Improving child health – whole society or individual approaches?

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The whole society approach: Making a giant leap on childhood health (August 2020) by the IPPR starts with an historical analysis of two giant leaps in health outcomes during the 20^th century (reducing infant mortality and treating acute diseases) which led to continuous increases in life expectancy. These were both whole society focused drives led by central government with social responsibility and the pursuit of profit not regarded as incompatible.

IPPR suggest that current reductions in life expectancy and years spent free of disease for some living in deprived communities signals a potential end to this cycle of continuous improvement. According to the paper, the defining health challenge is now “chronic, long-term conditions, such as cancer, diabetes, dementia, heart disease or mental ill health”, requiring “a radical shift to prevention”. Because early intervention is the most cost-effective, IPPR suggest childhood health should be at the forefront of health policy.

The paper suggests there are two main starting points which are mutually reinforcing:

Childhood obesity, (1 in 10 children are obese by the time they begin primary school, and 22 cent of boys and 18 per cent of girls entering secondary school are obese) is linked to substantial threats to health and wellbeing throughout life and has an adverse effect on “children’s physical health, social, and emotional well-being, and self-esteem”.
Mental Health Needs (increasingly common in children and persisting into adulthood) can adversely impact on “learning, school attendance, physical health”. Many children do not get the treatment they need, and those that do often experience long waiting times. Mental health conditions are associated with other risk factors such as tobacco and alcohol use, and poor diet, putting people at risk of further long-term conditions.

IPPR make the case that the “time for action is now” as Covid-19 is contributing to a further worsening of child health outcomes through (i) a decrease in physical activity and access to open space; (ii) access to “diverse and nutritious diets” has worsened for some; and (iii) social interactions and opportunities for support outside the family home have been reduced. Childhood obesity has also been identified as a risk factor for Covid-19.

Defining a strategy on Childhood Health

The report suggests that strategy should focus on the risks that children face that are likely to impair their health outcomes. These include:

Personalised advertisements focused on children which have intensified the “influence and persuasiveness of advertising campaigns”;
Social media which impacts on young people’s mental health in a number of ways;
Applied behavioural science in the form of product placement has a significant impact on behaviour and leads to the development of consumer culture which can inhibit children from pursuing healthy choices;
Traumatic and adverse experiences in childhood (neglect, abuse, exclusion, divorce or incarceration) are on the rise.

For IPPR these risks and challenges have grown and evolved over the past decade at the same time as wider austerity has impacted on preventative services, education and poverty rates, as highlighted in the Marmot report earlier in 2020 (see Related Briefings).

Shifting from Personal to Collective Responsibility

The report says that the current stress on personal responsibility underpins significant health injustices across the UK. Risks fall on those whose capacity to make healthy choices is inhibited by their social and economic circumstances – with children, particularly those in vulnerable circumstances, the most “exposed to health threats they have little control to prevent”. IPPR argue that a stronger approach to public and childhood health would help to prevent the kind of outcomes we are seeing with Covid-19 which has exposed the variations in risk across Britain’s communities.

For IPPR “inequality on this level cannot be down to poor choices or consumer preference alone”. They suggest that governments should more actively manage the level of external and environmental health risks that people face, including focusing on “how marginalised groups are systematically and disproportionately exposed to those risks”. They argue that “reasonable intervention on the basis of health has always been a part of a free society” and a government focused on ensuring personal liberty can still recognise the environments within which individuals make decisions.

They suggest that the government’s new approach to childhood obesity in 2020 marks “a shift from a ‘blame and punish’ paradigm, focused on personal responsibility and individual action, to a more empathetic engagement with the environment people live in”. IPPR suggest the approach needs pushing further and extending to childhood health as a whole.

The economic opportunities for bold action

IPPR finds that childhood health is important for social justice, NHS finances and national health outcomes. Good health in childhood is a prerequisite for social justice, as health inequities are avoidable, but a healthier population also provides opportunities to improve the national economy. They suggest there is a health dividend for business as a stronger economy can result in improvements to labour supply, productivity, household wealth and earnings.

Their analysis calculates that current levels of obesity will generate up to £74 billion in NHS costs and £405 billion for wider society through lost productivity and sickness over the course of the lifetime of the current cohort of schoolchildren, giving a total of almost £480 billion for a single cohort. Including future cohorts will make their estimates higher still.

The cost benefits of the current government target of reducing obesity by half, on this analysis, look enormous. IPPR suggest that setting a ceiling of 10 per cent on childhood obesity rates across all ages would be a better target, as it would (i) target more appropriately areas where child obesity is especially prevalent and (ii) address social justice and help reduce regional health inequalities. They estimate a further £12 billion of NHS savings on the current target of halving child obesity, and an additional £68 billion of wider savings. The potential gain from targeting and addressing 10% of the mental health burden among children today could generate cumulative savings of £37 billion for the NHS and £116 billion for wider society by 2040, if it led to a subsequent decrease in the adult mental health burden. Meeting IPPR targets on obesity and mental health could result in significant reductions in ill health for workers and 129,000 and 1.8 million days of additional National Insurance contributions each year, respectively,

As the costs of these childhood health issues fall to a greater extent on deprived areas, addressing them is also about delivering on the current government’s pledge to ‘level-up’ the country – that is, to provide people with more equal opportunity, regardless of where they live.

A ‘whole society approach’

IPPR think that the targets they suggest will only be achieved with boldness and a “move even further towards a collectivist approach” that is called a ‘whole society approach’. The core principle is action should be taken together across different settings, institutions and actors, including individuals, businesses, the NHS, schools, local authorities and national government. Funding, powers or regulation should come from the centre, but delivery and action be in other places. In their view collaboration is crucial to a giant leap forward in health, the effects of which would be felt over the next 100 years.

Key features of an IPPR proposed strategy include:

Asking digital giants to pay for the mental health costs of their platforms, using the ‘polluter pays’ principle. They cite evidence of cyber bullying, negative “psychosocial outcomes”, social isolation, and intensified peer pressure. Obesity can also be driven by social media through the development of unhealthy coping mechanisms, and “increased energy intake while promoting a sedentary lifestyle”. Online product placement through influencers is part of this.

IPPR suggest “there has been a suspicion that social media companies are not working towards the common good”, but given they generate large profits thanks to their younger users, social media companies should be expected to contribute to services that can support children online. The current levy on internet companies should be doubled to ensure that the level of taxation is proportionate to turnover and social harm. This policy should be pursued in combination with wider digital reforms. IPPR want to see movement towards their concept of public responsibility for what they term a “digital commons”.

Use fiscal incentives to drive reformulation of food and drinks beyond the current sugar beverages levy through a ‘non-essential food levy’. This is needed as the “ready availability of calorie dense foods” has played a role in rising child obesity. Increasing deprivation resulting from the Covid-19 pandemic or Brexit arrangements can drive a further increase in uptake of such foods. They suggest that fiscal policies work. The sugary drinks levy, for example, led to soft drink companies decreasing sugar content. IPPR recommend a similar approach to that used in Hungary with a tax applied on a wide range of pre-packaged products, beverages, snacks, and confectionary. This should be backed up with wider work in schools to address food poverty and begin to break the deprivation/obesity link.

Fund a healthy food incentive scheme using tax revenue from the non-essential food levy would provide financial incentives for people as well as business. Using ideas put forward in New Zealand, as part of a ‘Healthy Schools’ scheme, vouchers should be available to all children receiving school meals (as an additional element), that could be used for anything not covered by the ‘non-essential food’ tax highlighted above. The value of the vouchers should be over £20.00 a week, and it would also encourage businesses to change through competing for the additional revenue.

Build greater health capacity in schools as schools are integral to (i) ensuring children have the skills and knowledge to lead healthier lives, and (ii) identifying children in need and providing them with support in a nurturing environment. Additional funding is needed to address a considerable drop in the school-based health workforce in recent years, and legislation is needed to guarantee a ratio of one school nurse or qualified professional for every 600 students.

In support of this the public health budget should be increased by a minimum of £850 million to deliver preventative services, in addition to any extra funding which has been provided to cope with the Covid-19 crisis. Budgets for the most deprived communities should be the first priority. The paper recommends that the budget for public health should continue to rise by 3.4%, in line with NHS spending increase, for the next five years enabling spending on child health programmes and obesity services to get back to the previous levels. IPPR also suggest that the impact of the ‘fair funding review’ of local authority budgets should be reversed as the relationships between spending and levels of deprivation (as measured by the index of multiple deprivation) “has become weaker”.

More health visits can have a positive impact on health outcomes for young children and their families. The 5 mandated health visits for a new-born child in England should increase to 7 before a child is 5 year’s old for those (i) born into poverty, (ii) who live in temporary accommodation or (iii) whose parents face acute social and economic difficulties. In addition, they recommend that during the perinatal period, the mother should receive two visits to help prepare for the birth and to identify any areas in which additional health support would be necessary.

There should be a significant expansion of social prescribing beyond ‘social activities to help people keep fit’. They suggest a joint working group from National Institute for Health and Care Excellence (NICE) and the replacement for Public Health England should be tasked with establishing the evidence of how effective social interventions on childhood obesity and mental health are. Their review should include considering new technology, digital tools and apps, peer support (both individual and group), exercise, food subsidies, education and skill building programmes and professional coaching. Where interventions are cost-effective they should be guaranteed for patients. Social prescribing should include a range of activities including “arts activities, group learning, gardening, cookery, healthy eating advice” and a whole host of other community-based initiatives, as emerging evidence suggests there are potential benefits for health and wellbeing.

Online Harms was the subject of a white paper published in April 2019 which has not been implemented. IPPR would like to see this acted upon, and they recommend it should include an online harms regulator whose powers should include (i) Fines for bullying, child abuse, terrorism, and fake news (France recently implemented fines for hate speech), (ii) the capacity and workforce necessary to keep up with the changing practices and growing size of the digital sector; (iii) allowing ‘super complaints’ from designated bodies (which could include mental health charities) as is already allowed in the Enterprise Act 2002, (iii) a code of conduct for senior managers, making those who commit acts of gross negligence, or work to intentionally cause harm, legally liable, (iv) a legally enforceable duty of care which asks digital platforms to identify and act on ‘reasonably foreseeable risks’, including mental health risks, and (v) data sharing by social media companies should be compulsory, so that children can be protected as the sector evolves.

Place-based protections are needed as reducing the prevalence of fast food restaurants and create healthier alternatives in deprived communities is integral to promoting healthier lifestyles. The poorest areas in England are often “fast food hotspots” with fast food outlets often sited near schools and colleges. Local authorities should look to ensure that there are no fast food restaurants within a mile radius of local schools, with local authorities compensated for lost revenue when they use their powers to limit the opening of fast food outlets.

Comment

This section explores two themes; whether wider evidence supports the IPPR analysis, and what would the impact of such proposals be on local authorities, schools and public services be?

Wider evidence

A brief review of publications in medical journals support’s the IPPR thesis that the Covid-19 pandemic may be making existing health inequalities worse. Mitigating the wider health effects of covid-19 pandemic response in the British Medical Journal suggests that “in addition to the direct disease burden from covid-19, the pandemic response is already causing negative indirect effects … these are borne disproportionately by people who already have fewer resources and poorer health. Prolonged or more restrictive social distancing measures could increase health inequalities in the short and long term”.

An opinion piece Covid-19: Mental health services must be boosted to deal with “tsunami” of cases after lockdown published in the same Journal quotes a survey by the Royal College of Psychiatrists that found that 43% of members were seeing an increase in urgent and emergency cases, including patients who had suicidal thoughts or were self-harming. At the same time, 45% reported a fall in routine appointments. Wendy Burn president of the Royal College of Psychiatrists, said, “We are already seeing the devastating impact of Covid-19 on mental health with more people in crisis. But we are just as worried about the people who need help now but aren’t getting it. Our fear is that the lockdown is storing up problems which could then lead to a tsunami of referrals”.

Fears grow of nutritional crisis in lockdown UK published in late August 2020 backs up the IPPR contention that obesity, mental health, and economic security are intrinsically linked saying that the “Covid-19 pandemic has exacerbated nutritional problems associated with food insecurity. These include obesity, undernourishment, nutrient deficiencies, and mental health problems such as anxiety, low self-worth, and depression. … there are signs that many families have experienced profound changes to their diets, which are known to be associated with effects on health”.

The Good Childhood Report 2020 from the Children’s Society suggests that the well-being of children and young people in the UK has been deteriorating slowly for at least a decade, and was amongst the lowest in comparable European countries before the Covid-19 Pandemic. They make two points of particular significance to the issues raised in the IPPR report. The first is that well-being is not just dropping overall but appears to be dropping fastest amongst the most deprived. The second point relates to the role of the family as the most important support mechanism for most young people; yet the medical journal articles quoted above suggest that the pandemic will have put the most disadvantaged families under increased pressure.

From Unnoticed to Invisible: The Impact of COVID‐19 on Children and Young People Experiencing Domestic Violence and Abuse published by the Association of Child Protection Professionals explores further some of the pressures experienced in vulnerable families during the Covid-19 health measures, which “saw a 25 per cent increase in calls to the National Domestic Abuse Helpline” and increased demand on Domestic Violence and Abuse (DVA) services. However, an increase in referrals to local specialist DVA services was expected but did not materialise for children and young people. Vulnerable children consistently say that school is one of the only safe spaces they have. With schools being closed children and young people living in difficult family contexts are being overlooked as victims of DVA, whilst the focus is on the parent/carer who is seen as the primary victim.

Challenges and issues from IPPR paper for local services

The whole society approach: Making a giant leap on childhood health from the IPPR is immediately important at a local level in the evidence it provides for the losses suffered by local councils, public health and preventative services during the period of austerity. It also provides some startling estimates of the future cost benefits of preventative work now that may be helpful in budget debates. Its first effect is likely to be pushing preventative childhood medical services up the agenda at both national and local levels. Local level review of the effectiveness of these services and how they tie into other local services may well be an important starting point. For example, the report could provide a trigger for reviewing the longstanding resource and referral issues related to children’s mental health services. The effective implementation of the government’s new obesity strategy may also be a pre-requisite for arguing for further expansion and development.

The second challenge laid down by the paper is its focus on a cohesive ‘whole society’ approach that links individuals, public services, business and government. The important role and function of schools in identifying and referring to public agencies comes out strongly from the report and the experience of the Covid-19 pandemic. But the report is suggesting we can push beyond this to programmes such as a ‘healthy schools’ programme that links wider support, campaigning and regulation. Whilst national funding and support are important, there may be steps that can be taken locally which will help develop both a cohesive pandemic strategy and address further prevention through childhood health programmes.

The National Audit Office report Childhood obesity (September 2020) reports on five case study visits to local authorities showing how linking childhood obesity to other initiatives is being achieved.

The third point in relation to the IPPR paper is how it is located within a prevailing international debate that is questioning the balance between individual and collective actions. This is illustrated well by a joint US – French academic webinar entitled ‘Turning Points’ which asks “are widening inequalities and the wealth gap at a turning point?”. The conjunction of a global health pandemic with economic and political events is raising the core issue of health inequalities globally – but within a context of also asking if political and economic policies focused on the individual and personalisation are increasingly being questioned following the Covid-19 pandemic. A previous briefing on a ‘child’s rights’ approach: how one question can help councils plan fairer and healthier futures is also illustrative of re-focusing policy on collective issues.