Hilary Cass’s research while affiliated with Royal College of Paediatrics and Child Health and other places

The prime minister’s commitment to “fighting against the burning injustice that if you’re born poor, you will die on average nine years earlier than others”1 is welcome and achievable. As her government has acknowledged,2 half of this difference in life expectancy is due to the higher rates of smoking among the least affluent, so major improvements can …

There is growing concern that the UK is not performing as well as it should in securing and promoting health for children and young people.1 The reasons behind the UK's child health problems are complex, including socioeconomic conditions and other upstream determinants of health, and health systems and healthcare factors, as shown in figure 1. A comprehensive strategy to improve UK child health should therefore include action across all the domains and determinants of health. Integrated care is about joining things up in order to meet health needs, and in ways that make sense to children and families. Therefore, it should make an important contribution towards improving child health. Although this hypothesis is plausible, and is the basis of a great deal of policy, evidence is still indirect and limited. A concerted effort towards improving healthcare and child health must be supported by a strong drive to improve children's health services and systems research. Figure 1 Determinants of child health. Currently there is a mismatch between health needs, which are increasingly about chronic conditions (physical and mental), and the health system that exists to meet health needs. Problems in healthcare partly explain the mismatch. Services are still largely centred around urgent care, but despite the focus on these services quality is variable and sometimes poor, and demand continues to rise.2 ,3 Planned care for children with long-term conditions often takes second place, and management of children with long-term conditions is suboptimal, leading to reduced quality of life and increased costs as these young people move into adulthood. Furthermore, workforce data suggest that our model of healthcare for children is not sustainable, but more importantly it is not fit for purpose in terms of outcomes.4 The resultant combination of poor health, suboptimal care outcomes and inefficient services is …

The purpose of the study was to determine the proportion of pediatric deaths investigated by HM Coronial autopsy which were potentially preventable deaths due to treatable natural disease, and what implications such findings may have for health policies to reduce their occurrence. A retrospective study of 1779 autopsies of individuals between 7 days and 14 years of age requested by HM Coroner, taking place in one specialist pediatric autopsy center, was undertaken. Cases were included if they involved a definite natural disease process in which appropriate recognition and treatment was likely to have affected their outcome. Strict criteria were used and cases were excluded where the individual had any longstanding condition which might have predisposed them to, or altered the recognition of, acute illness, or its response to therapy. Almost 8 % (134/1779) of the study group were potentially preventable deaths as a result of natural disease, the majority occurring in children younger than 2 years of age. Most individuals reported between 1 and 7 days of symptoms before their death, and the majority had sought medical advice during this period, including from general practitioners within working hours, and hospital emergency departments. Of those who had sought medical attention, around one-third had done so more than once (28 %, 15/53). Sepsis and pneumonia accounted for the majority of deaths (46 and 34 % respectively), with all infections (sepsis, pneumonia and meningitis) accounting for 110/134 (82 %). Around 10 % of pediatric deaths referred to HM Coroner are potentially preventable, being the result of treatable natural acute illnesses. In many cases medical advice had been sought during the final illness. The results highlight how a review of autopsy data can identify significant findings with the potential to reduce mortality, and the importance of centralized investigation and reporting of pediatric deaths.

The development of a United Nations sponsored Millennium Development Goal (MDG) relating to childhood survival contributed significantly to reducing mortality among children under 5 years old in many countries in the first years of the twenty-first century.1 The development of an independent authoritative mechanism, the Countdown to 2015 Collaboration contributed significantly to global progress towards the goals. While childhood mortality in the UK has also decreased over the past 40 years, the UK's child mortality trends and excess deaths figures compare unfavourably with many European countries.1 ,2 It is increasingly clear that the UK could do better in ensuring the best possible conditions for children to survive and thrive. Several recent publications have highlighted the extent of the problem, and stimulated responses from government and non-governmental sectors.3-7 We propose now that an independent cross-sector mechanism be set up to agree targets for reduction of UK excess child and adolescent mortality, identify gaps in knowledge, monitor progress in reaching goals and make recommendations that contribute towards improving UK child survival. In this paper, we first review the UK's performance on child and adolescent mortality compared with other wealthy countries in order to establish a baseline for future monitoring. We examine why the UK has higher child and adolescent mortality compared with some other European countries, by describing main causes and social determinants of death. Finally we explore what can be done to reduce mortality, and make recommendations to improve UK child and adolescent survival. Trends in UK and European child mortality We used data from the Organisation for Economic Cooperation and Development (OECD) for infant mortality8 and the WHO World Mortality Database for 1-19-year-olds9 to calculate centiles of child and adolescent mortality for a group of comparable wealthy countries identified as appropriate comparators for UK mortality.1 ,10 These countries are the …

More than half a million children have taken up smoking since the government first announced it would consult on plain standardised packaging of cigarette packs in 2011,1 2 and every day hundreds more join them.3 After a strongly supportive government commissioned independent review of the evidence,4 the public health minister said she wanted to introduce the necessary regulations …

> Trust your hunches. They’re usually based on facts filed away just below the conscious level. > James Joyce (1882–1941) Child protection is one of the most challenging aspects of paediatric practice. The consequences of missing a case of serious abuse are self-evident, with one child dying every week as a result of deliberately inflicted injury, abuse or neglect; indeed recently released data identified this as the single largest category of childhood deaths with modifiable factors in England.1 Clinicians working in this field need the most sophisticated diagnostic, communication and team working skills and great personal resilience to deal with the emotional demands of the work. Despite this, the role has often been undervalued and poorly supported, with some viewing it as a ‘Cinderella specialty’. The stress on clinicians has also been exacerbated by high-profile media cases in which paediatricians have been vilified in the press, both for missing diagnoses and conversely for making positive diagnoses which have subsequently been overturned in court. From a public perception, there is a view that medicine is based on a robust body of evidence, with little tolerance for error, or understanding of the fact that diagnosis is actually the art of making a best estimate based on probabilities. This is particularly the case for child protection, in which the evidence base has been slow to emerge and forms only part of the picture. Hence, diagnosis is dependent on the trigger of an initial index of suspicion, supported by a mix of corroborative detail, experience, triangulation, monitoring, review and above all the highest level of multiagency communication and cooperation. Fortunately, there is a slow but steady change in status and perception of the specialty, in large part due to clearer guidance and better multiprofessional working. Alongside this, the gradual emergence of a more robust evidence …

The coalition government’s Health and Social Care Bill is unlikely to deliver the improvements in children’s health services that are urgently needed. Useful lessons can be learnt from how other European countries deliver healthcare for children, say Ingrid Wolfe and colleagues