1. Executive summary
1.1 The Select Committee is asked to focus on child health and wellbeing as an urgent consideration.
1.2 The wellbeing of children and young people should be made the government’s top priority coming out of coronavirus (COVID-19).
1.3 Children and young people should be spoken to by government about coronavirus (COVID-19) and their voice heard regularly now and into the future.
1.4 Children and young people should be put front and centre of the post coronavirus (COVID-19) NHS.
1.5 There should be an all out assault on child poverty and the associated childhood epidemics of obesity, mental illness, infant and preventable deaths.
2. Introduction
2.1 The National Network of Designated Healthcare Professionals for Children (NNDHP) is made up of all the NHS Designated Professionals (Doctors and Nurses) who work in the areas of Child Safeguarding, Looked After Children (LAC) and Child Death Overview Panels (CDOP).
2.2 Designated professionals are clinical experts and strategic leaders for child safeguarding and Looked After Children and as such are a vital source of advice and support to health commissioners in CCGs, the local authority and NHS England, other health professionals in provider organizations, quality surveillance groups (QSG), regulators, and Local Safeguarding Children Partnerships. Child Death Overview Panel Designated Paediatricians support Child Death response and Overview processes [1,2].
2.3 Further, Designated Professionals provide advice on policy and individual cases to statutory and voluntary agencies, including local Police and local authority Children’s Social Care departments [3,4].
2.4 The NNDHP is actively engaged in the cross government departmental implementation of the Children and Social Work Act 2017 as a member of the Implementation Board.
3. Background
3.1 Our approach to this inquiry is based on children’s safeguarding legislation [5,6,7] statutory guidance and the NHS safeguarding framework. It is our role to support the best possible standards of child safeguarding. Child safeguarding includes child protection, and promotion of the welfare of all children, which last includes access to the best possible healthcare.
3.2 We have noted that children are not referred to directly in the seven issues to be covered by the inquiry. We understand that the nation is in the grip of the most serious crisis it has faced in many decades, with the national focus clearly set on saving as many lives as possible. However, to avoid the subject of the impact of this pandemic on the health and wellbeing on children would be a derogation of our duty.
3.3 It is our position that children are perversely suffering during this pandemic for the benefit of adults [8], and that this comes on the back of a national child health crisis about which calls for action have already been made [9,10,11,12]. There are 1200 to 1500 excess infant deaths per year compared to other countries in Europe and we remain a European outlier for childhood deaths for preventable conditions such as asthma, epilepsy and pneumonia. National levels of childhood obesity and mental illness are a serious blight.
3.4 Supporters of the status quo will point to investment to improve matters, but nothing changes the fact that significant health outcomes for children are deteriorating, because the state of child wellbeing was not a priority during the austerity, and that these outcomes are linked directly to social determinants of health [13].
3.5 This thesis – of non prioritization of health needs of children – applies to the management of this pandemic. The government response has been overwhelmingly to save (almost exclusively) adult lives. To assist with this ambition, children were displaced from schools and healthcare settings, and thereby out of sight of caring professionals. Although efforts have been made, particularly by schools, to mitigate the predictable consequences of increased levels of harm and neglect, the overall impact will be of delays in spotting signs of maltreatment, and of delays to receiving physical and psychological treatments.
3.6 Given the paramouncy of the needs of children, parallel Governmental efforts to protect and maintain their healthcare needs should be being made at the same time as efforts to save adult lives.
4. The Issues
4.1 Our comments will be based on the needs of children alone.
- How to achieve an appropriate balance between coronavirus (COVID-19) and ordinary health and care demand.
- Meeting the wave of pent up demand for health and care services that have been delayed
due to the coronavirus (COVID-19) outbreak.
4.2 For children, there is no balance to be struck. In the epidemic, the objective of the best possible healthcare for all children has been swept aside. The drive to save lives has lead to dramatic cuts in demand for all child healthcare services, whether in primary care or quaternary centres. This has lead to falling immunization and health visitor work rates, dramatic declines in emergency departments attendances and hospital admissions, and disruption to other child health pathways such as initial and review health assessments for looked after children. The idea that the NHS has coped well misses the fact that it has not coped well for non coronavirus (COVID-19) patients who are almost exclusively children.
4.3 The path to achieving a restoration of normal services result must be by
- Scoping the outstanding and backlog service needs across all child health services
- Implementing a “no expense spared” action plan – identical to that deployed to save adult lives – to catch up with the unmet child healthcare demand, and the new demand that will have developed during the epidemic.
The overarching principle must be that the health of the nations children must be recovered as completely and as soon as possible. To do otherwise is for children to remain second to adults with their needs to be only met after adults have been fully served. How this is overcome is a matter of cultural change that should engage the private sector in the same way as the public. For example, private employers should be required to make allowance for the current working from home stressors for parents who are also providing child care.
4.4
- Meeting with extra demand for mental health services as a result of the societal and economic impacts of lockdown.
The need for extra mental health services for children is already established. However, the additional resources must include a determination to engage with children and young people in designing the services they need as well as consulting with them on the lifestyle problems that have lead to the escalating levels of anxiety, depression and self harm that are being seen. These include online bullying and maltreatment in particular. There has been a reported high percentage increase in predatory online activity monitored by the National Crime Agency.
4.5
- Meeting the needs of rapidly discharged hospital patients with a higher level of complexity
- Providing health care to vulnerable groups who are shielding
It is our view that the healthcare needs for these two groups should be restored to normal as a priority as hospitals reduce their coronavirus (COVID-19) workload. The practice in many hospitals of clearly demarcated coronavirus (COVID-19) areas should be developed further to increase patient and professional confidence in the safety of facilities. This will need a further step change in access to PPE so that it is routinely and widely available for all and any child healthcare situation.
4.6
- How to ensure positive changes that have taken place in health and social care as a result of
the pandemic are not lost as services normalise
It is not safe to assume that there will be a return to pre-coronavirus normality. The way in which children have been affected is predictable insofar that we understand the harm that adults can do to children. But it would be wise to take a cautious approach to predicting other outcomes from this unprecedented social upheaval.
4.7 However, we would assert that there are some principles and services that should
remain or be bolstered:
- Children should always be seen face to face in healthcare settings.
- The focus on early intervention in childhood should be reinvigorated and the reduction in health visiting and school nurse services over recent years should be reversed.
- Given the manner in which education staff have taken up the role of moral support of children, the sector should be made statutory safeguarding partners.
- The twin epidemics of childhood obesity and mental illness, and the complex issues of infant and preventable childhood deaths should be made top government priorities.
4.8 We would emphasise the vital role of the school nursing service in supporting children re-integrating into school life following self-isolation with the anxieties many will have about covid, returning to school, possible experience of strained and even harmful family relationships during lockdown and an uncertain future. School nurses are skilled in building therapeutic relationships, assessing holistically and identifying support systems for children and young people both on an individual basis and in group settings.
4.9 Furthermore, school nurses are the gatekeepers to specialist services such as CAMHS and can ensure that appropriate referrals are made and will be crucial in preventing those services being overwhelmed. Building capacity to do this will be a challenge and will require addressing priorities, continuing aspects of some of the new ways of working and using skill mix appropriately.
4.10 Similarly, the loss of health visitors and their focus on the vital early weeks and months of life is having an impact on spotting early signs of family stress and the consequent impact on child wellbeing. This vital resource has been whittled away, with the consequence that in many areas, only mandated services are provided, and there are professional arguments about the freedom to engage in safeguarding concerns and processes.
4.11 We would also note that mental health issues for care leavers have been significantly exacerbated by lockdown – isolation, loneliness, lack of support networks, re-triggering of childhood trauma – and we need to be aware of this going into the post pandemic workload. At the same time there has been a positive response to online mental health services by young people, which should be studied and deployed further.
4.12 The huge reduction of numbers of children coming into care, and how current Initial Health Assessment systems will struggle to meet the demand of a surge of assessment requests must be planned for, while the impact of out of area placements on children’s health and social care needs when local authorities and health systems are prioritising their “own” children must also be catered for.
5. Discussion
5.1 In 2008 the financial crash placed a great strain on the national economy. Today, another great strain has come from the Covid 19 crisis. The response of the UK government to the previous crisis was to implement austerity. Unfortunately, there is now ample evidence that the measures undertaken have had an adverse effect on the welfare and development of children.
5.2 Poverty is by far the biggest determinant of child health, wellbeing and development. Since 2010 there has been a steady increase in child poverty. To quote the above report:
“Child poverty is not an inevitability, but largely the result of political and policy choices in areas including social protection, taxation rates, housing and income and minimum wage
policies.”
5.3 At present 22% of children live in poverty, the figure rises to 30% when housing costs are included in the calculation. The equivalent figure for the best countries in Europe is 10%. The social determinants of health make the UK 19th of 20 in European league tables. At the same time as child poverty has been rising, there have been cuts in youth services and funding per pupil in secondary education. There has been a 29% reduction in funding for Children and young people’s services, and sadly this has fallen more on areas of greatest need.
5.4 Institute for Fiscal Studies data (Marmot, figs 3.36-37) shows that tax and benefit reforms since 2010 have led to a 15% fall in net household income for the most deprived decile in society, whilst having no effect on the best off.
5.5 We recognise that socio-economic issues may not be the normal consideration the Department of Health and Social Care, but we would ask that they become so. We recognise and applaud efforts to end austerity and its impact on child health. However, we are fearful that the current economic situation may undermine those aims. And so we invite the Select Committee to put themselves into the ‘lived experience’ of these families, both before, and during coronavirus (COVID-19) where the effects of overcrowding and poor housing in deprived neighbourhoods have been sharply magnified and may have resulted in increased mortality within these groups.
5.6 We would also ask that the Select Committee inquires particularly into the impacts on children and young people of:
- Delayed access to care as a result of parents’ and carers’ fear of attending health
care - Anxiety and stress of lockdown on mothers of unborn children
- Lockdown and strong ‘war-like’ messages about an invisible enemy
- Increased levels of domestic violence on children and young people
- Increased levels of adults with mental illness and increased drug and alcohol misuse
issues - The dramatic reduction in child protection inquiries.
5.7 We are also especially concerned that the long-standing cultural inclination to keep the needs of children and young people as an afterthought to those of the adults should remain unchallenged. It is the duty of adults to support and encourage children and young people. Children and young people should be spoken to regularly and directly by government and involved in national and local problem solving as it applies to issues that affect them.
5.8 Lastly, the principle of the paramouncy of the needs of children should be put into effect in whatever new form the NHS may develop. Children and young people should be placed front and centre in NHS strategic thinking: they should always be the first consideration in any impact assessment when services and changed or commissioned.
6. Conclusions
6.1 We call for the voice of the child to be recognised as an integral part of government business as it moves through the coronavirus (COVID-19) pathway and beyond, with information for children and young people being provided as a matter of routine, and their engagement in all matters that may have an impact on their lives. The principle of paramouncy should be taken up by government as it is by other statutory bodies.
6.2 As the root cause of so many of the problems that befall the next generation, and that have been thrown into stark relevance by the epidemic, we seek an all out assault on childhood poverty and the consequent reduction in child health services. The evidence on the subject is overwhelming, and the longer action is delayed the greater the burden that is
handed down from this generation to the next.
6.3 The future of the NHS should be redefined by placing children and their wellbeing front and centre of future plans and policies. They have not been at the forefront of the plans for coronavirus (COVID-19) to date, but that situation should change as fast as possible.
6.4 Above all, we ask that the burden of paying for the recovery from coronavirus (COVID-19) will not, on this occasion, fall on our children. Were that to happen, the resultant effects on health and wellbeing of children will not reflect well on this generation of leaders, and will be a stain on all our legacies.
7. Footnotes
- Safeguarding children, young people and adults at risk in the NHS: Safeguarding Accountability and Assurance Framework 2019
- Working Together to Safeguard Children and Young People 2018
- Intercollegiate Document (Safeguarding Children and Young People) 2019
- Intercollegiate Document (Looked after Children) 2015
- The Children Act 1989
- The Children Act 2004
- The Children and Social Work Act 2017
- Ellimand D Daily COVID-19 telephone conference of NNDHP 15th April 2020
- Horton R Offline: the UK’s child health emergency. Lancet 2018;392:106
- 1016/S0140-6736(18)31614-3 30017117 10 Risks to Children and Young People during Covid 19 pandemic BMJ 2020; 369 doi
- NNDHP Voice of Health statement
- RCPCH State of Child health in the UK 2020
- Marmot Review 10 years on