Age distribution and causes of death in the UK and Europe

More than 5000 children and young people between 0 years and 19 years of age died in the UK in 2012. The majority of child deaths (60%) happen before 1 year of age and the next largest proportion happen in adolescence (18%), and the causes vary substantially between age groups.11

Poverty, and social and economic inequities shape the chances of child survival

Children who live in poverty and deprivation are less likely to survive than their richer peers. This is true in the UK, as it is elsewhere in Europe. A social gradient for survival affects infants and adolescents,19 and continues through the life course. The distribution of wealth within a country matters too. Children who live in countries with wide gaps between rich and poor people are more likely to die than their peers living in countries where wealth is more equitably shared. It is notable that infant mortality in the UK slowed less rapidly from around 1990 onwards, coincident with rising income inequality in the UK. Absolute child poverty is an increasing problem in the UK,20 35% of households with children do not have an income that is high enough to ensure an acceptable standard of living,21 and the UK remains in the upper range of income inequality among European countries.22 Pressures on families are increasing throughout Europe, and are likely to be exacerbated by ongoing economic problems and reduced public service funding. Among families receiving services, there are increasing rates of alcohol and substance addictions, mental ill health, relationship difficulties, challenging behaviour in children, intimate partner violence and parent-child conflict.23 ,24 The UK is notable because poverty and deprivation disproportionately affect children and young people compared with other age groups.25 As shown in figure 3, this is in distinction to many other European countries, where poverty and social exclusion are more fairly shared between age groups. By contrast, in Britain, recent social spending cuts disproportionately affect families with children. A third of British households have children, but those families bear two-thirds of the burden of recent benefit cuts.26 Food poverty and hunger are growing problems in the UK, with increasing numbers of families reliant on food banks.27

• Download figure
• Open in new tab
• Download powerpoint

Figure 3

UNICEF. ‘The Children Left Behind: A league table of inequality in child well-being in the world's rich countries’, Innocenti Report Card 9, Florence. UNICEF Innocenti Research Centre, 2010.

How do poverty and inequity kill? Babies born in poverty are more likely to be stillborn or die in infancy.12 ,15 Babies who are born too early or who have low birth weights are at higher risk for infant death, and there is also a link to other risk factors such as age at motherhood. Babies with mothers aged under 20 years or in their 40s have higher rates of infant death than those with mothers aged between 20 years and 34 years. In the UK, over 5% of mothers of babies born in 2010 were under 20 years old, whereas in Sweden, 1.6% of mothers were under 20 years.12 Adverse health behaviours that are linked to low birth weight and preterm birth, such as poor antenatal care, substance abuse, poor nutrition in pregnancy and smoking, are more common in less advantaged socioeconomic groups.28–30 Smoking in pregnancy, for example, is associated with a 20–30% higher likelihood of stillbirth, a 40% higher rate of infant mortality and a 200% higher incidence of sudden infant death syndrome.31 Low birthweight rates are higher among teenage mothers, possibly because of competition for nutrients between the fetus and its mother who is also growing and developing.32 Breastfeeding, which can protect babies from infection and help prevent sudden infant death syndrome, is less common in more disadvantaged socioeconomic groups.33 Adolescents and young people who grow up in disadvantageous conditions face higher risks of external injury, and are more likely to engage in excessive alcohol intake and other risk behaviours.34 Finally, there is evidence to suggest epigenetic effects of early disadvantage may add cumulative risk throughout the life course and may be transmitted to subsequent generations.35

Deaths that are preventable through health systems policy and healthcare practice

The concept of avoidable deaths in childhood provokes controversy and challenge. How would we go about defining what proportion of childhood deaths ought to be preventable? Sweden currently has the lowest child mortality rate in Europe. Excess deaths indicate the scale of difference between countries’ mortality rates, in a way that is meaningful to public and politicians. The UK has just under 2000 more deaths among children under 14 years old than it would do if it had the same mortality rate as in Sweden.2 But is Sweden's mortality rate as low as is realistically achievable in the current state of social advancement and medical progress? Crucially, is there any reason why the UK could not achieve at least the same mortality rate as Sweden?

The proportions of the UK's excess child and adolescent death rates attributable to social determinants, health system factors or healthcare are not clear. Since most deaths happen in the 1st year of life, when there is a strong association between social disadvantage and risk of death, it has been argued that social determinants explain most of the excess mortality in the UK, while micro-level healthcare-related causes provide an overly simplistic explanation for lay media seeking to explain country differences. How much does healthcare contribute to population-level child health? Attempts have been made to estimate the proportion of adult deaths that are healthcare-amenable or avoidable, with answers ranging from 20% to 40%,36 but no estimates appear to have been published for children. It is widely accepted that medicine probably contributed rather little to health gain before the middle of the 20th century, but paediatrics has advanced considerably since then, increasingly technically able to intervene more effectively and in many more diseases and problems than ever before. While it is likely that the marginal contribution of healthcare to health has increased, social determinants of health and health system factors remain vitally important.

Although mortality rates are crude measures of healthcare quality for children and therefore of limited use on their own as quality indicators, assessing signals of concern around quality of care can help point to areas deserving further enquiry and efforts towards improvement. Approximately one in five deaths among children and young people is considered preventable through policy and practice changes in health services and the wider health system,37 though the lessons from statutory reviews of childhood deaths have yet to be translated comprehensively into effective policies.38 There are no reliable comparable figures for European countries, so we cannot answer with precision the question why children are more likely to die in the UK than in some other European countries. Indeed there are no overall measures of quality of healthcare for children. In addition, between-country comparisons are fraught with difficulties relating to definition and coding consistency, so rigorous comprehensive comparative assessments are currently unavailable. However we can identify where systems and practices vary notably between countries, and we can also identify deficits in UK practice which are remediable and may therefore improve mortality and morbidity.

In the year ending 31 March 2013, 21% of the 3857 deaths reviewed in the child death reviews published by the Department for Education, were judged to have had modifiable factors which may have contributed to death and which through nationally or locally achievable interventions may reduce the risk of future deaths.37 The highest proportion of deaths with modifiable factors (nearly 30%) were among children aged between 1 month and 1 year old, and between 15 years and 17 years old. A recently published report reviewing deaths from asthma found that a key risk for children and young people was the failure, in primary and secondary care, to recognise risk of adverse outcome, and that in 93% of deaths reviewed, routine care was inadequate.39

What system-level factors are important for ensuring a high functioning children's health service? Health systems comparisons across Europe can give indications where the UK performs well, and where and how improvements could be made. The UK's tax-funded nationalised health service delivers high quality outcomes for the general adult population and overall performs efficiently and well in high-level indicators compared with many similar OECD and European countries.40 However recent health system reforms in England seem to be producing increasing fragmentation of commissioning and provider functions, and accountability for the quality of children's healthcare remains unclear. Sweden followed the UK's example of market-based reforms in the 1980s, however in response to increasing fragmentation of services, later reverted to a more cooperative model. For example, extensive decentralisation was partially reversed with the formation of elected regional health authorities, while county-level taxes for funding a high proportion of health sector costs were intended to enhance system responsiveness.41 Child health professionals are involved in planning children's health services, to help ensure a child-centric model of care. At a micro level, ‘chains of care’ backed by financial incentives were developed specifically to improve integration and encourage cooperation between professionals and providers.42

An important advantage in the UK compared with many other countries, is an equitable and accessible system of universal primary care, since countries with strong primary care systems deliver high quality outcomes.43 However much less is known about exactly how best to organise everyday healthcare in the interests of children and young people. Primary care has an important gatekeeping role in the UK and delivers the majority of healthcare for children, so a strong primary care service, which is essential for children and families, is also crucial for the rest of the health service to function well. It is challenging to ensure optimal balance between expertise and access in primary care for children, and it is crucial to ensure that workforce is appropriately skilled and resourced.44–46 For example, in England GPs make up only 16% of the primary and community care team (67% are nurses, 14% pharmacists and 3% allied health professionals),47 yet there is no mandatory requirement for training in child health across the primary care workforce, and in contrast to much of the rest of Europe, paediatricians do not routinely work alongside general practitioner (GP) colleagues in primary care settings. Furthermore, integrated care, variously defined as a means of ensuring strong cooperation between providers and sectors, is held as an important mechanism for services to become more responsive to evolving health needs. Shifting care away from a hospital-centric model towards a strong community-based primary care service that can effectively prevent illness and manage children and young people with chronic conditions, as well as acute minor illness, has become a policy imperative.48 Countries with strong primary care systems which also enable close cooperation between health professionals seem to be making progress in delivering high quality care.2 ,18 There are several factors which facilitate such cooperation, including financial incentives for team working and co-location, for example in the Netherlands and Sweden. Workforce numbers, training and teamworking are also important; Sweden has more doctors per child than the UK, and GPs in Sweden are required to be trained specifically in paediatrics and work in teams with children's nurses and doctors.49

Notable differences between country approaches to strengthening important determinants of health, risk factors for death, and health systems policy and practice helps provide a rational approach to making recommendations for reducing child mortality in the UK to bring rates closer to European levels.

Government and civil society

From before birth, social determinants such as poverty and inequity and the policies that reinforce or mitigate their effects, influence children's health, development, happiness and future economic prosperity.50

Approximately a quarter of all infant deaths in England and Wales would potentially be prevented if all babies were born in circumstances as favourable as the least deprived families.51 Supportive family policy can help protect children from the damaging effects of poverty and inequality. Countries that spend more on social protection for families have lower child mortality rates.2 Child survival in Britain would be improved through macroeconomic policies to redistribute wealth and narrow the gap between rich and poor people. Social policies that protect children and families would also help ensure that children survive and thrive. More downstream policies designed to improve social determinants of health are sometimes translated into policies to modify health behaviours. These interventions need to go beyond providing information on healthy choices, since social disadvantage is often linked with poor self-esteem, lack of personal agency and poor mental health. Improving negative health behaviours such as smoking and alcohol consumption requires a nuanced and evidenced approach to health policy. Making healthy choices the easy ones to make means implementing policies such as financial subsidies on fruit and vegetables and taxes on less healthy foods, plain packaging of tobacco, and minimum price per unit of alcohol.52 Finally, policies to improve social determinants must be targeted proportionately across the social gradient to reduce health inequalities.53

Health systems, public health and healthcare

Health system stewardship, financing and organisation are important for ensuring accessible high quality and responsive care for children and young people. Primary care and the structures and processes that foster integration—horizontally (between health, education and social care) and vertically (between primary and secondary care), are important aspects of health systems that affect children. Information systems that enable coherent health service planning, and foster cooperation between institutions and individuals, are equally critical to the delivery of high quality care.

While the explanation for country differences is not yet clear, there are measures that would be likely to improve the quality of care for children and young people in the UK. A renewed focus on primary care, delivered by a team of professionals that achieves an optimal balance between access and expertise for physical and mental health, social care and other specialties, should enable the majority of children's urgent and scheduled health needs to be managed in community settings.18 Such a comprehensive strong model of care, backed by wider policy actions to reduce risk and enhance resilience and quality of life, would help improve prevention and care of long-term conditions in children and young people.

Public health policies and services delivered at population or individual levels are important means of preventing deaths in the longer term. Public health interventions that directly or indirectly reduce risk factors and causes of child mortality include interventions to reduce or prevent smoking, alcohol consumption, and non-intentional and maltreatment-related injuries.

Smoking habits often begin in adolescence, yet there are effective policies for tobacco control that could usefully supplement existing policies. Although the UK scores highly on implementation of tobacco control policies compared with some other countries,54 specifically for children and young people, and women who are planning or expecting a baby, there are further actions that could be taken. Legislation for standardised packaging of tobacco has now been introduced, and this should be welcomed.55 Alcohol consumption among young people in the UK is a considerable public health concern, with signs of alcohol-related liver disease affecting people at increasingly younger adult ages.56 ,57 There is good evidence that minimum pricing of alcohol is effective at reducing consumption, and there are further alcohol-related harm reduction strategies that can be implemented.54 ,58 There are effective policies to prevent most common causes of death from injuries, however legislation, policy implementation and enforcement are crucial.59 Given the lack of progress in reducing violence-related deaths and injuries among children and young people, an effective policy response is needed urgently. The England and Wales Children Act 1989 (section 17)60 places a duty on local authorities to provide services to children in need of additional services beyond universally available care. The intention is to ensure children achieve a reasonable standard of well-being or that their health or development is not significantly impaired. However increasing demand and reduced funding puts pressure on social workers, which can result in rapid turnover of staff, such that there is a risk that professionals working in social work and safeguarding roles are inexperienced or inadequately supported. Legislation in most European countries has been reviewed in light of the United Nations (UN) Convention on the Rights of the Child61 and although there are many common features in country approaches to services, for example an emphasis on working collaboratively with parents and families, encouraging self-referral and providing readily available social work services in local settings such as Sure Start Children's Centres (though many have now closed62), there are many interesting differences. Despite the team around the child (or family) approach that is commonly recommended, the extent of interagency working between social and mental health services and youth criminal justice services, varies between countries.63 In England, youth justice services are separate, unlike in Scotland or Sweden, for example. Another interesting difference in many European countries such as France and Italy, is the social pedagogue, a qualified professional who works alongside children and parents, usually more highly trained than UK family support workers.63 Finally, in some countries, for example France and Italy, child psychiatrists and clinical psychologists play an important role as lead professionals for vulnerable children and young people.63

A population-based approach to planning, delivering and evaluating children's health and social care is wholly dependent on measures of health and social care need and system performance. The Nordic countries’ system of national data registries strongly supports the ability to deliver health and care services tailored to need. Universal data collection and widespread data sharing is a point of national pride and enables health service improvements and research that are important elements contributing to their leading position in many of the European league tables of health system performance. In the UK, data sharing is developing well in Scotland and Wales. Major problems have developed in England, however data sharing may be more complex in England because of the plurality of providers of healthcare who compete with each other for business, and difficulties with data linkage systems.