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Healthcare prioritisation and inequitable inequalities: why a child health perspective should be incorporated into the current NHS guidance

Healthcare prioritisation and inequitable inequalities: why a child health perspective should be... Viewpoint the opportunity to benefit, rather than a Healthcare prioritisation and inequitable discriminatory assessment of children’s immediate social or economic worth, that inequalities: why a child health matters in this argument, this view seems intuitively appealing. Children’s health- care should be prioritised to avoid the perspective should be incorporated into distinctively bad and unfair outcomes that happen without an explicit means of giving the current NHS guidance visibility to their longer term capacity to benefit. Given that all people age, securing 1 2,3 Sapfo Lignou , Ingrid Wolfe childhood as a more important stage has also been suggested as prudent resource allocation strategy that most people would One of the main aims of the post-CO VID group is likely further to exacerbate reasonably accept. National Health System (NHS) is to tackle vulnerability. This is particularly evident Yet despite its appeal, this approach inequalities in experience, access and in the case of children with chronic and presents several challenges. Having to health outcomes that compromised the complex conditions, who, due to poor choose between candidates for treatment health of the most vulnerable patients in care coordination and system failures, who differ in many respects requires the time of crisis. This aim suggests that already faced poorer health outcomes decisions about how other disadvantages in reducing the current care backlog for prior to the pandemic compared to their within and across population groups treatment, equity considerations should be counterparts in many other European should feature. Furthermore, we must traded off against efficiency when priori- countries. Disruptions to planned outpa- consider what sacrifices we are willing tising healthcare. Giving priority to cate- tient care have further exposed these chil- to make in order to redress injustices on gories of care or population groups is dren to further risk and avoidable harm. children. For instance, deprioritising adult necessary to address preventable and Unmet needs are closely associated with care may require favouring equity over undesirable health inequalities in keeping disadvantage, raising profound ethical and the more usual efficiency maxim that with Marmot’s proportionate universalist policy concerns. In the case of children underpins resource allocation decisions. approach to reducing inequalities in these concerns are distinctly important as Addressing health inequities requires diffi- health, and reflects our moral intuitions not only the immediate interests of a child cult choices informed by reflection on to ensure that those who have already are affected but also their developmental values which are ‘essentially contestable’ experienced significant misfortune are not and future interests. and lead to very different strategies. further disadvantaged. Children who experience multiple The complexity of such decisions, Equity considerations regarding health- interacting and often compounding disad- however, does not discharge us from our care prioritisation are currently framed by vantages are more likely to experience duty, as society, to be just to children. socioeconomic and ethnic health dispari- diminished health and quality of life and A pragmatic, alternative approach that ties. Supported by evidence showing the reduced opportunities to experience a requires that children’s disadvantages disproportionate impact of the pandemic range of other important goods, such as do not add to current health injustices on the health of ethnic minority and lower attending school, socialising with friends is needed. Currently, the omission of an socioeconomic groups, these consider- and developing skills and abilities neces- ‘age- related’ needs criterion as a distin- ations are important in current decision- sary to maximise developmental potential guishing characteristic among patients making processes. Nevertheless, they and pursue life goals. Given the cumula- currently competing for treatment in do not capture the magnitude of health tive effects on long-term life prospects, NHS healthcare prioritisation decisions inequalities that should be considered health and care inequalities in childhood obscures issues of health justice particu- and addressed as part of a postpandemic may translate into social and economic larly in the case of children, in the post- project to address issues of health justice. inequalities over time. Worryingly, many COVID era. Introducing an ‘age-related To address health and care inequali- children who experienced missed oppor- needs’ criterion would serve as a crude ties efficiently and fairly, the stage of a tunities to receive care crucial for their measure of the priority given to care, patient’s life must be included in priority development during the peak of the taking into account the specific needs of setting. For the paediatric population this pandemic may continue to miss care in patients at different stages of life. This is particularly important. Adult ill health the current stages of health system turmoil criterion would help identify structural can begin in early childhood. Consider, and economic constraints because of care inequalities and health adversity for instance, the impact of adverse expo- prioritisation processes that are not sensi- between different age cohorts that must be sures on neurodevelopmental system). tive to their specific needs. addressed. In addition to using measures Furthermore, the combination of being a If we believe that children’s life course of healthy life expectancy such as quality- child and being in a socially disadvantaged stage must be taken into account when adjusted life years (QALYs) or disability- healthcare prioritisation decisions are adjusted life years (DALYs) that take made, then we must devise strategies to Ethox Centre and Wellcome Centre for Ethics and into account the remaining years of life, Humanities, University of Oxford, Oxford, UK equalise their health prospects and increase it is important to consider child- specific Guy’s and St Thomas’ NHS Foundation Trust, London, their care opportunities. How might this health factors as part of a comprehensive UK work? Transferring resources from the 3 understanding of age-related needs. This Institute of Women and Children’s Health, King’s care of adult patients to children has been approach would enable decision-making College London, London, UK argued as an ethically justifiable policy to that is aligned with and inclusive of the Correspondence to Dr Sapfo Lignou, NDPH, address the problem of scarce healthcare unique care needs of the pediatric popula- University of Oxford, Oxford OX3 7LF, UK; resources in the ethics literature. As it is sapfo. lignou@ ethox. ox. ac. uk tion, such as timely identification of health Lignou S, Wolfe I. Arch Dis Child Month 2023 Vol 0 No 0 1 Viewpoint To cite Lignou S, Wolfe I. Arch Dis Child Epub ahead of deterioration or identification of missed and across different generations currently print: [please include Day Month Year]. doi:10.1136/ developmental milestones. By incorpo- served by the NHS. archdischild-2023-325634 rating an 'age-related' needs criterion, we Received 26 March 2023 Contributors SL conceived the idea and wrote the can extend the concept of a‘fair chance of Accepted 25 April 2023 first draft. IW made contributions to and reviewed and treatment’ for children, ensuring that their approved the final manuscript. Arch Dis Child 2023;0:1–2. actual and developmental well-being are doi:10.1136/archdischild-2023-325634 Funding This research was funded in whole, or in properly considered in healthcare prior- part, by the Wellcome TrustThis research was funded in itisation plans without, however, adding ORCID iD whole, or in part, by the Wellcome Trust Sapfo Lignou http://orcid.org/0000-0002-9753-7298 further disadvantages to other groups by Competing interests None declared. arbitrary restricting their access to care. Patient consent for publication Not applicable. There are important ethical reasons for REFERENCES 1 NHS. 2021/22 priorities and operational planning Provenance and peer review Not commissioned; which health inequities should be at the guidance. Par468; 2021. Available: NHS England » externally peer reviewed. centre of healthcare policy concerns; in 2022/23 priorities and operational planning guidance particular for children. Preventable and [Accessed 10 Mar 2022]. undesirable health and care inequalities in 2 Carey G, Crammond B, De Leeuw E. Towards health equity: a framework for the application of proportionate childhood reduce the well-being of those Universalism. Int J Equity Health 2015;14:81. disadvantaged, and may have larger impli- 3 Morales DR, Ali SN. COVID- 19 and disparities affecting cations for human, social and economic ethnic minorities. Lancet 2021;397:1684–5. Open access This is an open access article distributed development in our societies. As such, 4 Horton R. Offline: the UK’s child health emergency. in accordance with the Creative Commons Attribution addressing health equity considerations Lancet 2018;392. 4.0 Unported (CC BY 4.0) license, which permits others 5 Lignou S, Sheehan M. Children with medical is important for decisions about elective to copy, redistribute, remix, transform and build upon complexities: their distinct vulnerability in health care prioritisation, and for the imminent this work for any purpose, provided the original work systems’ COVID- 19 response and their claims of consequences on the health system and the is properly cited, a link to the licence is given, and justice in the recovery phase. Med Health Care Philos indication of whether changes were made. See: https:// future challenges they may bring. 2023;26:13–20. creativecommons.org/licenses/by/4.0/. 6 Williams A. Intergenerational equity: an exploration Ethical questions must be considered of the ’fair innings’ argument. Health Econ © Author(s) (or their employer(s)) 2023. Re- use in policy design, balancing short- term 1997;6:117–32. permitted under CC BY. Published by BMJ. efficiency with a vision of a just society. 7 Heckman JJ. Skill formation and the economics There is a compelling case for addressing of investing in disadvantaged children. Science unfair health and care inequalities within 2006;312:1900–2. 2 Lignou S, Wolfe I. Arch Dis Child Month 2023 Vol 0 No 0 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Disease in Childhood British Medical Journal

Healthcare prioritisation and inequitable inequalities: why a child health perspective should be incorporated into the current NHS guidance

Archives of Disease in Childhood , Volume 109 (1) – Jan 19, 2024

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Publisher
British Medical Journal
Copyright
© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.
ISSN
0003-9888
eISSN
1468-2044
DOI
10.1136/archdischild-2023-325634
Publisher site
See Article on Publisher Site

Abstract

Viewpoint the opportunity to benefit, rather than a Healthcare prioritisation and inequitable discriminatory assessment of children’s immediate social or economic worth, that inequalities: why a child health matters in this argument, this view seems intuitively appealing. Children’s health- care should be prioritised to avoid the perspective should be incorporated into distinctively bad and unfair outcomes that happen without an explicit means of giving the current NHS guidance visibility to their longer term capacity to benefit. Given that all people age, securing 1 2,3 Sapfo Lignou , Ingrid Wolfe childhood as a more important stage has also been suggested as prudent resource allocation strategy that most people would One of the main aims of the post-CO VID group is likely further to exacerbate reasonably accept. National Health System (NHS) is to tackle vulnerability. This is particularly evident Yet despite its appeal, this approach inequalities in experience, access and in the case of children with chronic and presents several challenges. Having to health outcomes that compromised the complex conditions, who, due to poor choose between candidates for treatment health of the most vulnerable patients in care coordination and system failures, who differ in many respects requires the time of crisis. This aim suggests that already faced poorer health outcomes decisions about how other disadvantages in reducing the current care backlog for prior to the pandemic compared to their within and across population groups treatment, equity considerations should be counterparts in many other European should feature. Furthermore, we must traded off against efficiency when priori- countries. Disruptions to planned outpa- consider what sacrifices we are willing tising healthcare. Giving priority to cate- tient care have further exposed these chil- to make in order to redress injustices on gories of care or population groups is dren to further risk and avoidable harm. children. For instance, deprioritising adult necessary to address preventable and Unmet needs are closely associated with care may require favouring equity over undesirable health inequalities in keeping disadvantage, raising profound ethical and the more usual efficiency maxim that with Marmot’s proportionate universalist policy concerns. In the case of children underpins resource allocation decisions. approach to reducing inequalities in these concerns are distinctly important as Addressing health inequities requires diffi- health, and reflects our moral intuitions not only the immediate interests of a child cult choices informed by reflection on to ensure that those who have already are affected but also their developmental values which are ‘essentially contestable’ experienced significant misfortune are not and future interests. and lead to very different strategies. further disadvantaged. Children who experience multiple The complexity of such decisions, Equity considerations regarding health- interacting and often compounding disad- however, does not discharge us from our care prioritisation are currently framed by vantages are more likely to experience duty, as society, to be just to children. socioeconomic and ethnic health dispari- diminished health and quality of life and A pragmatic, alternative approach that ties. Supported by evidence showing the reduced opportunities to experience a requires that children’s disadvantages disproportionate impact of the pandemic range of other important goods, such as do not add to current health injustices on the health of ethnic minority and lower attending school, socialising with friends is needed. Currently, the omission of an socioeconomic groups, these consider- and developing skills and abilities neces- ‘age- related’ needs criterion as a distin- ations are important in current decision- sary to maximise developmental potential guishing characteristic among patients making processes. Nevertheless, they and pursue life goals. Given the cumula- currently competing for treatment in do not capture the magnitude of health tive effects on long-term life prospects, NHS healthcare prioritisation decisions inequalities that should be considered health and care inequalities in childhood obscures issues of health justice particu- and addressed as part of a postpandemic may translate into social and economic larly in the case of children, in the post- project to address issues of health justice. inequalities over time. Worryingly, many COVID era. Introducing an ‘age-related To address health and care inequali- children who experienced missed oppor- needs’ criterion would serve as a crude ties efficiently and fairly, the stage of a tunities to receive care crucial for their measure of the priority given to care, patient’s life must be included in priority development during the peak of the taking into account the specific needs of setting. For the paediatric population this pandemic may continue to miss care in patients at different stages of life. This is particularly important. Adult ill health the current stages of health system turmoil criterion would help identify structural can begin in early childhood. Consider, and economic constraints because of care inequalities and health adversity for instance, the impact of adverse expo- prioritisation processes that are not sensi- between different age cohorts that must be sures on neurodevelopmental system). tive to their specific needs. addressed. In addition to using measures Furthermore, the combination of being a If we believe that children’s life course of healthy life expectancy such as quality- child and being in a socially disadvantaged stage must be taken into account when adjusted life years (QALYs) or disability- healthcare prioritisation decisions are adjusted life years (DALYs) that take made, then we must devise strategies to Ethox Centre and Wellcome Centre for Ethics and into account the remaining years of life, Humanities, University of Oxford, Oxford, UK equalise their health prospects and increase it is important to consider child- specific Guy’s and St Thomas’ NHS Foundation Trust, London, their care opportunities. How might this health factors as part of a comprehensive UK work? Transferring resources from the 3 understanding of age-related needs. This Institute of Women and Children’s Health, King’s care of adult patients to children has been approach would enable decision-making College London, London, UK argued as an ethically justifiable policy to that is aligned with and inclusive of the Correspondence to Dr Sapfo Lignou, NDPH, address the problem of scarce healthcare unique care needs of the pediatric popula- University of Oxford, Oxford OX3 7LF, UK; resources in the ethics literature. As it is sapfo. lignou@ ethox. ox. ac. uk tion, such as timely identification of health Lignou S, Wolfe I. Arch Dis Child Month 2023 Vol 0 No 0 1 Viewpoint To cite Lignou S, Wolfe I. Arch Dis Child Epub ahead of deterioration or identification of missed and across different generations currently print: [please include Day Month Year]. doi:10.1136/ developmental milestones. By incorpo- served by the NHS. archdischild-2023-325634 rating an 'age-related' needs criterion, we Received 26 March 2023 Contributors SL conceived the idea and wrote the can extend the concept of a‘fair chance of Accepted 25 April 2023 first draft. IW made contributions to and reviewed and treatment’ for children, ensuring that their approved the final manuscript. Arch Dis Child 2023;0:1–2. actual and developmental well-being are doi:10.1136/archdischild-2023-325634 Funding This research was funded in whole, or in properly considered in healthcare prior- part, by the Wellcome TrustThis research was funded in itisation plans without, however, adding ORCID iD whole, or in part, by the Wellcome Trust Sapfo Lignou http://orcid.org/0000-0002-9753-7298 further disadvantages to other groups by Competing interests None declared. arbitrary restricting their access to care. Patient consent for publication Not applicable. There are important ethical reasons for REFERENCES 1 NHS. 2021/22 priorities and operational planning Provenance and peer review Not commissioned; which health inequities should be at the guidance. Par468; 2021. Available: NHS England » externally peer reviewed. centre of healthcare policy concerns; in 2022/23 priorities and operational planning guidance particular for children. Preventable and [Accessed 10 Mar 2022]. undesirable health and care inequalities in 2 Carey G, Crammond B, De Leeuw E. Towards health equity: a framework for the application of proportionate childhood reduce the well-being of those Universalism. Int J Equity Health 2015;14:81. disadvantaged, and may have larger impli- 3 Morales DR, Ali SN. COVID- 19 and disparities affecting cations for human, social and economic ethnic minorities. Lancet 2021;397:1684–5. Open access This is an open access article distributed development in our societies. As such, 4 Horton R. Offline: the UK’s child health emergency. in accordance with the Creative Commons Attribution addressing health equity considerations Lancet 2018;392. 4.0 Unported (CC BY 4.0) license, which permits others 5 Lignou S, Sheehan M. Children with medical is important for decisions about elective to copy, redistribute, remix, transform and build upon complexities: their distinct vulnerability in health care prioritisation, and for the imminent this work for any purpose, provided the original work systems’ COVID- 19 response and their claims of consequences on the health system and the is properly cited, a link to the licence is given, and justice in the recovery phase. Med Health Care Philos indication of whether changes were made. See: https:// future challenges they may bring. 2023;26:13–20. creativecommons.org/licenses/by/4.0/. 6 Williams A. Intergenerational equity: an exploration Ethical questions must be considered of the ’fair innings’ argument. Health Econ © Author(s) (or their employer(s)) 2023. Re- use in policy design, balancing short- term 1997;6:117–32. permitted under CC BY. Published by BMJ. efficiency with a vision of a just society. 7 Heckman JJ. Skill formation and the economics There is a compelling case for addressing of investing in disadvantaged children. Science unfair health and care inequalities within 2006;312:1900–2. 2 Lignou S, Wolfe I. Arch Dis Child Month 2023 Vol 0 No 0

Journal

Archives of Disease in ChildhoodBritish Medical Journal

Published: Jan 19, 2024

Keywords: Child Health; Covid-19; Ethics; Healthcare Disparities; Paediatrics

There are no references for this article.