Written evidence submitted by the Royal College of Paediatrics and Child Health
The Royal College of Paediatrics and Child Health (RCPCH) is responsible for training and examining paediatricians, setting professional standards and informing research and policy. RCPCH has over 19,000 members in the UK and internationally. We work to transform child health through knowledge, research and expertise, to improve the health and wellbeing of infants, children and young people across the world.
RCPCH is carefully monitoring the risks and impacts of COVID-19 on children and young people, our members and the wider child health workforce. We have produced guidance for our members on paediatric services, staffing and rotas, and education and training. We have also produced advice for parents. We are currently collecting data on the impact of COVID-19 on child health services, to assist future planning of services.
We have recently published a statement on schools re-opening.
Children and young people are generally less seriously affected by COVID-19 than adults in direct terms, but they are more at risk from the negative longer-term consequences of the current pandemic.
Whilst it is fortunate that children are not as severely affected by COVID-19 as adults, we recognised quickly that children and young people became ‘collateral damage’ from the crisis. This risk is escalated due to the impact the reduction of public health services have on children and young people’s health. Some of these are delivered through schools, and so have not been taking place for the previous few months.
Necessity has meant we have had to reconfigure and pause child health services, and redeploy child health professionals to adult services as part of the NHS’ overall response to the pandemic. With regard to schools and children’s services, managing the pandemic has seen schools close to the majority of pupils. As a consequence, we are storing up health problems for our children and young people that may have significant impacts on their lives, and increase pressure on services in the future. In many areas, local authorities have needed to pause the delivery of children’s and public health services to allow them to focus on responding to urgent need in the context of a pandemic.
Schools play a significant role in the health and wellbeing of all children and young people, and a pivotal role in identifying vulnerable children, providing the setting from which children can access health surveillance, support and advice, as well as individual and group therapeutic programmes. Widespread school closure has reduced children and young people’s access to these health benefits, and also allowed vulnerable children to slip under the radar.
The Government must work with local authorities, NHS bodies and other organisations to reduce the impact of children becoming the ‘collateral damage’ of the COVID-19 pandemic. This includes providing long-term funding to ensure community services can effectively address the impacts of COVID-19, and work to stop the pandemic entrenching existing health inequalities. RCPCH considers that a multi-departmental children and young people’s health strategy will see this achieved.
1. Health benefits of school for children and young people
Schools play a key role in promoting children and young people’s health, social and mental wellbeing. They also provide the setting from which children can access health surveillance, support and advice as well as individual and group therapeutic programmes. These may include:
2.1 Impact of distancing measures on children and young people
Social distancing measures have adverse effects and are disproportionately affecting children, who are likely to experience milder symptoms compared to adults if they contract COVID-19. Schools and early years services support the social, educational and emotional development of children and young people. The widespread closure of schools and early years services means children and young people have less contact with their friends, teachers and those outside their immediate household. In addition, there has been an increase in family stress for households facing additional financial pressures as a result of the pandemic. This has a significant impact on their health and wellbeing in the short, medium and long term. RCPCH has produced guiding principles for paediatricians and those influential in safeguarding partnerships, along with practical suggestions to help them safeguard the welfare of children in the current environment.
2.2 Defining vulnerable children and young people
There are three key groups of vulnerable children – those who have been identified and referred to services, those who have not been identified, and those for whom vulnerability could be triggered as a result of not being at school.
2.3 Vulnerable children and young people known to children’s services
This group includes those in Local Authority care, care leavers, on Child Protection/Child in Need Plans, and those who have Education, Health and Care Plans, and Statements of Special Educational Needs. They are already living in families identified as requiring additional support and are known to local authority services.
This group are now at a much higher risk of harm because of the increased level of stress in families, their reduced access to normal support services and the significantly reduced amount of professional and community oversight.
Schools remained open to those identified as vulnerable, however we know that most of these children are not taking up their school places.
The majority of initial and review health assessments for looked after children (LAC) are currently being performed remotely. This group of children are additionally most likely to have the increased health needs already identified for all children and young people. Similar processes are in place for adoption medical assessments and SEN health assessments.
There has been increased risk of foster care placement breakdowns, and delays in moving young people in and out of semi-independent placements and changing foster placements. Care leavers and those in semi-independent placements are having to manage without as much support from social services.
2.4 Children and young people not yet referred to children’s services
There is a group of children and young people who are vulnerable to abuse and/or neglect, but are invisible to children’s services. Schools and school staff play a vital role in identifying and referring these children to statutory services. With schools closed to the majority of pupils, the children are now more vulnerable and there are very limited opportunities for early recognition and intervention.
Despite the increased stress in families and reduced resources and support for families, there appear to be both reduced numbers of referrals to police and children’s social care, as well as referrals for Child Protection Medical assessments.
2.5 Children and young people who have become vulnerable as a result of not being at school
For children and young people without a medical or known social vulnerability, not being at school could trigger a vulnerability because the loss of opportunities for school staff to identify concerns, and access initiatives to boost their wellbeing and the sources of support that have previously been available to them have been removed. This is exacerbated by the financial repercussions of the pandemic. One possibility is that increased numbers of children and young people with emotional health and wellbeing issues refuse to go back to school when they reopen, because of time away from a more social environment. This could become a child protection issue if parents are unable or unwilling to convince them to attend after a number of days or weeks.
3. Health challenges of children and young people in the context of COVID-19
3.1 Vulnerable children and young people’s health needs
Schools and children’s services address three key areas of children and young people’s health in addition to safeguarding. All children and young people enjoy health benefits through attending school. But for the most vulnerable children, the health benefits are much greater. Thus, the current circumstances make these vulnerable children more at risk of developing increased health needs in the coming weeks, months and years.
Schools play a pivotal role in addressing and minimising health inequalities, by performing functions that protect the mental health of children and young people and supporting the public health of our communities.
3.2 Health Inequalities
Data consistently show that poverty and inequality impact a child’s whole life course, affecting their education, housing and social environment and in turn impacting their health outcomes. Socially vulnerable children have worse
health outcomes than their less vulnerable counterparts. Being out of school has a more significant impact on their health and life chances.
3.3 Mental Health
We know that 56% of referrals to CAMHS come from primary schools. Schools provide a vital vehicle in seeing children and young people that need access to mental health services are referred. Some schools also provide counselling, cognitive behavioural therapy (CBT) and play therapy.
We know that early intervention is key in children and young people’s mental health; 75% of all mental health problems start in childhood. Children from deprived backgrounds are more likely to experience mental health problems, meaning the most vulnerable children will be most impacted.
3.4 Public Health
The redeployment of community paediatricians and other child health professionals to acute paediatrics or adult services in light of the pandemic has reduced the provision of public health services in local communities. RCPCH has been collecting data from local services to track this; 13.2% of community career grade staff (plus 31% of community trainees) had been deployed to other areas of paediatric care. The deprioritisation of community services means the interruption of care pathways, including vaccination and screening programmes.
3.5 Children with special educational needs and disability (SEN)
The process of assessment and support for SEN and neuro-developmental disorders within schools has been suspended during the pandemic. Children with SEN have therefore been disproportionately disadvantaged by the lockdown. Some of these children use equipment to support their learning, like physiotherapy or communication aids. These are largely based in schools and so children have not had access to them for several weeks.
Additionally, schools provide an important source of respite for the families of those with SEN. The widespread closure of schools means many families have been caring with no assistance for a number of weeks.
4. Capacity of children’s services to support vulnerable children and young people
4.1 Service recovery
It is vital for child health and wellbeing outcomes that primary and community care and children’s services have the resources they need to provide essential public health services. A key part of service recovery will be the return of community paediatricians from their work in secondary care, and the standing up of other community services like health visiting. In the context of the financial pressures facing local authorities – exacerbated by further demands on local authorities in light of the impacts of the COVID-19 pandemic – it will be difficult to respond to the level of demand for services provided by local authorities.
In addition to increased demand on services, there will also be a need catch up with routine health appointments, including screening and immunisations. Additionally, children’s services, which have largely been undertaking assessments virtually in the current context, will need to address a backlog of face-to-face appointments in addition to dealing with the likely increase demand. Thus, there will be a dual burden on services to address the pause to routine service provision, and the surge of new presentations to some services as a result of the pandemic.
4.3 New work
There will inevitably be a considerable volume of new work for paediatric and children’s services in the coming months. Reports from RCPCH members suggest that children and young people have been presenting to health care settings later than they would since the pandemic started. The British Paediatric Surveillance Unit (BPSU) is currently undertaking a ‘snap-shot’ survey to understand the scale of this issue. These delayed presentations can lead to long-term health problems, which means more demand for paediatric services in the future.
There will also be a surge in assessments for children with SEN as they have been suspended whilst schools have been largely closed. This surge for support will also be seen in CAMHS services.
There is likely to be an increase in the numbers coming into the care system, and increased foster and adoption placement breakdowns, which will exert further pressure on looked after children’s services.
4.5 State of Child Health in the UK
Our State of Child Health 2020 report shows our challenge in reaching optimum health outcomes for children across the UK. COVID-19 will likely frustrate our journey towards ‘levelling up’ outcomes for health compared with our European counterparts. We have long called for governments to address widening health inequalities and whilst
COVID-19 is a human tragedy, it is sending shocks through the global economy. Children from socially vulnerable backgrounds will fall at the sharp end of this pandemic. Health services provided through or with the collaboration of schools will be critical in ensuring the current pandemic does not entrench existing health inequalities.
5. Calls to the UK Government
In order to support the restoration of children’s services and the delivery of health services in the community, we are calling on Government to:
 Department for Education, Coronavirus (COVID-19): attendance in education and early years settings. https://www.gov.uk/government/publications/coronavirus-covid-19-attendance-in-education-and-early-years-settings
 Safeguarding Board Northern Ireland, Safeguarding Board highlights drop in referrals for children that may have experienced harm during COVID-19.
 RCPCH, State of Child Health, 2020, https://stateofchildhealth.rcpch.ac.uk/evidence/family-and-social-environment/child-poverty/
 NSPCC, June 2018, https://www.nspcc.org.uk/what-we-do/news-opinion/one-third-increase-in-school-referrals-for-mental-health-treatment/
 MQ, November 2017, https://www.mqmentalhealth.org/posts/12-statistics
 RCPCH, State of Child Health, 2020, https://stateofchildhealth.rcpch.ac.uk/evidence/family-and-social-environment/child-poverty/
 RCPCH, 8st May 2020. https://www.rcpch.ac.uk/resources/impact-covid-19-child-health-services-tool-results
RCPCH, State of Child Health, 2020. https://stateofchildhealth.rcpch.ac.uk/