The mental and physical health and wellbeing of today’s children and young people (CYP) will be one of the key factors in determining whether the UK is healthy and prosperous over the next 50 years. There are 15.5 million children and young people under 20 years in the UK. Today’s CYP are the workforce of the 2020-2040s and the parents of the generation that will work through to the late twenty-first century. Their health will be one of the factors determining whether the UK is healthy and prosperous over the next 50 years.[1]

Forecasting the future is not a new venture for RCPCH. In 2018, we published a report looking ahead to 2030. We used long-term historical data on key CYP health outcomes in England and various projection modelling methods to estimate CYP outcomes in 2030 in England/the UK compared with other wealthy European and western countries. Our comparison group was the EU15+, consisting of the 15 countries of the EU in 2004 plus the other similar countries to the UK, i.e. Australia, Canada and Norway. The data led us to two concerning conclusions:

• England/the UK currently have poorer health outcomes than the average across the EU15+ in most areas studied, and the rate of improvement in England/the UK for many outcomes is lower than across the EU15+. This means that unless current trends improve, England is likely to fall further behind other wealthy countries over the next decade.
• The marked inequalities observed in most key outcomes are likely to widen over the next decade as problems in areas such as infant mortality and obesity are worsening more quickly amongst the most deprived section of the population.

Which aspects of child health are of greatest concern? In 2020, we published an updated version of our State of Child Health report, which tracks progress in more than 20 indicators of child health and wellbeing status across the four nations of the UK.[2] Among these, some areas have seen slight improvements since we first reported on the same data in 2017. However, the report also highlights areas where progress has stalled, and in some cases where things are getting worse. Even in areas of improvement, including emergency hospital admissions for long term conditions and teenage conception/births, we still fall behind comparable high-income countries in Europe and beyond.

There are a number of admirable policy actions already in place – the Childhood Obesity Plan in England being one. However, actions in single policy areas are not enough, and, in many cases, they lack the necessary ambition, resources and leadership to have a major impact. Our State of Child Health work concluded that coordinated action is needed in the form of three core areas:

1. Reduce health inequalities
2. Prioritise public health, prevention and early intervention
3. Build and strengthen local, cross-sector services to reflect local need

Future challenges

Our state of child health 2020 work covered a range of wider determinants of health that are a concerning risk to UK children. All of these remain important future challenges. We have focused here on two of these that we are particularly concerned about and felt were not covered elsewhere in this project: rising poverty, and the impact of climate change.

Child poverty

A total of 4.1 million children live in relative poverty in the UK after considering housing costs, approximately 30% of the population. That means over 500,000 more children are in relative poverty in 2017/18 compared to in 2011/12. This is projected to rise to 5.2 million children by 2022, which would mark a record high in relative poverty rates for UK children.[3]

Poverty lies at the root of many other risk factors for infant mortality and all of CYP health. Poverty is associated with adverse developmental, health, educational and long-term social outcomes. Child poverty is linked to a wide range of poorer health outcomes,[4] including:

• Low birth weight (200g lower than affluent counterparts);
• Poor physical health (linked to chronic conditions and obesity);
• Mental health problems / low sense of wellbeing;
• Experience of stigma and bullying from peers;
• Academic underachievement;
• Subsequent employment difficulties;
• Social deprivation.

Authoritative projections suggest that child poverty and resultant health inequalities are likely to rise over the next decade – with concerning implications for CYP health.[5] Whilst reduction of poverty is outside the direct control of the health services, the health community has a crucial advocacy role in reducing poverty and the health system has indirect influence through population planning for health services and improving access to and quality of care for poor families. Conditions amongst CYP that are related to poverty are cared for within the health system, and CYP that die from poverty-related disorders usually die within the health system. A high-functioning health system should work to reduce inequalities and ameliorate the effects of poverty on health.

Climate change

Changes in warming and weather events are not evenly distributed across the globe, and some populations, including children, the elderly, and outdoor workers, are more vulnerable than others. The Lancet Countdown tracks annual progress on health and climate change across 41 indicators, building on the work of the 2015 Lancet Commission. The data published elucidate the ongoing trends of a warming world with effects that threaten human wellbeing.

Of particular relevance to the UK is Indicator 3.3: air pollution, transport and energy. Exposure to ambient air pollution, most importantly fine particulate matter (PM2·5), constitutes the largest global environmental risk factor for premature mortality, and results in several million premature deaths from cardiovascular and respiratory diseases every year. Globally, more than 90% of children are exposed to PM2·5 concentrations that are above the WHO guidelines, which can affect their health throughout their life, with an increased risk of lung damage, impaired lung growth and pneumonia, and a subsequent risk of developing asthma and chronic obstructive pulmonary disease.[6]

Climate change and human health are interconnected in a myriad of complex ways. Climate change has known impacts on the social and environmental determinants of health – affecting clean air, safe drinking water, sufficient food and secure shelter. Children are among the most vulnerable to these resulting health risks and will be exposed to the health consequences for longer. Globally, climate change is expected to cause approximately 250,000 additional deaths per year between 2030 and 2050. This is likely to have a significant impact on the health sector.[7]

Impact of COVID-19

The earlier analyses, and indeed much of our Paediatrics 2040 work, took place before the COVID-19 pandemic. Despite direct effects on children from the COVID-19 virus being rare so far, the indirect effects of the COVID-19 pandemic worldwide could be catastrophic for children, with considerable excess death and suffering.[8] At the time of writing, data on the impact of COVID-19 are still in its infancy. It is unclear whether the current impacts we have seen on our children and young people (e.g. on mental health and wellbeing, loss of education, lack of access to child protection, and reduced physical activity and obesity) will have long-term impact.

Early reports suggest that COVID-19 has had a significant impact on utilisation of healthcare services in the UK. The trends in utilisation both during and after the pandemic will be of interest to policy makers seeking to configure future services. Data regarding the impact of earlier SARS epidemics on healthcare provision and utilisation both during the outbreak and the period following this may help to provide a basis from which to predict alternative trends in healthcare use following the COVID-19 pandemic. Below are our findings from a brief literature search on this.

Key findings

The SARS epidemic was caused by SARS-CoV-1, first identified in November 2002 and declared contained by the WHO in July 2003. SARS affected over 8000 people from 29 different countries and 774 people died.

There are several studies describing the impact of SARS on healthcare utilisation, predominantly from Taiwan, China and Canada, which together accounted for almost 75% of cases of SARS. Analyses ranged from single centre experiences to whole countries/territories. There was only one paediatric-specific study, from the Hospital for Sick Kids ED in Toronto.

In keeping with observations during the COVID-19 pandemic, the SARS studies report significant reductions in both planned and unplanned healthcare activity. For example, Huang, Yen and Huang et al in a single-centre study in Taiwan showed a 43% reduction in ED attendance at the peak of the epidemic.[9] Similarly, in the Greater Toronto area, a further ‘hot zone’ in the SARS epidemic, Schull et al reported that overall admissions and emergency department visits fell significantly during the peak.[10] From a paediatric perspective, the study from the Hospital for Sick Children ED reported a fall in daily attendances from a baseline of around 150/day to 75/day at the peak.[11]

Although these findings during SARS are of interest, trends in healthcare activity following containment of SARS are of greater importance. The available data here is less consistent. For example, Huang et al reported that inpatient expenditure had almost returned to baseline levels by August 2003 while Schull et al reported that all-cause admission had returned to baseline by Autumn 2003, with non-urgent healthcare utilisation also returning to baseline within this time-frame. This picture was mirrored by Boutis et al in their assessment of attendances in a paediatric emergency department in a tertiary centre.

However, Chu et al showed that by 2005, outpatient visits and inpatient admissions had only reached 85% and 87% of their baseline activity by 2005, although ED attendances were no longer statistically different from the baseline year of 2002 by 2005.[12] However, this was a single centre study in a hospital that was essentially closed to all normal operations and became a designated hospital for Taipei City. Therefore, it may not be appropriate to apply these findings more widely. Additionally, Heiber et al in a single centre ED attendance study showed that although attendances by adults had returned to normal by March 2004, visits by pre-school age children remained lower than baseline.[13]

Implications

The available data showed that both unplanned and planned healthcare activity were reduced by approximately 50% at the peak of SARS. This is consistent with what has so far been observed during the COVID-19 pandemic. The limited data suggest that most activity had rebounded to baseline within 6 months of containment of SARS but had not “overshot” baseline.