England has some of the worst child health outcomes in Europe with rising obesity, uneven vaccination coverage and persistent inequalities. Added to this more than 80,000 children are waiting for over a year for their first assessment in community paediatrics. What are NHS systems doing to address these issues? Kathy Oxtoby reports
The first 1,000 days of life may be ‘universally recognised as a critical window for child development’.
However, while investment in early intervention is ‘highly cost-effective’, England continues to record ‘some of the worst child health outcomes in Europe, including rising obesity, uneven vaccination coverage and persistent inequalities’, according to a report by the Health and Social Care Committee, published this January.
The First 1000 Days: a renewed focus report looks at what action is needed to deliver the Government’s ambition of giving every child the best start in life.
It welcomes the Government’s announced expansion of the Family Hub network to one in each local authority. However, the Government ‘must go further and ensure there is access to Family Hubs in every community, backed by long-term funding’, the report says.
It calls for the Government to ‘urgently rebuild the health visiting workforce’ and for a funded plan to recruit at least 1,000 additional health visitors immediately.
The report also highlights that there are ‘stark regional and ethnic disparities’ with vaccination, and recommends reinstating the 95% coverage target in NHS planning guidance, accelerating pilots for health visitor-led vaccination delivery and ensuring Integrated care boards (ICBs) have named leads for coordinating local vaccination strategies.
The state of children’s healthcare
Children’s healthcare is at a ‘critical point’, says Rukshana Kapasi, director of health at Barnardo’s.
While the 10 year plan makes commitments to child health, and there are wider government commitments such as expanding the Family HubProgramme and mental health support teams, ‘there are crucial gaps for children’, says Ms Kapasi.
‘When we look at the health inequalities data, the evidence is quite stark. Work that we’ve done over the last three years with the Institute of Health Equity shows that children in the most deprived areas have worse outcomes across nearly every measure. This is driven by poverty, poor housing, and food insecurity,’ she says.
Across Barnardo’s 650 services ‘we see children full of potential, whose health is held back by circumstances they can’t control’, she says. ‘That’s one of the reasons why we are calling for a cross government child health action plan that brings together health, education, and social care with clear accountability and metrics for success.’
Children’s healthcare is under ‘a significant amount of pressure, and has been for a number of years’, says Dr Ronny Cheung, officer for health services at the Royal College of Paediatrics and Child Health (RCPCH). For example, there is rising demand for community paediatric services – both in neurodevelopmental assessments and also children’s developmental services – and for acute paediatric services where there is still a post Covid elective recovery backlog, he says.
The disparity between community children’s services and community adult services is ‘shocking’, he says. There are more than 80,000 children who are waiting for over a year for their first assessment in community paediatrics – that accounts for 25% of the community waiting list in children. In comparison, 1.1% of adults are waiting more than a year.
With healthcare, the focus is on ‘a growing and aging population, but as a result we’re falling behind from the children’s side’, he says.
There is also increasing demand for mental health services for children and young people, and many are not able to access the support they need, including early support, he says.
Regarding the responsibilities of ICBs and children’s health, Ms Kapasi says their role has now changed to that of strategic commissioners for their local – and now much bigger – populations.
She says the cuts to ICBs’ running costs and the wider restructuring mean ‘there’s a real risk of reducing local capacity at a time when there’s rising need’.
Dr Cheung is concerned that short term financial returns and short term need will be prioritised, ‘rather than investing in preventative child health services like health visiting or early years, where the benefits are apparent later in the life journey’.
Pockets of good practice
With children’s health in the system there are ‘pockets of good practice’, says Dr Cheung. For example, ICBs and local providers within ICBs have done ‘a lot of good work’ around Neighbourhood Health Hubs and children and young people.
In London, paediatricians and GPs have been pioneering integrated Child Health Hubs, working with commissioners locally, which have reduced hospital referrals and attendances, and improved health outcomes for children and young people, through establishing population level links between primary and secondary care, he says.
To act against health inequity, Barnardo’s established the Children and Young People’s Health Equity Collaborative, a partnership with the UCL Institute of Health Equity (IHE) in 2022.
By sponsoring this programme, Barnardo’s says it ‘sought to build evidence about practical ways for the health and care system to reduce inequalities among children and young people through action on the social determinants of health and to demonstrate the value of collaboration, bringing together charities, academics and integrated health and care systems’.
Barnardo’s led the recruitment of three Integrated Care Systems to partner with. NHS Birmingham and Solihull, NHS Cheshire and Merseyside and NHS South Yorkshire were recruited.
The programme ran from 2023 to 2025, when the findings from the evaluation of the programme were launched.
Barnardo’s says the programme provided ‘important proof of concept’ for how ICSs, the VCSE sector, and children and young people can collaborate to strengthen the focus on health equity within local systems. Its work ‘demonstrated how partnership-based and preventative approaches can improve outcomes for children and young people, particularly in areas such as mental health, wellbeing, and resilience, all of which sit within the remit of local commissioning and service design’.
Ms Kapasi highlights how under the programme, Cheshire and Merseyside ICS developed a storytelling initiative called ‘Tell Me a Story, Liverpool’, to strengthen school readiness and family literacy among teenage parents to address the growing number of children in their area experiencing language and communication issues. ‘Parents found that sharing stories and books strengthened their bond with their children,’ she says.
In partnership with dental health charity Dentaid, Barnardo’s has created a programme of work called ‘Healthy Children, Happy Smiles’, which is delivering enhanced oral health clinics that support children and families facing barriers in accessing mainstream dental services.
Areas of concern
Challenges and areas of concern within children’s health include community services, and in particular, the rising demand for neurodevelopmental assessments and diagnosis, says Dr Cheung.
With mental health, he says ‘demand continues to massively outstrip the capacity of services to manage them’.
Childhood obesity ‘continues to be a significant problem’, and oral health issues, such as dental extraction and tooth decay, are one of the most common reasons children are admitted to hospital, he says.
And vaccination rates across the country continue to decline, especially in London, he says.
Ms Kapasi says ‘inequalities for children are widespread’. ‘Families are struggling to get timely support for all sorts of areas, including autism, ADHD, obesity, and dental health, and waiting times are massively increased for children compared to adults’.
‘There are pathways across acute community and primary care that are fragmented, and there is so much variability in local provision that it leaves too many children without early help. It really is a postcode lottery.’
There are 2.7 million children and young people aged 0-25 with disabilities in the UK. Disabled children frequently have poorer health and education outcomes than their non-disabled peers, according to Kids, a national charity for disabled children, young people and their families. Demand for special educational needs and disabilities (SEND) support is growing, not just for those 2.7 million but also for those without a formal diagnosis, the charity says.
‘Too often this group of children and their needs, are an afterthought in policy-making and systemic reform,’ says Anna Collishaw-Nikodemus, head of policy, voice and influencing at Kids.
Any long-term changes to the NHS must include a plan to tackle the long waiting-lists for assessments and diagnosis and have clear milestones and timescales, says Ms Collishaw-Nikodemus.
‘Early assessment, diagnosis and intervention is widely recognised as the right course; but is not happening in practice. Children are waiting years for proper assessment and diagnosis of conditions such as autism and ADHD with disastrous, and costly, consequences,’ she says.
The Schools White Paper Every Child Achieving and Thriving, published this February, could ‘transform childhood for disabled children and their families by giving every child the chance to go to a school where they can learn, make friends and achieve their potential’, says Katie Ghose, chief executive of Kids.
The charity welcomes the investment across all ages and stages of education – early years, schools and post‑16 – ‘a crucial signal that real SEND reform must be about investing upfront, not cutting costs’.
She says the charity will ‘continue to press for credible workforce plans, strong joint accountability across education, health and care, and firm safeguards to ensure children are properly supported, included, and have their rights respected in practice’.
‘Children’s health must be a national priority’
Overall, despite the ‘huge efforts’ of those working in child health, workforce and resource issues and rising demand mean ‘we are failing our children and young people’, says Dr Cheung.
While there is much that ICBs are doing well in children’s health, ‘more needs to be done’, says Ms Kapasi.
‘Children’s health must be a national priority. It must be a system priority. It can’t be an afterthought. And ICBs need to be held to account on this.’
Dr Cheung would like to see oversights and accountability at ICB level for funding and delivery of services for children and young people within their footprints.
He says it is crucial that ICBs make it a priority to reduce long waits for children and young people.
Taking a system wide approach, it is important forICBs to work with schools and local authorities to consider how children and young people are supported in a wider context, such as healthy eating, oral health and supporting children and young people with neurodevelopmental problems, he says.
There should be a children’s investment standard to safeguard spending on children’s health, including on prevention in the NHS, he says.
Dr Cheung also asks for parity with adult services – the provision of services for children and young people, should be ‘no more and no less than what should be available to adults’.
ICBs need ‘named leadership for children and young people, accountability, and decisions that are tested against the impact they have on children’, says Ms Kapasi.
‘Prevention and early intervention need to be properly funded and protected. And children and young people must have a genuine voice in decision making.’
ICBs should ‘strengthen the partnerships with the voluntary and community sector, recognising the unique role that organisations like Barnardo’s can play in reaching families early, building trust and supporting children before problems escalate’, she says. ‘Integrated care can only really work when those partnerships are properly valued and resourced.
‘We need sustained investment, a relentless focus on tackling inequalities, and to make the right choices around protecting early intervention and designing services around the most disadvantaged. If we don’t do that, the long term cost for children, for families, the system, and the economy will be far greater.’
With children’s health ‘we are at a crossroads’, says Ms Kapasi. ‘There’s a huge amount of opportunity too, and initiatives like the Children and Young People’s Health Equity Collaborative demonstrate that when systems focus on equity, get the right partnerships, listen to children, and work with communities, outcomes can improve,’ she says.
‘We all recognise the system is under enormous strain. But with proper investment, and strong partnerships between the NHS, communities and the voluntary sector, we can reverse some of these trends that we’re seeing in the health inequality statistics, to build the healthiest generation.’
