Increasing demand for children and young people’s services, and increasing acuity of patients, have been growing concerns among trust leaders in recent years. Trust leaders tell us that due to a unique combination of pressures, services are struggling to keep pace with increasing levels of need. This is resulting in concerns about quality of care and patient safety.
NHS trusts and foundation trusts provide a variety of essential services for children and young people at home, in the community, in hospitals and inpatient settings. These include health visiting, speech and language therapy, audiology, neurodevelopmental services, acute psychiatric inpatient care and paediatric surgery.
Our previous work on children and young people’s services, which focused on health inequalities (NHS Providers, 2023), community services (NHS Providers and NHS Confederation, 2023) and mental health services (NHS Providers, 2021) has sought to understand and raise the profile of pressures being experienced in this sector. This report builds on these findings to provide a comprehensive view across the provider sector of the state of children and young people’s healthcare services in England – across acute, ambulance, community and mental health services. It gives an overview of the challenges facing children and young people in accessing care; shares examples of the local initiatives and progress made by providers and their partners; highlights the national and system-level action needed to further support trusts; and makes a set of recommendations for the government.
We hope to highlight the importance for all trusts and foundation trusts of prioritising improving outcomes for children and young people. Our findings demonstrate that where one part of the system fails to meet children and young people’s needs, there will be a knock-on impact elsewhere on service demand. Without concerted action, we are storing up problems for future demand and society at large.
Prevention is better than cure
Childhood is a key period of life. It is one of change and development, where children and young people learn and adopt behaviours that can either benefit or worsen their health outcomes, such as sleep patterns, diet, self-care and rates of physical activity. Most long-term health conditions are developed during childhood – for example, 75% of mental health problems are established before the age of 24 (National Library of Medicine, 2005).
Intervening during this period is therefore critical to improving children and young people’s health outcomes both now, in the present, and into the future, ensuring a healthy and thriving society and population in the long-term. Research has shown that interventions to improve health outcomes for children are particularly effective in comparison to intervening later (Academy of Medical Royal Colleges, 2023), and providing high quality services for children and young people can prevent ill health in later life (NHS Providers, 2023).
In our picture of health vision for the next generation NHS (NHS Providers, 2024), we called for a focus on prevention and early intervention to ensure the sustainability of the NHS and to secure a significant social and economic return on investment. Improving the health of children and young people today will enable them to contribute fully to the future workforce, boost economic activity and help public services, including the NHS, to keep pace with demand.
Despite the recognised importance of this age group, children and young people have not routinely been prioritised within policy and decision making, or within service commissioning and planning. Healthcare expenditure is higher for older age groups (UK Health Security Agency, 2019), reflecting the needs of older age groups. Yet we know children and young people represent a significant population group with their own healthcare needs. In 2020, approximately a quarter (23%) of 11-15 year olds in England reported living with a long term illness, disability or medical condition (National Institute for Health and Care Excellence, 2020) – contributing to the UK having one of the highest rates of 16-24 year olds with long term health conditions (Nuffield Trust, 2019), in comparison to similar countries. These trends are expected to worsen over time, as research (Health Foundation, 2023) has projected that nearly 1 in 5 adults will be living with a major illness in 2040.
Current trends are moving in the wrong direction. While the Hewitt Review (Department of Health and Social Care, 2023) called on systems to increase investment in prevention, this has not yet been delivered in practice due to the financial pressures healthcare systems. The environment in which children are born and grow inevitably impacts upon their health and wellbeing, including factors such as housing, education, financial security, and air pollution (the ‘wider determinants of health’). Arguably, we are seeing deteriorations across many of these areas, with unequal impacts experienced by specific groups of children and young people.
The Covid-19 pandemic had a unique and significant impact on children and young people, in terms of their education, social development and interaction with wider public services. Those from disadvantaged backgrounds, ethnic minorities, and those with disabilities have been particularly affected. However, it is not the only factor; child poverty levels were high in the decade leading up to the pandemic (Independent, 2021) and NHS waiting lists were growing. The cost of living crisis has only exacerbated these trends; in 2022/23 4.3 million children were living in relative poverty, after housing costs (The End Child Poverty Coalition, 2024). We do not yet know the long term implications of these broader societal trends, which will play out in the years ahead, but can anticipate the impact of delays to children and young people’s physical, social and emotional development. Trust leaders have told us that they are already experiencing a rising level of demand for services, coupled with increasing complexity of childhood presentations.
Impact on provision of children and young people’s services
The Children’s Commissioner for England has described access to children and young people’s healthcare services as a ‘postcode lottery’ (Children’s Commissioner, 2024), highlighting specific barriers for particular groups of young people experiencing disadvantage. The Royal College of Paediatrics and Child Health (RCPCH) has gone further in stating that we are ‘failing a generation of young people’ through our lack of dedicated focus and attention (RCPCH, 2024).
Evidence suggests that children and young people’s services are recovering at a slower rate post Covid-19, in comparison to adult services, impacting on waiting lists and the availability and accessibility of services. The latest NHSE data show record levels of demand. In May 2024 282,200 children and young people were on the community health services waiting list, with 88,900 of this group waiting over 52 weeks. For planned acute care, 356,200 children and young people were waiting as of May 2024; an increase of 110,000 in just three years. The latest data for mental health services also paints a concerning picture: there were over half a million children and young people waiting for mental health services, an increase of 16.5% on a year ago and almost double the levels seen four years ago . The RCPCH has highlighted the disproportionate impact of long waits on children and young people (RCPCH, 2024), in relation to the need to administer treatments within specific developmental timeframes, alongside implications on education and wellbeing.
Children and young people have themselves shared their hopes for how children and young people’s healthcare services can be improved. The Children’s Commissioner’s Big Ambition survey of 367,000 children found health to be a key priority for children, describing them as a “health conscious generation” (Children’s Commissioner, 2024). Results demonstrated that children and young people do not distinguish between mental and physical health and recommended improving the join up between children and young people’s services to improve their experiences and outcomes. Similar research has found that children and young people value good communication with healthcare professionals, who help them to understand what is happening. Importantly, children and young people want to feel listened to and heard (National Children’s Bureau, 2021), and they want to be included in decisions about their care.
Results of the Care Quality Commission (CQC)’s children and young people’s survey (CQC, 2020) found overall positive experiences of treatment, but that children and young people were less positive about feeling involved in decisions about their care, and about not having enough to do or play with in hospital settings. The National Institute for Health and Care Excellence (NICE) has developed a guideline for delivering good patient experience for babies, children and young people in healthcare settings (NICE, 2021). Recognising the formative period of childhood and adolescence, children and young people’s experiences of healthcare services can potentially impact on how they engage and interact with services into the future. Though it can be easy to overlook the views of children and young people, they are vitally important for improving experiences of services.
Time to act
The evidence indicates that children and young people risk being a forgotten generation – but prioritising children and young people in decision-making presents the opportunity to improve our nation’s health, bring down the pressures that are currently impacting services, and enable a prosperous society.
No single organisation is responsible for taking on this challenge: all provider types, local systems and national leaders have a part to play in improving outcomes for children and young people. Trusts are willing and committed to this agenda - and are already working hard to make improvements, some examples of which are set out in this report – but they require backing of the government to see meaningful change. Health services alone cannot provide the solution, we need to see collective action across education, housing and other areas to truly prioritise the needs of children and young people.
A new government led by Prime Minister Sir Keir Starmer was elected on 4 July, making this is a timely moment to focus attention on the issues facing children and young people’s services. The Labour Party’s manifesto (Labour Party, 2024) made it clear that children and young people are a priority, and its commitments to roll out a cross-government child poverty strategy and mental health hubs in every community are welcome. We believe the findings and recommendations in this report will support further, meaningful, urgent action on the issues outlined, enabling the new government to fulfil its promise to raise the “healthiest generation of children and young people in our history”.
About our research
The themes in the report are informed by a recent survey of NHS trusts. The survey was open from April to May 2024. We received 134 responses from 95 unique trusts, accounting for 45% of the provider sector. We received responses from a mix of leadership roles, including chairs, chief executives, strategy directors, chief operating officers and directors of children and young people’s services. All regions and trust types - including acute, community, mental health and ambulance - were represented in the responses.
For the purpose of this survey, we define children and young people as those aged between 0-25 years old to reflect the commissioning and provision of these services within the NHS.