UK children have “alarming gap” in health between rich and poor, report finds

We welcome the findings of the Royal College of Paediatrics and Child Health (RCPCH) report into the state of child health (1). It accurately describes the scale of the public health challenges, clearly recommends actions to improve child health, and portrays urgency for action.

The report highlights the stark inequalities in child health in the UK and its poor performance on a number of specific health indicators when compared with other Western European countries. It offers important policy recommendations and calls for action including implementation of strategic and coordinated cross-UK actions and the reduction of child poverty and inequality. Specific aspects of health in these recommendations include women’s health during and after pregnancy, tobacco control, obesity and mental health. We strongly endorse the report’s calls for ‘child health in all policies’ and for a reversal of public health cuts in England (reported as disproportionately affecting children’s services).

We are pleased that one of the under resourced public health areas – accident prevention, was acknowledged as a leading cause of death. Inequality in risk of injury is clear. For example, children living in the most disadvantaged areas of the country have a 50% higher risk of being burned, scalded or poisoned than those living in the most advantaged areas (2). However, it has to be noted that in the past much success has occurred in relation to accident prevention (3,4), and that much more could be done, both in homes and on the roads (5,6).

Young people’s views are drawn on throughout the report and mental health was highlighted as a major area of concern. Two sections in the report have a specific mental health focus and offer a good set of key actions. We would have liked to see some of these actions brought out more explicitly in the summary ‘report in a glance’ to ensure the importance of mental health is conveyed clearly to those who may not read the full report.

We agree that better data is needed for planning, evaluation and for promoting action. In addition we approve of some of the indicators that have been chosen. However, more of them need to be positive health indicators, particularly at a higher level than the individual (7,8). For example, the proportion of health promoting schools, and the proportion of health promoting hospitals. Indicators at this level will help to move the focus away from “victim blaming” and towards the unhealthy environments.

General practice could be one part of the solution to tackling health inequalities. Tools such as advocacy, preventative care and social prescribing could be used more. But, GPs and their teams would need additional support. Moreover workforce issues need to be addressed. It is now widely recognised that there are not enough GPs, particularly in areas of greatest public health need (9-11). Given the key roles of midwives and health visitors in pregnancy and early childhood we welcome the report’s statement that these services to all mothers should be preserved.

The RCPCH report quite rightly stresses the importance of comprehensive personal, social and health education (PSHE) in schools which can lead to improved health outcomes and social mobility. Unfortunately, there are also workforce issues in this sector. Schools in disadvantaged areas are struggling to recruit. In addition, they are more likely to have unqualified, inexperienced, inappropriately trained and high turnover teaching staff (12). This may explain the substantial attainment gap between rich and poor pupils as quality of teaching is a critical determinant of pupil attainment (12).

Making PSHE statutory for all schools would be a very good initial step forward in trying to improve child health and reduce inequalities. In the report children themselves expressed the need for PSHE and offered their suggestions for practice. However, if teachers are to be effective at encouraging good health – they will need training and support.

We continue to recommend increased investment in public health within local authorities in order to allow Directors of Public Health to take effective action on health inequalities (13-15). Well-resourced and multidisciplinary teams would be able to lead, support, train and drive forward improvements in child health.

It should also be noted that other local authority sectors have the potential to impact on child poverty and health inequalities through, for example, support for children’s centres, play provision, and actions to reduce obesogenic environments. The ongoing cuts in overall funds to local authorities are, therefore, a major concern.

We firmly believe that early intervention, prevention and health promotion can reduce and resolve issues before they become entrenched and more difficult to treat later in life. As the report recognises there is already an existing evidence base on interventions to guide practice and barriers to implementation need to be overcome. Radical action is now needed to urgently address the “alarming gap” in health between rich and poor children (16).

1) Royal College of Paediatrics and Child Health. State of child health. 2017.

2) Orton E, Kendrick D, West J, Tata LJ. Independent Risk Factors for Injury in Pre-School Children: Three Population-Based Nested Case-Control Studies Using Routine Primary Care Data. PLoS ONE 2012 7(4): e35193. doi:10.1371/journal.pone.0035193

3) Hemenway D. While We Were Sleeping. Success Stories in Injury and Violence, Berkeley: University of California Press, 2009.

4) Watson M C and Errington G. Preventing unintentional injuries in children: successful approaches. Paediatrics and Child Health.2016; 26(5), 194-199

5) Public Health England. Reducing unintentional injuries in and around the home among children under 5 years. London: Public Health England, 2014.

6) Public Health England. Reducing unintentional injuries on the roads among children and young people under 25 years. London: Public Health England, 2014.

7) Catford JC. Positive health indicators – towards a new information base for health promotion. Community Medicine. 1983; 5: 125-132.

8) Watson MC and Watson EC. Premature deaths across England. Time to focus on positive health indicators to reduce health inequalities BMJ 2013;347:f4210.

9) Goddard M, Gravelle H, Hole A, Marini G. Where did all the GPs go? Increasing supply and geographical equity in England and Scotland. Journal of Health Services Research & Policy. 2010; 15(1): 28–35.

10) Limb M. Increase GP trainees by 450 a year to avoid crisis, says taskforce. BMJ 2014;349:g4799.

11) Baker M, Ware J, Morgan K. Time to put patients first by investing in general practice. Br J Gen Pract 2014;64:268–9.

12) Social Market Foundation. Social inequalities in access to teachers. Social Market Foundation Commission on Inequality in Education: Briefing 2. 2016. London: SMF.

13) Watson M C and Lloyd J. Promoting the health of the population BMJ 2014;349:g6195.

14) Watson M C and Lloyd J. Need for increased investment in public health BMJ 2016;352:i761.

15) Watson M and Tilford S. Directors of public health are pivotal in tackling health inequalities BMJ 2016;354:i5013.

16) Mayor S. UK children have “alarming gap” in health between rich and poor, report finds. BMJ 2017;356:j377

Competing interests: No competing interests

30 January 2017
Michael Craig Watson
Associate Professor in Public Health.
Professor Sylvia Tilford (President, Institute of Health Promotion and Education, Welwyn AL6 0UD, UK.
University of Nottingham, Faculty of Medicine and Health Sciences, D86, Queen's Medical Centre, Nottingham. NG7 2HA
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