“A child doesn’t come into your emergency department or your clinic with deprivation on their forehead. It’s there in the background, and it’s this kind of insidious factor.”
Camilla Kingdon, president of the Royal College of Paediatrics and Child Health, has been a paediatrician in the NHS for almost 30 years. Poverty and child health inequality have always existed in this time, but the current cost of living crisis is exacerbating the problem, with its effects presenting in children in hospitals up and down the country, she tells The BMJ.
“It’s something that’s occupying a lot of my headspace at the moment,” Kingdon says. “The more you dig, the more you find.”
From a clinical perspective, Kingdon, a consultant neonatologist in London, believes that social deprivation is a “far bigger problem” for children’s health now than it was 5-10 years ago.
In response to what paediatricians are seeing, the college has become increasingly outspoken on the issue and has developed a toolkit to encourage its members to be more “professionally inquisitive” about poverty’s effects on children’s health.1 For example, it encourages them to understand how child poverty is defined in the UK, how to develop clinical skills for talking to families, how to prepare their own quality improvement project, and how to influence local children’s services.
“We are absolutely compelled by the evidence out there around rising levels of poverty,” Kingdon says. “It’s only when you start asking questions that you start realising how ubiquitous this problem is.”
Deprivation changing practice
Kingdon says the use of food banks is now “unbelievably common” among the families she sees. Discussing issues such as nutrition and housing with patients and their carers gives doctors a true grasp of how far reaching the problem is, she adds.
She cites asthma as one example where the UK is failing because of social factors. “The UK has some of the worst asthma outcomes and some of the highest rates of death due to asthma in children in all of Europe,” she says. “Of course, it’s complex, but . . . we’ve got some of the worst housing stock in Europe. If you’ve got a child who’s got a propensity to asthma, and you’re living in damp accommodation where the heating doesn’t work, where you’ve got mould on the walls, where the route you have to walk your children to school is extremely polluted, then we know that all these factors interplay to make that child’s asthma much more problematical.”
Poor oral health and nutrition are other child health problems linked to deprivation,2 and Kingdon describes having to “take a deep breath and think really carefully” when talking to parents of some children she is treating, in recognition of the struggles they’re facing.
“Arguably, that’s just good medicine, but I would say it’s a change in practice that’s happened in the last two years in my clinical practice,” she says. “I’m having to deliberately roll back on some of the advice I would have given before, because I know these families can’t afford to buy green leafy vegetables or meat. Of course, we can give practical advice about alternatives, but it’s definitely altered the way we are talking to families.”
Policy interventions
Kingdon argues that there are specific policy interventions that the UK government could make to tackle these issues. “The precursors of obesity occur really early on in infancy,” she says. “I would be arguing you need to start really early on with how we support families to make those choices around the food they give their children and how we support people to do that, both practically but also financially.”
Increasing the value of the government’s Healthy Start vouchers to keep up with inflation, expanding the provision of free school meals, and cracking down on junk food advertising on television between 6 pm and 9 pm are all interventions that could and should be done, she says. She accepts that policies such as free school meals have a cost attached but adds, “I would argue, from a child health perspective, that it’s a cost and an intervention worth doing.”
Missing white paper
The government’s failure to publish its white paper on tackling health inequalities has led to deep frustration and questions about its commitment.3 Kingdon is unequivocal that failing to make good on the promise for legislation will result in damage to children’s health and society as a whole in the coming years. “There are policy areas and decisions that could be made,” she says. “I’m not pretending this is easy. Health inequalities are deeply entrenched, and it is going to take many, many different ways to tackle them. But we need to start somewhere, and there needs to be an intention.”
The government’s inaction has prompted the college to launch a campaign to encourage its members to lobby politicians on their commitment to reduce child poverty and health inequalities.4 As a result of the coordinated action, more than 100 college members have written to their local MP asking for clarity. The fundamental question? Will you be publishing the health disparities white paper and, if not, what will appear in its place?
“I think most paediatricians—and I think most doctors—don’t see themselves as activists,” Kingdon suggests. “What we’ve been trying to say is that actually there are things you can do to influence your local politicians on this agenda. We’ve tried to make it as easy as possible.”
Is the UK failing children?
Given the scale of the problem and the fact that the white paper has been kicked into the long grass, does Kingdon think the UK as a country is failing children?
“What we are saying as paediatricians is that, if we can’t tackle this more proactively, this is going to have a generational impact going forward,” she warns. “When children can’t access open green space for exercise, where they can’t be guaranteed three meals a day that that are of a decent nutritional value, where the quality of home life is tough because both parents are juggling often more than one job each, all of this essentially eats away at what we believe the kinds of key components of a healthy childhood are.”
She laments the lack of long term thinking in public policy, a longstanding issue that she believes has worsened since the pandemic as we lurch from “crisis to crisis.” She says, “Whether it’s obesity, whether it’s mental health, whether it’s chronic illnesses like diabetes and asthma and so on, we are just stacking up significant health problems for the future of this country.
“If we do not focus on this, we are putting ourselves in a very perilous place as a nation.”
Kingdon on . . .
Economic pressures
“People cannot afford to take the time off work. I don’t ever remember a time when we often had many consecutive days when parents couldn’t visit their unwell baby in my neonatal unit.”
Early intervention
“We ought to be doing far more to prevent disease early on—principally in childhood—so that the NHS is freed up to do the work it needs to do.
Lack of long term planning
“We are very reactive to what’s happening in front of us. The ability for politicians and other leaders to think longer term has been massively reduced because we’ve lurched from crisis to crisis in the short term.”
The covid-19 public inquiry
“We wrote to [inquiry chair] Baroness Hallett specifically raising the issues around children. We laid out our case around the impact on mental health, education, and life chances. We were very gratified that that has now been incorporated into the inquiry and we will be actively engaging with that.”