Intended for healthcare professionals


Children’s health and the financial crisis

BMJ 2009; 338 doi: (Published 15 May 2009) Cite this as: BMJ 2009;338:b1783
  1. Terence Stephenson, President
  1. 1Royal College of Paediatrics and Child Health, 5-11 Theobald’s Road, London WC1X 8SH
  1. terence.stephenson{at}

    Children’s services should not be an easy target to save money

    In 2007, a Unicef report ranked the United Kingdom bottom of 21 developed countries in measures of child wellbeing.1 The Children’s Commissioner for England said that this had resulted in “a generation of young people who are unhappy, unhealthy, engaging in risky behaviour.” Three further reports this year suggest that the care of British children is still falling short.2 3 4

    The Good Childhood Inquiry, published in February 2009 by the Children’s Society, received evidence from 30 000 children, adults, and professionals.2 It concluded that British children are unhappy, largely because of parental behaviour, especially mothers going to work.

    Children might be unhappy but are they healthy? A week later, the Department of Health and Department for Children, Schools, and Families launched Healthy Lives, Brighter Futures, the long delayed child health strategy for England.5 A government child health strategy should be a big event and something to celebrate. Healthy lives, Brighter futures claimed that children and young people growing up in England are healthier than ever.

    The infant mortality rate is a quarter of what it was in 1960. Pneumococcal vaccine averted 470 cases and 28 deaths in its first 18 months. Vaccination against cervical cancer will save 400 lives a year, and some of the women saved will be under 30. Over the past quarter of a century, Haemophilus inflenza meningitis has been eradicated, “cot death” incidence has been halved, and survival from leukaemia has increased dramatically. Between 2000 and 2006 the number of consultant paediatricians increased from 1605 to 2232.

    Children might be both unhappier and healthier, but many questions about the evidence need answering. Might the Unicef league table be flawed, as France came 16th, Austria 18th, and the United States 20th?1 Do all 21 countries collect data as assiduously as the UK? Is a very preterm baby who survives for a few gasps counted as a live birth in the UK but not in other countries? The use of relative rather than absolute poverty indices by Unicef indicated that Hungary has fewer “poor” children than the US, although the average family income is three times higher in the US. For one of the six indicators (death rate from accidents), the UK has the second lowest rate—perhaps the UK would have fared better if alternative measures to the five other arbitrary indicators had been used?

    The research from the Children’s Society also has problems.2 Firstly, nature versus nurture. If loving, firm parents have children with better “outcomes” (the inquiry’s phrase), it may not be the result of this “authoritative” parenting style. It may just be that sensible, mature parents are more likely to have sensible, mature children. Secondly, reverse causality. It is probably easier to be authoritative when interacting with a cooperative child. The inquiry assumes that the successful child is produced by the parenting style. It may be the reverse. In contrast to the Good Childhood Inquiry, the 2006 British Household Panel Survey found that only 0.8% of 11-15 year olds described themselves as being completely unhappy and 4.2% were somewhat unhappy.6

    But we should not be complacent. Apart from the welcome £340m (€380m; $500m) for children with chronic disorders, Healthy Lives, Brighter Futures offered no new resources. The strategy emphasised child health promotion and recommended managed networks (for example, for paediatric surgery and for safeguarding, which includes protecting children from abuse) but was not explicit about how these would be funded.

    In March 2009, Lord Laming set out the progress made in improving the protection of children in England since the failures revealed by the death of Victoria Climbié.3 7 8 The Laming review commented on the need for political leadership and particularly noted that training and workforce problems need to be resolved to support the use of the Working Together to Safeguard Children guidance.9

    Staff in accident and emergency departments should be able to tell if a child has recently presented at any such department or is the subject of a child protection plan. Previously, children’s medical notes could be “flagged” to indicate if they frequently attended with unusual “accidents.” This was abandoned for fear of labelling a child and the implication that the parents might be assumed guilty until proved innocent.

    The day after the Laming review, as if to reinforce its concerns, a Healthcare Commission report on hospital standards for children highlighted the inadequacies in training, including recognising and managing suspected child abuse. 4 The report assessed progress on children’s services by 154 NHS acute trusts since 2005-6; the proportion of trusts classified as “deteriorated” or “consistently low performing” for basic training in child protection, paediatric life support, and managing children’s pain was 29%, 41%, and 74%, respectively.

    The report emphasised that all those involved in the care of children must be appropriately trained. When summarising the effect of the Healthcare Commission, its outgoing head, Ian Kennedy, said “following the collapse of banking, people in the sector that used to shout loudest about regulatory burdens feel more warmly towards regulation.”10

    In the public sector, performance indicators can have a role but do not serve children well if the priority targets do not include children, if case loads to meet targets overwhelm training and professionalism, and if the targets are not backed up by extra resources.

    Over the past five years, the Healthcare Commission has not seen the improvements that Kennedy hoped “for those least able to look after themselves, who have historically been forgotten.”10 But what will make the next five years different? What is going to make all the new recommendations in these four recent publications happen? Other than the £340m for children with disabilities and chronic disorders, are these just fine words?

    Words raise awareness, but people and resources help children. The UK is in a very tight financial squeeze, and the public sector deficit has increased. An election is looming and children have no votes—children’s services should not be an easy target to save money. A child’s school report would say of the government’s performance, “On the right track but must try harder.”


    Cite this as: BMJ 2009;338:b1783


    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; not externally peer reviewed.