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Abstract
The UK’s ‘cost of living crisis’ (COLC) has thrown millions of families into poverty in 2022, delivering an intensifying economic shock that will likely eclipse the financial impact of the global coronavirus pandemic for children, families and communities alike. But what is the relevance for paediatricians? Written by doctors who spend considerable time confronting social problems from clinical, public health and advocacy perspectives, this article aims to untangle the COLC for those working in child health and seeks to stimulate a meaningful conversation about how we might reimagine paediatrics for life in the 21st century.
Taking the current crisis as our point of departure, we argue that the UK’s COLC can be best understood as a ‘crisis of inequality’, which has been created through social, economic and political processes that were not inevitable. The health impacts, then, are a matter of health equity and social justice. While the acuity of the crisis unfolding in the UK garners much attention, the implications are global with lessons for paediatricians everywhere. We propose that using a ‘social lens’ for understanding the true ‘causes of the causes’ of complex challenges such as COLC is essential for the 21st century paediatrician, as the consequences for child health is deep, wide-ranging and long-lasting. However, the current gap in knowledge, skills and infrastructure in this area leads to disempowerment in the profession.
We end with this provocation: What, after all, does it mean to be a paediatrician in a time of economic crisis? We offer thoughts about how paediatrics might respond to social challenges, such as the COLC, acknowledging that organised and concerted action must be taken both inside and outside of health systems if we are to help bring about the changes that our patients and their surrounding communities urgently need.
- Ethics
- Epidemiology
- Health services research
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Key messages
Seen through a ‘social lens’ the UK’s cost of living crisis can be understood as a symptom of a much deeper, worldwide disease, the ‘crisis of inequality’.
Given that the social, economic and political processes that created the crisis of inequality were not inevitable, doctors can see the resulting impacts on health as a matter of health equity and thus social justice.
Doctors can conceive of their role in attending to social justice as occurring both inside and outside of health systems.
Inside health systems, doctors can change how they conduct clinical encounters, the shape service user pathways and the orientation of research and improvement to deliver more equitable outcomes.
The medical profession needs to be actively involved in promoting social justice. This invites deep professional transformation with an expansion and reimagining of what it means to be a doctor in the 21st century.
What is the ‘cost of living crisis’?
In the UK, media and public discourse have characterised the ‘cost of living crisis’ (COLC) as the result of substantial energy price rises and soaring inflation. Both are already having devastating implications for the financial security of millions of households and businesses reflected in the greatest drop in living standards since records began 60 years ago.1 The often cited ‘heating or eating’ dilemma has become an intractable everyday reality for families at the sharp end of disadvantage; research published in May 2022 shows that 2.6 million children report having smaller meals and regularly skip meals altogether.2
The UK’s so-called ‘COLC’ is in fact part of a wider social, economic and political emergency: what we are calling a ‘crisis of inequality’. The arising differences in health, wealth and power are not simply an imbalance, or result of a passive natural process, but instead are the result of unjust and unfair political and social processes. Health inequalities result from political and social inequities.3 The resultant outlook for children and the society that surrounds them is bleak and will only worsen with time.
The Russian invasion of Ukraine and global supply chain volatility undoubtedly exacerbates economic turmoil, but looking beyond the UK shoreline helps to contextualise the issue. While varying degrees of neoliberal economic policy have been adopted the world over, the British public find themselves in an especially precarious situation owing to the extent of deregulation, market and corporate power and ideological stance of recent governments.4 Comparable economies are providing greater stability for households, businesses and communities resulting in little change in living standards in keeping with stronger post-2020 economic recovery.5 6
Rising energy bills will still drag many households into extremely difficult circumstances this winter despite the government’s intervention on energy price caps, which will see average dual energy bills increase by 96% compared with last winter, not to mention the inequitable impact of a destructive, incoherent and deeply inequitable fiscal agenda. French household energy bill rises on the other hand are capped at just 4%.7 This is a far cry from households in the UK which also incidentally boast the least energy efficient homes in Western Europe.8
From this vantage point, demands for lower energy prices are important but simply not enough. Rather, a ‘causes of the causes’ lens recognises that 40 years of neoliberal political ideology and policy have put profit ahead of people, private wealth ahead of state or common ownership and the class interests of a privileged few ahead of those of wider society.9 The ‘COLC’ has been a chronic-lived experience for the poorest long before the media took notice this year. The ‘new poor’ are being absorbed into the orbit of hardships faced by the ‘old poor’ and those well accustomed to decades of political dispossession. After all, 4 million children in the UK were already in poverty by 2020—well before the pandemic and Russian invasion of Ukraine.
Focusing on energy bills and price inflation as the drivers of the current crisis is myopic. It turns a blind eye to the converging assault of falling wages, rising rent costs and asset inflation, growing intergenerational wealth inequality, precarious employment, anti-union laws, austerity and cuts to public services, departure from the EU, enclosure of commons and natural resources, and the privatisation and deregulation of a fossil-fuel-reliant energy market.10 The true ‘causes of the causes’ of COLC are not overseas conflict and supply chain disruption, but a history of political choices that reflect an ideology based on social, economic, and environmental injustice and concentration of power and wealth in the hands of a small minority (see box 1).11–13
Examples of increasing inequality between rich and poor and its impact on children
In the UK, wealth is even more unevenly shared than household income; by 2022 the wealthiest 10% of households held 43% of all the wealth. In contrast, the bottom 50% held only 9% of all wealth.11
The number of people in in-work poverty has increased by 2 million million since 2010. It is now at a record high, as is the number of children in poverty living in a house where at least one adult is in work.12
The UK is fifth from bottom among 27 European countries for infant mortality. Since 2010 there has been a rise in infant mortality rates for the poorest children, compared with falling rates for more advantaged infants13
What is the impact on child health?
In light of alarming increases in poverty and inequality, the UN Special Rapporteur on poverty found the UK government in breach of its human rights obligations to children in 2019.14 The cost of extreme inequality is paid through the impact on child health across the life course. In the context of the COLC, the poorest households are struggling to afford necessities, which historical evidence tells us results in greater infant mortality, lower birth weights and poorer neurocognitive and social development as well as anxiety, depression and suicide and worse outcomes for those with chronic conditions.15 Poor health, in turn, impacts the healthcare system. Children from households in areas of greater deprivation are much more likely to attend emergency departments and accrue unplanned hospital admissions. Children experiencing chronic ill health fare worse than those from wealthier backgrounds.16
The alarm bells are already ringing as increasing numbers of families find themselves in financial hardship. Research from the Childhood Trust reports a catastrophic picture for children’s mental health and well-being and a 17% jump in self-harm.17 Fears of widespread child hunger have sparked calls for universal free school meals as 800 000 children in poverty do not qualify under current benefit regimes.18
For health workers in emergency departments, wards and surgeries up and down the country, this crisis of inequality has now become an embedded reality of their daily work; asthma exacerbations owing to damp and unsafe housing, increasing hospital admissions due to undernutrition, and inordinate numbers of young people presenting in acute yet preventable mental health crises.16 Paediatricians are treating the symptoms of social and economic policy that are fundamentally at odds with the interests of their patients.
The moral and practical considerations for paediatricians addressing inequality
Ought doctors to be dealing with economic issues? Economies shape health, and the health of patients is, after all, the core concern of the medical profession. The social, economic and political drivers of inequality remain ascendant, and until there is a significant rethink of the current world order, inequality is here to stay. That said, a number of cautions deserve serious consideration here.
First, is the contention that doctors should stick to dealing with the medical aspects of patient care. While undergraduate medical training now increasingly makes reference to the ‘social determinants of health’, curricula still largely exclude explanations of political economy or critical social science perspectives on health. Moreover, many clinicians may legitimately feel that dealing with social problems is ‘not their job’. If medicine’s boundaries are to be wider, can they be redrawn without medicine becoming a general social service for dealing with all the problems people have?
Second, even if there is a legitimate role for doctors on the determinants of health, such as economic inequality, many clinicians would argue that there is neither the time nor resource in current health systems to do this role justice. After all, health systems around the world are facing cost crises of their own; the repeated assaults of the 2008 financial collapse, austerity programmes and the COVID-19 policy response in the run-up to the current time understandably leads to something of a ‘crisis fatigue’.19 Working in these conditions is hard and morale in health services across the world is at an all-time low.20
These questions deserve to be—and are being—explored more deeply by the entire profession. In the meantime, we suggest that, regardless of where in the world we are practising, what unites paediatricians globally is that our patients are our first concern.
What does it mean to be a paediatrician in a time of crisis?
Building on previous work on medical professionalism and health determinants, we propose that paediatricians approach complex, social problems by applying what is called a ‘social lens’ to their work: thinking outside the confines of their clinical roles to instead see their ethical responsibilities extending beyond the clinician–patient relationship.21–23 We suggest this can best be done by thinking of action in two distinct spaces: inside and outside of health systems. By no means exhaustive, and seen rather as a stimulus for creative thinking, tables 1 and 2 give a flavour of the kinds of responses that might result from such an approach, focussing here on economic crises.
Addressing inequality from within health systems
Addressing inequality from outside the health system
Addressing inequality from within health systems
Within healthcare settings, growing interest and energy in healthcare is being directed towards initiatives such as screening for social risk factors, social prescribing and on-site provisioning of resources24 25 (see table 1 for more details). Taken together, these practices can be understood as medicine’s most developed answer to social problems. When handled sensitively, the power of these interventions for bridging sociodemographic divides and empowering patients to better manage their own conditions should not be underestimated (table 2).26
However, as others have argued, ‘public health problems do not necessarily have effective individual clinical solutions’.27 Attempting to address social problems from the clinic or from a purely individualistic acute perspective treats the symptoms but not the underlying cause; these are sticking plaster tools for emergency situations. For more far-reaching and transformational outcomes for child health, a more systemic, connected and preventive approach is required.
In the longer term, clinicians have the duty and power to help shape clinical services to better deal with and mitigate the effects of social inequality. At the level of local service provision, a social lens encourages the removal of barriers to care, greater respect for the autonomy of patients, and the development of more collaborative ways of working for child health professionals. Indeed, children and young people’s services in the UK are increasingly seeing the introduction of new models of care designed to embody these more socially conscious values, and often it has been the efforts of ordinary clinicians using tools such as research and quality improvement to conscientiously address the issues that matter most to them.28
Addressing inequality from outside the health system
Embedded social challenges such as inequality and the COLC will not be solved by the health system alone. Instead, what is required is for society to reorganise itself in ways that genuinely allow people to live happy, healthy lives and that ultimately requires addressing the political and social determinants of health through political and societal change. We suggest that medical professionals have a responsibility to support these efforts in two ways: through ‘profession building’ and ‘society building’, respectively (table 2).
Profession building
We must first set our own house in order before we can put the world to rights.
A social lens also helps health professionals to understand themselves as social beings and the effects their own work environments have on their ability to do their jobs and function as healthy persons. Thus, as well as reconfiguring services to benefit patients in a direct way, reconfiguration could be partly aimed at producing a more humane working environment, which thereby better serves patients.
It is our responsibility to demand better to support professional aspirations to truly act in the best and collective interests of our patients. We discuss two particular aspects of this in more detail now.
Training
Many paediatricians experience frustration and helplessness in the face of social problems such as the COLC, reporting that their training has ill equipped them for the world their patients must survive. Despite a year-on-year increase in the incidence of poverty-related disease in UK child health,29 paediatric training fails to provide clinicians with the specialist skills needed to recognise the signs and symptoms related to deprivation.30 In addition, a failure to acknowledge the importance of—not to mention provide rigorous structural analysis of—the social determinants of health leads to obvious and glaring gaps in both undergraduate curricula and postgraduate training. As a result, the paediatric workforce must look outside of well-worn paths if they want to make up for the public health, policy or economic understanding that is required.
In the UK, the Royal College of Paediatrics and Child Health (RCPCH) is the normative and standard-setting body for paediatricians. ‘Progress Plus’ is the most recent instantiation of the curriculum that all paediatricians in the UK (and elsewhere in the world) are expected to meet by the end of their training. While we welcome the increased reference to ‘public health’ competencies, it is noteworthy that the accompanying curricular guidance document, ‘Paediatrician of the future: Delivering really good training’, fails to mention the idea of ‘advocacy’ for paediatricians even once in all of its fifty pages, and the term ‘social determinants’ only twice.31 This is striking given the now explicit emphasis of ‘population health management for clinicians’ in the National Health Service (NHS) Long term Plan.32 In some senses, what we see in paediatrics merely reflects the long-standing, and admittedly even more pronounced, blindness of the entire modern medical profession in relation to wider conceptions of health and thus the role of doctors in society. To its credit, the RCPCH finally responded to calls for more with a statement acknowledging the role of paediatricians in addressing inequality in late 2022.33
Education is a political act; by eliding politics, doctors’ training is denuded of meaning.34 The result for ordinary paediatricians who wish to pursue professional commitments to help patients who are suffering under social emergencies such as COLC is that they have little to go on. Holmes et al. argue that such a blind spot means that medical care ignores social forces, resulting in ‘misdiagnosis, mistreatment and harm’.35
Working conditions and culture
Professionalism is much more than narrow competencies and a checklist of skills. It is also an ethical and political orientation about how the job is done and how one views one’s role in society, as well as the supporting conditions in which to enact it.36 In the current climate, even if there were better institutional guidance about addressing social problems such as COLC and inequality, paediatricians face other significant obstacles. Rota gaps, heavy workloads, and a culture of training that offer little flexibility or creativity all serve to raise the barrier to entry for clinicians engaging in anything beyond their skeleton job descriptions.
What are we doing as a profession to give ourselves the space to make a meaningful difference in children’s lives? Medical institutions, including the RCPCH, have in general, not done enough to challenge the policies of cuts, closure and commodification that have made working conditions in the NHS increasingly constrained and pressured in recent decades. If we are to be able to act on behalf of our patients, we must challenge the limits of our workplaces, and argue for the time and space to be able to do so safely and effectively.
But the onus also falls on us as ordinary clinicians. Neoliberalism has not only created an unequal world through economic policy but has also reinforced a popular culture in which collective action, agency and empowerment are minimised in favour of a rhetoric of individual responsibility and self-interest.37 We argue that paediatricians must fight against this mentality—even in the face of burnout and resource constraint—if we are to fully realise the potential of our role as advocates.
How can we make addressing the social determinants of health easier for ordinary clinicians? What can we do to create the spaces for mobilising and organising outside of the formal setting? If we, as a profession, want to move beyond rhetoric and platitude towards action, then we must take the responsibility for developing the tools and approaches we need ourselves.
Society building
How can paediatricians aid in the process of building a society fit for children and young people to thrive? As individual clinicians, it is easy to feel overwhelmed and insignificant, but for our patients, nothing could be further from the truth. As argued elsewhere, ‘Doctors carry significant social and cultural capital; our messages are listened to’.22 Paediatricians are uniquely positioned to function as public advocates for child health. Public trust in doctors is very high; to the public, doctors are a credible source of information.38 Given their social standing, doctors enjoy an unusual degree of access to policymakers, local and national leaders, and citizens; thus, they possess a great deal of leverage in influencing public processes and priorities. Never underestimate the power of clinicians to help shape public discourse around an issue; their voices count and now is a critical time to use them. Table 2 draws on examples from around the world to help illustrate how doctors can be part of, and moreover help to accelerate, change.
Conclusion
The UK’s COLC pushes millions more families into poverty, further stripping their lives of dignity and the capabilities to grow and live healthily. While the job of addressing economic crises such as COLC ought not to be left solely to health workers, the paediatric profession must act. For even though policies have been introduced to address the high cost of energy bills, what is needed is a deeper, wholesale change in how the economy and society is organised.
While much has been written about how paediatricians might engage with the determinants of health, we propose that addressing economic crises such as COLC calls for a different approach.
We propose that applying a ‘social lens’ will help to realign paediatric professional roles and our purpose so that they are directed towards addressing both the true ‘causes of the causes’—as well as the effects—of the social, economic, political and environmental determinants of health. This is essential if we are to challenge an economic and professional paradigm that encourages reformist tinkering at the edges over something more transformational.28
A willingness on the part of the paediatric profession to completely question and re-envision their collective professional roles to help address the great challenges of our time—both inside and outside of the health system—is urgent and necessary. It is time to ask for more: changes to medical education and training to empower practising paediatricians to meaningfully engage in economic justice; an overhaul of outdated workforce plans which only perpetuate inequalities through disparities in structured and protected opportunities to tackle inequality in policy and clinical settings; and a cultural shift wherein advocacy is seen as something which occurs on both a collective and population level as well as just between the doctor and the patient. Ultimately, inequality is everyone’s responsibility.
This is a big task and one that needs the whole profession to mobilise and come together. The COLC, and inequality more generally, presents an opportunity to proactively reshape professionalism to better suit 21st century needs of our patients. If not now, when?
Ethics statements
Patient consent for publication
References
Footnotes
Twitter @DrGuddiSingh
Contributors GS conceived the article and wrote the first outline. GS wrote the first draft later added to by AU-C. GS and AU-C subsequently edited and added to further drafts. Table 1 was designed by AU-C and table 2 and 3 by GS, but jointly populated by both GS and AU-C.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.