Education and debate

Who is speaking for children and adolescents and fortheir health at the policy level?
Albert Aynsley-Green, Maggie Barker, Sue Burr, Aidan Macfarlane, John Morgan, Jo Sibert,
Tom Turner, Russell Viner, Tony Waterston, David Hall
The Bristol inquiry has put children at the heart of the
public’s agenda on health. This contrasts with theseemingly low position of children on the Westminster
government’s own health agenda. This status isexemplified by the current consultation exercise to
draw up a national plan for health. Although this,
together with the increase in funding for the NHS, iswelcome, paediatricians are dismayed at the inadequate voice for children and adolescents in the modernisation action teams that are taking forward thedefinition of the plan.1 Only one registered children’snurse and a health visitor have been appointed to becustodians of the interests of all children and young
people. This reinforces a widely held perception bychildren’s doctors and nurses that the government is
not committed to ensure that the interests of children
and adolescents—whose needs are different from thoseof adults—are spoken for as a client group in the healthservice. We argue that there is an urgent need for children and adolescents to be explicitly represented at alllevels of health policy. Furthermore, measures need to
be implemented to deliver not only a coherent strategy
for children’s health in England, but also more effective
responsibility for integrating service delivery at the
local level.
These criticisms may seem unfair in view of thegovernment’s clearly stated intention to transformsociety through economic and social policies designed
to reduce inequality and poverty. It has responded to
the Acheson report on inequality and provided muchneeded direction on improving education andchildren’s welfare, particularly in vulnerable families. It
has also emphasised the need for “joined up” working,particularly through the Quality Protects initiative, andhas created new structures in the NHS, including
health action zones, health improvement programmes,
the Commission for Health Improvement, and the
National Institute for Clinical Excellence. Although it is
too soon to assess the impact of these far reachingchanges, they are likely to benefit the lives and health ofchildren and adolescents, and this is welcome.
However, until now these initiatives, with some
exceptions such as Sure Start, have been introduced
without children and adolescents being recognised as adefined client group with specific needs. In England,
despite the government’s support for the United
Nations’ Convention on the Rights of the Child, there
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Personal view p 249

Summary points
Children and young people are a nation’s mostprecious resource, and their health is vital for the
future success of our society
Despite this, improving the health of English
children is not a key government target
Children are not young adults: their special healthneeds should be acknowledged
A strategy needs to be defined for children andyoung people, with responsibility allocated for
integrating care within the health service andbetween sectors
It needs to be recognised that children havefundamental human rights for which protection isneededhas been no national or governmental body or person
specifically charged with protecting the rights ofchildren nor with assessing the impact on children of
the policies emerging from individual ministries. For
the NHS, improving the health of children and adolescents in itself is not a key target. Although identified fordevelopment in due course, the process for creating anational health service framework for children andadolescents has yet to be implemented. In those thathave been implemented, children are excluded, withthe exception of those with diabetes. Children are
mentioned only in passing in the recently announced
reforms of funding for research and development, and,with some exceptions, improving child health is not ahigh priority for local service delivery. Few English
health authorities have health purchasing commissioners dedicated exclusively to children, children’s needs
are found in only 16% of health improvement plans,
and only 1 in 10 health authorities has any policies onadolescent physical health.2 3 Furthermore, there iscurrently a dismantling in some districts of services
that have been well integrated and commended in theHouse of Commons select committee’s report on thestate of children’s health.4 Finally, specific services forGreat OrmondStreet Hospital forChildren and theInstitute of Child
Health, University
College London,
LondonWC1N 1EH
AlbertAynsley-Green
president, Associationof Clinical Professorsof Paediatrics
Russell Viner
senior lecturer inadolescent medicine
Camden and
Islington Health
Authority, London
NW1 2LJ
Maggie Barker
director of publichealthRoyal College ofNursing, London
W1M 0ABSue Burr
adviser in paediatricnursing
Public HealthResource Unit,
Institute of Health
Sciences, Universityof Oxford, Oxford
OX1 3PT
Aidan Macfarlane
consultant
University of Wales
College ofMedicine,
LlandoughHospital, Penarth,
Cardiff CF64 2XX
Jo Sibert
professor ofcommunity childhealthNational Children’s
Bureau, London
EC1V 7QR
Tony Waterston
consultant
paediatrician
continued overBMJ 2000;321:229–32

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Education and debate
Royal College ofPaediatrics andChild Health,London W1N 6DE
Tom Turnercollege officer for
ScotlandJohn Morgan
college officer for
Wales
David Hall
president
Correspondence to:
A Aynsley-Greena.aynsley-green@
ich.ucl.ac.uk

children are still not available in 40% of the country.
This is despite reduced inpatient stay and an increasing
number of children and adolescents with complex
needs for continuing care. The recent creation of eight
Diana Children’s Community Nursing Teams is
welcome, but they are not financed by monies from the
Department of Health.
This unsatisfactory position contrasts starkly withchild focused initiatives appearing from the newnational governments, particularly in Scotland. There,
an accessible minister for children has been appointed,
the health of children is one of four health priorities
for 2000-2003, paediatricians serve on key policy
groups, and the needs of children are the responsibilityof local health boards on which paediatricians sit. The
National Assembly for Wales has also identified theneeds of children to have high priority and will soon beappointing a commissioner for children. There is also a
minister for children and a health secretary who has a
special interest in children’s affairs. Children’s healthissues are at the top of the agenda for the Specialised
Health Services Commission for Wales.
If the benefits to children and adolescents in
England from the current financial and policy reforms
are to be realised, then several fundamental culturaland organisational changes are needed (box). Implementing these changes depends on effective advocacy
for the interests of children and young people at alllevels from central government to local communities. If
these proposals require justification it can be found byanswers to several questions.

Cultural and organisational changes that would
benefit children and adolescents in England• As articulated in the UN Convention on the Rightsof the Child, there should be explicit recognition thatchildren have fundamental human rights for which
protection is needed• Children should be acknowledged to have special
requirements for health and should not be regarded as
small adults• Specific authority should be delegated to individuals
and bodies to be responsible for defining strategy forchildren and adolescents and for integrating carewithin the health service and between sectors

high priority in the government’s philosophy, policy,
and strategy, and in allocating resources. It seems perverse that so much resource is currently being targetedto the palliation of adult disease, with so little focus onaddressing the antecedents of adult health inchildhood and adolescence. Although social policy
interventions to reduce poverty are important in areas
such as obesity, diabetes, cardiovascular risk, injury
prevention, and mental health, other interventions inearly life are likely to be more cost effective than at anyother age. The need for urgency in addressing theseissues is supported by the fact that in many areas, key
indicators for youth health are going the wrong way—these include obesity, smoking, suicide, and exercise.
The successful prosecution of the case for children andadolescents demands effective advocacy.

Key questions

Are children just small adults?
Childhood encompasses specific groups: newly bornbabies, infants, children, and adolescents. Each is at adifferent stage of emotional, neurological, and physicaldevelopment, and each demands policies, services, andsupport tailored to reflect these differences. Since mostcannot speak for themselves or are not given theopportunity to express their views, others must
advocate for them. Children are not small adults, yethealth professionals caring for children and adolescents fight a continuous battle for this concept to beunderstood. With an increasingly older population andthe demands of services for the elderly, the needs ofchildren, unless made specific, are increasingly likely to
be overlooked.

JEZ COULSON/INSIGHT

Why are children important?
Although it might seem superfluous to ask thisquestion when children and adolescents represent
about 25% of the population, the answer is fundamentally important. Children are vital for the future
strength and success of our society. They are our guarantee for the future, yet currently one in three children
lives in poverty, with major effects on their health.
Although healthy children become healthy adults,
much adult disease has its origins in early life, andevents in childhood and adolescence have long term
sequelae that determine adult wellbeing. There would
seem to be an irrefutable case for giving child healthSome of the basic principles in the health care of children are ignored

230

Are the fundamental human rights of children
being compromised by the present lack of
responsibility for them?
One example illustrates a health consequence of thepresent lack of responsibility for children andadolescents. Children are denied effective treatment by
the failure of government and professional bodies andthe market imperatives of the pharmaceutical industry
to ensure that the use of medicines is informed by hardscientific evidence of efficacy and safety. Thus, 50% of
drugs given to children in general hospitals, 60% given
to them in specialist centres, and 90% given toseriously ill neonates are not licensed for use in childhood. Because of the failure to recognise their needs
and to perform appropriate research, children are
denied access to information that adults would
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demand as a fundamental right—is this because theycannot vote?

Proposed strategies for improving the status ofchildren and adolescents• Children and adolescents should be seen as adefined and specific client group in all hierarchies of
responsibility• An independent children’s commissioner orombudsman for England working with others in
Scotland, Wales, and Northern Ireland should be
responsible for integrating and evaluating the impactof all threads of government policy that relate tochildren and adolescents and for protecting theirrights• A national strategy for children’s and young people’s
health should be informed by multiprofessional
strategic forums that have direct access to the
management executive, chief medical officer, and chief
nurse and implemented by designated officials withidentified responsibilities for children• Individuals should be appointed at regional, district,and trust level to be responsible for defining local
health policy, priorities, and practices relating tochildren and adolescents. This is particularly
important to ensure that the opportunities provided
by the development of primary care groups and trusts
are not compromised by the creation of new
functional barriers between service providers• Authority should be given to implement change andto deliver effective services in the light of specificbudgets for children and adolescents and their healthneeds within the framework of local healthimprovement programmes for young people• Children’s health improvement programmes shouldbe truly intersectorial embracing other joint children’splanning devices, particularly children’s and young
people’s services plans• Local multiprofessional forums between education,social services, and health should be created to inform
strategy, monitor performance, and develop jointcommissioning• Effective leadership is needed at all levels to facilitate
joined up working, with effective intersectorialcommunication, collaboration, and working practices• Improving the health of children should be a key
priority for research and development in the NHS• The views of parents, children, and adolescents
together with those of clinicians dealing with young
people urgently need to be incorporated into theformulation of strategy and delivery of services

A voice for children and adolescents
So, who does speak for the health of children and adolescents? In 1996, under an exercise initiated by theConservative government, the special advisory groupon NHS research and development priorities toimprove the health of mothers and children soughtcomment from the 260 bodies it identified to haveinterests in children and their health.5 In 1997, the parliamentary health committee in seeking evidence on
the specific health needs of children and young people
sought advice from over 50 bodies and many individuals.4 Royal colleges and other institutions speak forchildren by being the custodians of standards for training and professional competence. The British Medical
Association has produced an authoritative reportfocused on the impact of social and economic inequality on child health.6 The public supports the health ofchildren through highly successful charitable fundraising. There is no lack of public interest orcommitment to children’s health.
What then is the problem? There is widespread
frustration among health professionals responsible forthe care of children and adolescents in England. Theynote that the government has failed to monitor the
implementation of existing guidance despite reports
showing that some of the basic principles in the healthcare of children are ignored.7 In many instances, incontrast to the focus given by local authorities andsocial services, they see fragmentation of young
people’s health services, with inadequate representation in the planning and strategic process. This islinked to the failure to charge anyone at any level withthe responsibility for ending the current fragmentationof children’s health services and the lack of cohesion inpolicy. They believe that there is unwillingness or an
inability at the policy, strategic, and operational levels
to accept that the needs of children and adolescentsare different from those of adults. Children and adolescents require resources and budgets specificallytargeted to their requirements.

PIERS CAVENDISH/IMPACT

Improving the status of children andadolescents

Events in childhood help determine adult wellbeing

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There should be better prospects now than for many
years to speak effectively for children, to improve theresponsibility for young people’s rights, and to addressin particular the fragmentation and lack of coordination of health policy and service provision. To achievethese we propose several strategies (box).
Children are our most precious resource. We urgethat proper recognition of this be shown by improving
the explicit profile given to them in government healthpolicy and practice. We hope that these proposals will
be considered carefully in the current debate on thenational plan for the NHS. Effective advocacy for children is the key to changing attitudes. Staff engaged in
caring for children have much to learn from our
American colleagues in training to become effective
advocates.8
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Education and debate
Contributors: AAG had the original idea of writing thepaper after being involved in discussing the issues at phase 2 of
the inquiry into the management of care of children receiving
complex heart surgery at the Bristol Royal Infirmary in January
2000. He wrote the first draft and will act as guarantor. MB, SB,
AM, RV, TW, and DH contributed to subsequent drafts fromtheir individual professional perspectives. JM, JS, and TT
critically reviewed the paper and contributed their comments on
the Scottish and Welsh perspectives. All authors saw and agreed
the final version of the paper.
Competing interests: None declared.
1

Department of Health. Health secretary announces membership of modernisation action teams to draw up national plan for health. London: Department of
Health, 2000. (Press release 2000/02081.)

2

3

4

5
6
7
8

Viner RM, Keane M. Youth matters: evidence-based best practice for the care ofyoung people in hospital. London: Caring for Children in the Health Services, 1998.
Improving children’s health. A survey of 1999-2000 health improvement
programmes. London: NSPCC, Children’s Society, National Children’s
Bureau, 2000.
House of Commons Health Committee. Second, third, fourth, and fifth
reports of session 1996-7. London: House of Commons Health Committee,
1997.
Improving the health of mothers and children: NHS priorities for research anddevelopment. London: Department of Health, 1996.
Growing up in Britain. London: British Medical Association, 1999.
Audit Commission. Children first: a study of hospital services. London: Audit
Commission, 1993.
Berman S. Training pediatricians to become child advocates. Pediatrics
1998;102:632-6.

(Accepted 21 June 2000)

Conflict and health
War and mental health: a brief overview
Derek Summerfield
This is the thirdof four articles
Department of
Psychiatry,
St George’s
Hospital Medical
School, London
SW17 0RE
Derek Summerfield
honorary seniorlecturer
Series editor:
Anthony B Zwi(Anthony.Zwi@
lshtm.ac.uk)
BMJ 2000;321:232–5

About 40 violent conflicts are currently active andnearly 1% of the people in the world are refugees ordisplaced persons. Over 80% of all refugees are indeveloping countries, although 4 million have claimed
asylum in western Europe in the past decade. Manywars are being played out on the terrain of subsistence
economies; most conflict involves regimes at war withsectors of their own society—generally the poor andparticular ethnic groups, such as the ethnic Albanians
in Kosovo. Atrocity—extrajudicial execution, torture,disappearances, and sexual violation—generates terror,
which maximises control over whole populations, as
does the intentional destruction of the fabric of social,economic, and cultural life. Community leaders, healthworkers and facilities, schools, academics, places ofworship, and anyone who speaks out for human rights
and justice are often targets. In many regions such war
is a factor in the daily lives and decision making of awhole society.

Individual effects
There is no such thing as a universal response to highly
stressful events. However, somatic presentations suchas headaches, non-specific pains or discomfort in torso
and limbs, dizziness, weakness, and fatigue are central
to the subjective experience and communication of
distress wrought by war and its upheavals worldwide.
This does not mean that these people do not have psychological insights but that somatic complaints reflecttraditional modes of help seeking and also their view ofwhat is relevant to bring to a medical setting.1 Some
researchers see somatic symptoms as physiologicalresponses driven by stress; others emphasise theircommunicational element—these may be the only
available expressions of the collective distress of
powerless and persecuted people denied societal
acknowledgment and reparation.2
Though the impact of combat on soldiers has beenstudied since the American civil war, the medical literature on civilians has burgeoned only in the past two
decades. It is still based mainly on clinic populations of
war refugees who have reached the West. One
232

Summary points
The reframing of normal distress as psychologicaldisturbance is a serious distortion
Personal recovery is grounded in social recovery
Rights and social justice shape collective healing
Researchers must attend to resilience factors andbeware of extrapolating from clinic based samples

exception is Northern Ireland, one of the few conflicts
from which comprehensive medical records areavailable. Over the past 30 years there has been no evidence of a significant impact on referral rates to mental health services.3 The current literature is dominatedby post-traumatic stress disorder, the successor toformulations such as “concentration camp syndrome,”“survivor syndrome,” and “war neurosis.” Althoughpost-traumatic stress disorder is reported to beprevalent worldwide in populations affected by war, theassumption that a Western diagnostic entity captures
the essence of human response to such events
anywhere, regardless of personal, social, and culturalvariables, is problematic.4 Features of post-traumaticstress disorder are often epiphenomenal and not whatsurvivors are attending to or consider important: mostof them remain active and effective in the face of continuing hardship and threat.5 Thus uncritical application of diagnostic checklists for post-traumatic stressdisorder may generate large overestimates of the numbers needing treatment.
Although some victims do develop significant psychiatric and social dysfunction, the relation between
traumatic experiences and outcomes is not clearcut. A
prewar history of psychological vulnerability is a risk
factor.6 Recent research shows that secondary consequences of war—on family, social, and economic
life—are important predictors of psychological outcomes.7 In Iraqi asylum seekers in London, poor social
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