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Starting young

Child health determines the health of the nation – and its prosperity. Preventing ill-health from an early age should therefore be the key focus for government, argues Neena Modi.

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Insight

Child health in the UK today is not as good as it should be. A fifth of five-year-olds and a third of 10-year-olds are overweight or obese, for example. One in three five-year-old children have dental caries, an entirely preventable condition, and admissions and deaths for asthma are higher than in many comparable European countries. 

Child health is not just important for children. Child health is also a powerful determinant of adult health, population health and national prosperity. For example, the majority of overweight and obese children will remain so in adult life. Obesity will shorten their lifespans and lead to the loss of between 15 and 20 years of healthy adult life. Their risks of developing type 2 diabetes, hypertension, and heart disease will be increased. They will add to the growing prevalence of chronic, non-communicable diseases that are crippling economies and health systems worldwide, and that has led, for the first time in history, to a reduction in America, over the last two consecutive years, of the life span of adults.  

The NHS and child health 

In all too many parts of the world today, and in the UK prior to 1948, healthcare was built around insurance, out-of-pocket payments, and charity. Children, particularly the children of the unemployed or poor, fared worst of all. The coming of the NHS brought an incalculable change; since its inception, no parent in Britain has had to live with the fear of not being able to afford healthcare for a sick child.  

The NHS is a powerful concept – healthcare for all, free at the point of need, funded through general taxation, available to all according to need, not ability to pay. It is magnificent in its simplicity, humanity, and wisdom. Beveridge’s aspiration was for ’a national health service for prevention and comprehensive treatment‘, but in the 1948 articulation of the NHS, the focus was predominantly on healthcare, not health, with the assumption that the predominant determinant of the latter is the former. Today, 70 years later, science shows clearly the extent to which health is the product of far more than healthcare.  

What determines health? 

Our health trajectories are initiated early, starting when our parent’s sperm and eggs are formed, then progressively influenced by the intrauterine environment, the postnatal environment and exposures in childhood and adult life. Injuries and accidents apart, health is the result of external factors interacting with our genes to determine how the messages they hold are translated. We have control over some, but not all, of these factors. 

Child health is influenced by conditions in early development and in turn influences health in adult life. Our health as adults, affects the health of our children. If your mother, and

possibly your father, were overweight, or malnourished, your risk of developing diabetes in adult life is substantially increased. If your mother smoked during pregnancy, you are at greater risk of chronic respiratory disease in old age, even though you seemed well in early adult life. And if as you grow older, you eat too much, live a sedentary life, and are exposed to air pollution or environmental toxins, further risks are added to a trajectory that leads to poor health in old age.   

Advocacy for child health 

Advocacy for child health has traditionally focused upon the moral case, though there is a very powerful scientific and economic case as well. Why then isn’t there a greater drive to improve child health? Is it because advocacy on behalf of children has been insufficiently persuasive? Is it because the wider long-term benefits to the nation are insufficiently understood?  Is it that treatment not prevention is the predominant driver of healthcare systems in the UK and around the world?  Is it that political ability to define the actions that are needed, and the will to implement change are lacking? Or is it that children have no vote and no voice and therefore their perspectives remain unheard by governments and outweighed by mighty corporations?   

Dangers for child health ahead  

Although a primarily publicly funded, delivered, and accountable healthcare system is the most effective means of reducing both healthcare costs and demand, we are witnessing the introduction in the UK of an ideology which is  particularly damaging to children. In this ideology, health is a matter of personal choice and healthcare is a commodity where activity and profit – not health – are the metrics of success. Here, it is argued, if an adult chooses to smoke and as a consequence gets cancer, let him pay for treatment, just as he pays for housing, food and clothing. Even if he didn’t smoke and the cancer was no fault of his, he should have the sense to insure himself against such misfortune, rather than expecting the bill to be picked up by the taxpayer.  

Children cannot exercise personal choice, and further, they stand to benefit the most from preventive measures. The view that there is benefit in treating healthcare as a commodity is particularly damaging to children because prevention can’t readily be bought and sold, unlike treatments. Thus in a marketised model, industries that thrive on ill health are promoted, be they insurers, for-profit providers, or the manufacturers of diagnostics and pharmaceuticals. Additionally, when health is considered primarily a matter of personal choice, industries that cause poor health also prosper. The long drawn-out battles to curb the powers of the tobacco, alcohol and junk food industries are cases in point. Health gains have been delayed with unquantifiable damage to children – and ultimately to the adult population – by superficial arguments that these industries boost the economy, raise tax revenues, and create jobs.  

Proponents of a marketised model argue that care for needy children can be provided by charity, as with the large US children’s hospitals, or by a supposedly benevolent state that picks up on payments. However, a need for charity is a cardinal expression of inequity in society, and state provision of healthcare for children is no redress against poor preventive health policies.   

The current system 

The current NHS doesn’t have responsibility for health, only for shouldering the consequences. The NHS can deal with illness and injury, but whose responsibility is it to address the early developmental and wider societal conditions that lead to ill-health or disease? Take the example of smoking, unequivocally shown to be bad for the health of those who smoke, their children, and those around them. Public information and education campaigns sustained over several decades made insufficient impact on reducing smoking prevalence. The measures that worked were the ban on public smoking (a public health measure), plain packaging (a regulatory measure), and increased taxation (a fiscal measure). Sadly, no cabinet minister today has responsibility for ensuring that national policies do not adversely impact upon health. Additionally, public health budgets are devolved to local authorities, an unnecessary abrogation of central responsibility given that the UK is a small country with relatively homogenous conditions and populations. Devolving responsibility for public health, with a repetitive review of evidence by each local authority, and decision-making criteria that differ around the country, is wasteful and inefficient. It is not surprising that the result is a postcode lottery where what is delivered comes down to the luck of the draw. The population would be far better served if evidence were reviewed and decisions made centrally and policies were applied consistently. 

The current discourse about the NHS scratches the surface, and does not get to the root cause of the prevailing malaise. The NHS as a cohesive entity no longer exists. The current UK healthcare system is fragmented – across the four nations, within England, and between public health, primary care, hospital and community services. Responsibility for training healthcare professionals is divorced from responsibility for provision of care and from immigration rulings regarding overseas staff. It is increasingly inefficient, as a confusing mix of public sector, private, and social enterprise providers are awarded public funds to deliver to contract, not to deliver health. It is unclear where responsibility now lies, as evidenced by the extraordinary spectacle of the non-elected chief executive of NHS England calling for more funding while government dissociates itself from responsibility.  

Wilfully or out of ignorance, as all evidence points to the contrary, false mantras are being promulgated, that universal healthcare is unaffordable and that a dominant private sector can deliver more efficiently than the public sector. The costs of healthcare are exorbitant only in inefficient systems. The NHS is the most cost-effective healthcare system that has ever existed and the UK pioneered the underpinning principles of the National Institute for Health and Care Excellence (NICE), namely fair cost containment based upon evidence. An exclusively or predominantly private system, in which a patient buys (directly or indirectly) and a doctor (or healthcare provider organisation) sells, or a system that is publicly funded but not publicly delivered as is increasingly the case in England, is multiply damaging. Administrative costs and  charges upon the taxpayer are increased. Perverse incentives are introduced and trust between doctor and patient is compromised. When money is the driving force for healthcare, everyone suffers; the poor from lack of care, the rich from over-investigation and anxiety, and preventive health takes second place.  

better future 

More funding for UK health services is certainly needed, but in large part, this is a distraction. So too is the endless reworking of so-called models of care. UK healthcare – for which read the NHS – needs to be brought conceptually into 21st century thinking.  

In a better system, health would be the desired outcome, not healthcare. Preventive health, focusing on early development and childhood, would be a cardinal focus. There would be clear understanding of the implications of the science of the early developmental origins and wider determinants of health and disease. These insights would be translated into policies underpinned by recognition of the national benefit that would result from adopting “life-course” and “health in all policies” approaches to health. The life-course approach would be operationalised by bringing public and preventive health together with primary, acute and long-term care, under the banner of the NHS. A “health in all policies” approach would mean that the health impact of policies would be a prime consideration for their adoption. The increasingly and unnecessarily fragmented funding and provider structure would be replaced with a system that is predominantly publicly delivered, integrated, and evaluated against nationally consistent criteria relevant to health, not to process, activity or profit. Private sector involvement in healthcare would be limited. Equitable cost containment methodologies would be improved, and coupled with fair assessment of what the nation could afford. Cabinet level responsibility and accountability for the quality and availability of healthcare would be reintroduced. The healthcare workforce would be valued and sustained, withan expansion in numbers, the return of nationally consistent terms and conditions, and a secure pension. And lowering the voting age, and possibly too, issuing parents with a proxy vote for each underage child would focus political minds upon policies that benefit children. 

Such change would no doubt be fiercely contested, just as was the introduction of the NHS. The country needs a Nye Bevan of the 21st century, a politician who understands that enriching the founding principles of the NHS with insights from science offers the opportunity to leave a lasting positive legacy for the nation, and who has the commitment and ability to carry through such visionary change.

Neena Modi

Neena Modi is professor of neonatal medicine at Imperial College London and immediate past-president of the Royal College of Paediatrics and Child Health.

@neenamodi1

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