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Everyone deserves the world. This is important because everyone is entitled to being healthy, happy and well, to be loved, not be hungry and be looked after.

RCPCH &Us1

Introduction

Health inequalities are the avoidable, unfair and systematic differences in health outcomes between different groups of babies, children and young people. The drivers of health inequalities are the social, economic and environmental factors in which individuals live that have an impact on their health outcomes. This includes ethnicity, income, housing, climate change and being looked after by local authorities.Ìý

This position statement focuses on poverty as a driver of health inequalities and outlines our recommendations to address this, which includes action for all four UK Governments, and on data and digital and workforce. The influence of poverty on children’s health and wellbeing is undeniable. Children living in poverty are more likely to have poorer health outcomes including higher risk of mortality, poor physical health, and mental health problems.

Living in poverty can create a self-perpetuating cycle as children growing up in low income households are at greater risk of ill health, which limits their education or employment opportunities and therefore makes it difficult for families to escape poverty. It is essential that health inequalities driven by poverty are addressed to improve child health outcomes, as well as reduce costs to the NHS in the long term.2

Spotlight from RCPCH &Us and partners

In 2021 we had the chance to question different people from health, education, the police, charities and the government on child poverty. We wanted to know how professionals notice that someone is living in poverty if the appointments are done on the phone or through a webcam. We also asked what they thought was the impact of child poverty on children and young people with disabilities, physical health or mental health conditions. We asked paediatricians about how to tackle the issues that are caused by poverty like stress or poor diet, and how can families get the help they need if they can’t afford to pay for medicines or evenÌýdata or phone calls with virtual appointments.

It is evident that child poverty is an issue that requires teamwork from different services in order to eradicate it and it is clear that it is a long-standing problem that plagues all of the UK. This plague affects a ludicrous amount of our children and can bring about dire consequences. It is time we bite the bullet and face the truth that we that we need to do better and that we should all come together as one fight and end it so no more children are living without adequate necessities and can instead focus on being bright and cared for members of our society.Ìý3

RCPCH &Us, YoMo Glasgow, Fitzrovia Youth in Action, Caerphilly Youth Forum

Child poverty in the UK

• Nearly 1 in 3 (30%) children lived in poverty in the UK in 2022/23,4 defined as living in a household with an income less than 60% of the median household income.
• The main drivers for child poverty are insufficient income and high living costs associated with raising children.5 ÌýHowever, employment does not necessarily provide a solution out of poverty; 75% of children in poverty have at least one parent working in at least one job.6
• Children in specific family types are at higher risk of poverty. For example, lone parent families, the majority of which are headed by women, and having someone with long-term illness in the household increases the risk due to barriers to employment.7
• There are stark ethnic differences in the rates of child poverty, and poverty is higher among certain ethnic minority groups. For example, 47% of children in Black and minority ethnic minority groups are living in poverty compared to 24% of children from white families.8
• The causes of poverty and how it affects child health and well-being will differ by geographical location. Of the UK nations, England has the highest rate of children living in poverty (31%), compared to Wales (28%), then Scotland (25%)9 and Northern Ireland (24%).10 There are regional variations within each nation as well as disparities between rural and urban areas too.11 ÌýWhile rural Cornwall, Derry, Glasgow and inner-city London all have high rates of child poverty, the challenges, opportunities and strategies required to address problems in these areas will vary.
• No recourse to public funds (NRPF) is a condition applied to those staying in the UK with any form of temporary immigration status. This prohibits migrant families from accessing most benefits, such as Universal Credit and free school meals, placing migrant children at increased risk of destitution.12

How poverty affects child health outcomes

Paediatricians have told us how poverty has affected their patients, including the following:ÌýÌý

• Parents in poverty are less able to afford healthy foods and offer their children a healthy lifestyle. Healthy foods are nearly three times more expensive than less healthy foods per calorie, which means families may be more likely to eat food that is cheap but nutritionally poor, leading to obesity and malnutrition in children.13
• Recent increases in household energy costs comes on top of food insecurity, which may mean families face a choice between paying energy bills and food. Living in a cold home has a negative impact on physical health by, for example, exacerbating respiratory illnesses14 .
• Low-income families may be unable to afford basic hygiene products due to financial constraints. For example, period poverty is the lack of access to sanitary products and 1 in 10 young people who menstruate are unable to afford period products, which can lead to missed school days or improvising menstrual products.15
• Adverse childhood experiences, which are usually multiple, have a cumulative negative effect on physical and mental health in later life and are three times more common in the context of poverty than in affluence.16
• Children in low-income families have less access to the medical care they need, for example there are fewer GPs per population head in more deprived areas.17 ÌýThe average cost of attending a clinic appointment is £35. Families have reported missing paediatric appointments because of the financial cost of attending one due to travel, parking, childcare costs and potential lossÌýin earnings, estimated to be an average of £50.18 ÌýLow income families may also be experiencing digital exclusion, where households may not have a smartphone or internet connection and are unable to benefit from digital health technologies as a result.19

Children and young people have told us how poverty affects them, including the following:

• Not enough money for healthy nourishing food, leading to a poor diet and unhealthy eating. It would be easier to get disease and get sick because of poor diet and poor hygiene. It would also be hard to sleep, which would also affect your mental health.Ìý
• Not able to afford to go to social events or sports clubs, go on holiday, or go on school trips. You might be left out.Ìý
• Can’t afford good housing, could be homeless. You would be lacking basic things like electricity, or hot, clean water – leading to poor hygiene (dirty clothes, hair etc).Ìý
• You may end up being bullied, or possibly becoming a bully. People might make fun of you, and you might be bullied because you can’t afford clothes, or have a dirty uniform.Ìý
• Poverty would result in poor mental health and could lead to depression or anxiety. You could feel angry and frustrated, and might lash out at people.Ìý
• You would become vulnerable and might be exposed to ‘dodgy’ people and drugs. You could be forced to make bad choices and get up to trouble.20

Evidence of how poverty drives health inequalities in the UK

Mortality in childhood

• The UK has high infant mortality rates when compared with other developed countries.21 Ìý

• There is a clear association between the risk of infant death and the level of deprivation. In England, infants in the most deprived areas are twice as likely to die in infancy as those in the least deprived.22 ÌýBetween 2011 and 2020, the child death rate was 70% higher in the most deprived areas of Wales compared with the least deprived areas.23 Ìý In Northern Ireland, the regional infant mortality rate within the most deprived areas (5.2) was 1.1 percentage points higher than the least deprived (4.1) per 1000 live births.24 ÌýIn Scotland, by 2016-18 infant mortality rates in the most deprived areas were 2.6 times the rate in the least deprived areas.25 Ìý

Acute and long-term illness

• Children living in poverty are significantly more likely to suffer from acute and long-term illness. They are significantly more likely to require hospital admission26 Ìýand were 72% more likely than other children to be diagnosed with a long-term illness.27
• Rates of obesity and severe obesity in children living in the most income deprived areas entering Reception and Year 6 are rising, while the rates are decreasing in the least income deprived areas in England.28 ÌýIn Wales, the gap between obesity prevalence in the most and least income deprived quintiles has increased from 5.9% in 2017/18 to 6.9% in 2018/19.29
• In Scotland, marked socioeconomic inequalities in child unhealthy weight have developed over the past 20 years. Children living in the most income deprived areas saw an 8.4 percentage point increase between 2019/20 and 2020/21, to 35.7% at risk of being overweight or obese, compared to a 3.6 percentage point increase, to 20.8%, in the least deprived areas.30 Ìý
• In NI the most recent data indicates that overweight and obesity among year 4-5 year olds (primary 1) was 7% higher in the most deprived areas. This increases to a 10% disparity for 11-12 year olds (year 8). In terms of obesity alone, the percentage of primary 1 pupils in the most deprived areas affected by obesity was more than double the proportion in the least deprived areas. The inequality gap in year 8 pupils affected by obesity was slightly lower, with the proportion in the most deprived areas almost double that in the least deprived areas.31 Ìý
• Children living in poverty are more likely to be at risk of tooth decay, in prevalence and severity. In England, children from the most income deprived areas are almost three times as likely to have tooth decay compared with those from the least income deprived.32 ÌýIn Wales, 42.2% of five-year olds in the most income deprived areas have tooth decay, compared to just 22.3% in the least income deprived areas.33 Ìý In NI the prevalence of experience of toothÌýdecay was higher in more deprived areas (45.25%) than the least deprived areas (16.27%). Furthermore, children from deprived backgrounds had more severeÌýlevels of decay than those from less deprived backgrounds.34
• Children living in the poorest 20% of households in the UK are four times more likely to develop a mental disorder as those from the wealthiest 20%.35

Indoor and outdoor air quality

• Air pollution exposure is highest in the most income deprived areas36 , and children are disproportionally impacted byÌýthe high levels of pollution when compared to adults.37   Ìý
• Children in more income deprived families are three times more likely to be exposed to second-hand smoke.38
• Children in income deprived areas are more likely to live in housing with poor ventilation39  and other features of substandard housing. Families in poverty may ventilate their house less because of problems such as fuel poverty.

RCPCH recommendations to reduce health inequalities as a result of child poverty

England

Reduce health inequalities

• We welcome the new ministerial taskforce to develop a child poverty strategy. The taskforce needs to consider the role of health in ending child poverty and to support this, the RCPCH recommends:Ìý
  • The appointment of a Cabinet-level Minister for Children and Young People. The Minister would:Ìý
    • Ensure the UK Government adopts a 'child health in all policies' approach to policy development.Ìý
    • Coordinate the development of a cross-departmental strategy to improve child health and wellbeing, which considers the role of each department in tackling the causes of ill health and ensure no policy exacerbates health inequalities.Ìý
  • Reintroducing national targets to end child poverty. The Department for Work and Pensions, the Department for Education and the Treasury in particular should undertake a review into the impact of recent welfare changes on child poverty and inequality.Ìý
  • Provide resource to introduce a Young Patients Family Fund for in and outpatients to help families cover the costs of attending hospital and accessing healthcare.Ìý
  • Restore the public health grant for Local Authorities with investment in public health provision allocated based on children and young people's health needs.Ìý
  • Expand the free school meals scheme to all children in primary schools so they can all be provided with a nutritious meal, without the stigma that can be associated with receiving free school meals.Ìý
  • End the two-child limitÌýto benefit payments to provide further financial support to children and their families. RCPCH is a signatory of the t which outlines further policy recommendations to eradicate child poverty.Ìý

Data and digital

• NHSE should set out without delay how they will collect, analyse and publish data relating to health inequalities for children and young people across the health service, as outlined in the Health and Care Act 2022, and use these to improve design and delivery of care to support better health outcomes.
• The Government should develop plans for use of the NHS number as single unique identifier for children and young people in England to enable professionals to share information more easily between agencies and services in order to provide better care for their needs.Ìý

Workforce

• Ensure the NHS Long Term Workforce plan sets out how to deliver an appropriately trained paediatric and child health workforce, including health visitors and school nurses, that is properly resourced and based on robust workforce data and modelling. Tackling inequalities should be a key objective and will ensure all children and young people receive the best possible care.Ìý

Scotland

Reduce health inequalities

We welcome existing commitments by the Scottish Government to reduce child poverty and health inequalities such as the introduction of the Scottish Child Payment, the Young Patients Family Fund and the ongoing expansion of free school meals. These commitments are making a real difference to children and young people across Scotland. There are, however, many children and young people who remain living in poverty and there is a real risk that existing policies will not deliver the child poverty targets included in the Child Poverty (Scotland) Act. Substantial action and investment are needed to ensure the targets are met.

RCPCH recommends that the Scottish Government should:Ìý Ìý

• Expand the Young Patients Family Fund to include both in and outpatients to help a greater number of families met the costs of attending hospital.Ìý
• Increase the Scottish Child Payment as a minimum to £30, increasing to £40 per week within in the lifetime of this parliament to help families in need.
• Roll out free school meals to all primary school children as soon as possible.
• Action all measures contained in the Best Start, Bright Futures Plan: tackling child poverty plan 2022-2026 and ensure these actions are appropriately resourced and funded.Ìý
• Improve access to and provide long-term, stable funding for cross-sector community-based services, resources and advice for children, young people, and families to support their health and wellbeing.

Data and digital

• The Scottish Government, Public Health Scotland and NHS Scotland should strengthen the collection of data to inform understanding of waiting list and workforce pressures and where to direct resource. This must also include the collection, analysis and timely publication of data relating to health inequalities for children and young people across the health service and use these findings to improve design and delivery of care to support better health outcomes.
• The Scottish Government should consider the use of a single unique identifier for children and young people in Scotland, expanding the use of the CHI number across multiple public services would enable professionals to share information more easily between agencies and services in order to plan for and adequately provide for individual children’s needs.Ìý

Workforce

A full review of the child health workforce must be carried out to ensure it is sufficiently resourced, funded and is focussed on tackling inequalities to ensure all children and young people receive the best possible care. The review of the child health workforce must include:Ìý

• A bespoke child health workforce strategy: Put plans in place to create a bespoke child health workforce strategy. The strategy should respond to immediate needs and financial pressures, taking emerging models of care into account, to deliver professional and service standards. The plans should consider future and growing children and young people’s needs in order to help tackle health inequalities and deliver the best possible care. Ìý
• ÌýA Whole System Approach:Ìý
  • Ensure future workforce planning considers the child health workforce as a whole and considers the role of the multi-disciplinary team. The roles played by nurses, health visitors, allied health professionals, school nurses, and other support roles within primary and secondary care, education settings, and in the community are invaluable.
  • Provide greater support for primary care colleagues by increasing the level of community-based paediatric services. Adapt existing ways of working with an aim to provide a Realistic Medicine model and develop the multi-disciplinary child health workforce, including in remote, rural and urban areas. By doing so, we can ensure that skills and expertise are being utilised effectively and sustainably.
• Engagement: To truly address health inequalities, children and young people must be consulted on what they need and would like from the child health workforce in order to live healthy happy lives.

Wales

Reduce health inequalities

In January the Welsh Government published the Child Poverty Strategy for Wales 2024.40 ÌýThe strategy recognises that poverty has a direct impact on health inequalities. It details ‘children living in poverty are more likely to have poorer health outcomes and experience health inequalities including low birth weight, poor physical health, and mental health problems’. We welcomed the recognition of this link within the strategy but could not overlook the fact the overall strategy comes up short, with no clear targets or any way to monitor the delivery.41 ÌýÌý

While the Child Poverty Strategy for Wales does reference health inequalities as a reason for many of its actions relating to food costs, health costs and the 20-mph introduction, there is very little in the strategy to directly address health inequalities beyond referencing Healthy Weight: Healthy Wales. RCPCH would like to see a specific emphasis on improving the health of children currently living in poverty.

RCPCH recommends the Welsh Government should:

• develop a monitoring framework that will allow for the implementation of the Child Poverty Strategy for Wales to be robustly and transparently monitored.Ìý
• improve health outcomes for children currently living in poverty by developing a cross-government delivery plan for addressing child health inequalities.

Data and digital

The NHS Wales Executive Child Health Network should work alongside the Welsh Government and Digital Health and Care Wales to embed tackling child health inequalities as a core aim for a digital health strategy. In doing so, they should ensure collection, analysis and timely publication of data relating to health inequalities for children and young people across the health service and use these to improve design and delivery of care to support better health outcomes

The Welsh Government should consider whether the NHS number could be used as single unique identifier for children and young people in Wales to enable professionals to share information more easily between agencies and services in order to provide better care for their needs.Ìý

Workforce

A full review of the child health workforce must be carried out to ensure it is sufficiently resourced, funded and is focussed on tackling inequalities to ensure all children and young people receive the best possible care. This should be done by Health Education and Improvement Wales (HEIW) alongside the NHS Executive Child Health Network.

A review must consider the entire workforce, including numbers working in child health settings, stage of their careers, place of work, demographics and working pattern. This should inform commissioning needs for the next 5, 10 and 15 years.Ìý

Building on this, the NHS Executive Child Health Network and HEIW should develop a bespoke child health workforce strategy. This should respond to immediate needs and financial pressures, taking emerging models of care into account and to deliver professional and service standards. The strategy should reflect the commissioning needs identified in the review outlined above and consider future and growing needs of children and young people. This will help tackle health inequalities and deliver the best possible care.Ìý

Northern Ireland

Reduce health inequalities

The return of the NI political institutions in 2024 provides the opportunity to progress a fit for purpose programme for government and a significantly overdue robust and measurable anti-poverty strategy. According to the latest NI Executive Poverty and Income Inequality Report, relative child poverty has reached 24%, the highest recorded since 2014/15 and the long-term trend shows that children are at a higher risk of living in poverty than the overall population in both relative and absolute measures.

Therefore, we recommend that:Ìý

• The Northern Ireland Executive should seek to renew the expired 10 year public health strategy ‘Making Life Better - A Whole System Framework for Public Health (2013-2023)’ which aims to achieve better health and wellbeing for everyone and reduce inequalities in health.
• The NI Executive, led by the Department of Communities must Ìýexpedite the Ìýpublication of an anti-poverty strategy that includes bespoke children and young people outcomes and indicators. Monitor, and report on, the health impact of poverty on children, young people and their families and target intervention to where it is needed most.
• The Northern Ireland Executive, led by the Department of Education should prioritise Ìýthe delivery of the Children and Young People’s Strategy (2020-2030) and maintain a focus on those outcomes that will help to reduce health inequalities.
• The NI Executive must act on the findings of the Annual Health Inequalities Reports which pertain to children.
• The NI Executive should consider all avenues to implement a young patients fund for NI.

Data and digital

• The Department of Health, Public Health Agency and HSC Trusts should improve the collection, sharing and utilisation of child health data supported by a fully resourced Child Health Partnership. Information and resource sharing between Health, Education and Communities should be prioritised. The Department of Health must ensure that the implementation of digitisation via the Encompass system across the Health Trusts in NI adequately meets the needs of children and consideration is given to the digitisation of the Red Book.

Workforce

• The Department of Health should develop a bespoke whole child health workforce strategy with an integrated approach including numbers working in child all health settings, career stage, demographics and working patterns. This should be based on transparent and independently verified projections of workforce supply and demand to ensure all children have equitable access to care.

RCPCH &Us

From RCPCH &Us.Ìý43

Reduce health inequalities

• We need more help for children, young people and families who are struggling to eat well, sleep well and live well.
• As well as staying physically healthy, we need more services to support our emotional wellbeing as children, young people and our families.
• We need the spaces and places around us (health services, schools, communities) to make us feel valued and help to break the cycle of feeling sad and alone.

Data and digital

• We need services to provide accessible information to children, young people and families about where we need to go to get the support we need.
• We need a voice in decision making.
• We need to have coordinated help so that we only have to tell one service once about what is going on for us, but with our permission, they can tell others to make sure we get the best help.

Workforce

• We need staff who know about different people and places that can help us. We need staff who are good at talking to us about what is going on in all areas of our lives.
• There needs to be more investment in services and support for children, young people and families facing inequalities that will affect our health.

The role of the RCPCHÌý

• In its 2021-24 strategy, RCPCH committed to continue to shape policy around health inequalities in childhood to drive better outcomes in children and young people’s health.
• In autumn 2022, RCPCH published ‘Child poverty and health inequalities in the UK - a toolkit for paediatricians’ to support members in working to reduce health inequalities in childhood locally.
• We will continue to advocate on the issues that matter most to our members, and to children, young people and their families. With the cost of living crisis having a detrimental impact to families, child poverty will be a key campaigning issue for RCPCH.
• RCPCH &Us, the children, young people and families network for RCPCH will continue to inform, influence and shape our thinking on issues that matter to them, including child poverty and health inequalities.

Thank you to the 500+ children and young people, parents and carers plus supporting paediatricians from London, Warrington, Belfast, Edinburgh, Warwick, Peterborough, Essex, Oxford, Rhyl, Belfast, Hartlepool, Liverpool, Glasgow and Caerphilly who joined RCPCH &Us in sharing the voices, views and ideas on child health inequalities in 2022.

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