Round Table meEting on Child Poverty
In November 2024, we hosted a roundtable meeting on child poverty, bringing together expert speakers and Deep End GPs. This report captures the key discussions and includes recommendations from Deep End Ireland. It was authored by Dr Patrick O’Donnell, Dr Bríd Shanahan, and Prof. Susan Smith.
Summary
It has been shown in the international literature that people living in deprived circumstances have worse health outcomes and endure more complex multimorbidity than the general population. We recognise that children in particular in these areas are at increased risk of disadvantage and they are often unable to advocate for themselves. This was recognised by the Government of Ireland in 2023 with the establishment of the Child Poverty and Well-Being Programme Office in the Department of the Taoiseach. The roundtable meeting described in this document and the recommendations stemming from it add our expert opinion to the discussion on measures seeking to ameliorate the conditions and lives of the children we meet daily in GP surgeries across the country.
Recommendations:
1. Resources to Address Child Poverty Need to be Allocated According to Need
2. Address Issues with GP Recruitment and Retention in Areas of Deprivation
3. Expand the Social Prescriber Remit to include Support for Children and their Families
4. Central Referral Pathway for Children’s Services and Family Supports
"All children deserve to be happy, healthy, have their material and emotional needs met, and be provided with the opportunity to realise their full potential. I believe that this can be a reality for all children in the State and that we can make Ireland the best country in Europe to be a child. Central to achieving this is ending child poverty and promoting child well-being."
Taoiseach Micheál Martin TD
February 2025
Tudor Hart, 1971
Child Poverty
What is Child Poverty?
“When a person does not have resources to live to an acceptable standard, they are in poverty. Typically, poverty describes financial hardship, but other dimensions include reduced freedom to express opinions and have choices, and impaired ability to access services and resources.” (Lee et al., 2023b)
Child poverty is thought to affect almost one in three children around the globe, and significant numbers of those children are living in extreme poverty (Schmidt et al., 2021). Poverty and material deprivation result in the unequal distribution of resources and power, which has direct impact on the material, environmental, economic and psychosocial conditions that children are living in (Schmidt et al., 2021). Poverty is linked to adverse health outcomes in childhood, and it can increase the subsequent risk of being diagnosed with physical or mental illnesses in later in life (Wood, 2003, Council On Community et al., 2016, Pascoe et al., 2016, Schmidt et al., 2021, Lee et al., 2023b). Poverty also affects the physical and mental health of parents which can then adversely impact their ability to provide adequate care to their children (Conger et al., 2010, Maître et al., 2025). Poverty negatively impacts the quality of accommodation available and the neighbourhood a person lives in, which can in-turn impact “children and young people’s cognitive development, achievement, engagement in school, behaviour and health” (Twenge and Campbell, 2002, Laurence et al., 2024). The effects of poverty in later life have also been documented, including that adults who grew up in poverty are more likely to endure material deprivation, have lower levels of education and higher levels of unemployment when they reach adulthood (Curristan et al., 2022).
The Royal College of Paediatrics in the UK and Lee et al. (2023b) have described the main drivers of child poverty as coming from a low income household and having to deal with high costs of living (Ref: www.rcpch.ac.uk/resources/health-inequalities-tool-1-improve-your-understanding-child-poverty-health-inequalities). These conditions can create a situation where a household has low financial resilience and limited ability to deal with unforeseen ‘shocks to the system’. When these characteristics are added to having a household member with a long-term condition, being in a lone parent family or being from certain minority ethnic groups, these can lead to significant child poverty. Fig 1 below highlights this cascade of financial difficulties.
Figure 1 The ‘Low Financial Resilience Model’ of family poverty: Structural financial drivers of family poverty
(Lee et al., 2023a, Lee et al., 2023b)
Mechanisms by which poverty can affect child health outcomes
Dahlgren and Whitehead described a model of the social determinants of health that includes lifestyle factors, community networks and wider socioeconomic, environmental and cultural conditions into which people are born and live (Dahlgren and Whitehead, 1991). There are then complex influences that can begin to contribute to worsen child health inequalities. Healthcare professionals can work to positively influence these mechanisms either directly though their clinical work, or indirectly through advocacy efforts. Lee et al. (2023b) summarised four key considerations in this regard:
1. “Parents in poverty are less able to offer their children a healthy lifestyle”
There are powerful time, resource and financial restrictions that limit what parents in poverty can provide for their children. Structural barriers and the upstream causes of poverty must therefore be addressed to seek to improve these inequities. Solutions to these challenges should be codesigned with experts by experience from affected families and communities.
2. “The odds stack up against children”
Recurrent exposure to adverse circumstances related to poverty accumulate over time, and the children affected are less likely to have protective factors to mitigate the effects of these repeated insults.
3. “The inverse care law”
Low socioeconomic status can be associated with having to avail of poorer quality healthcare. Children living in deprived areas may have less access to required medical services (Fisher et al., 2020). For example, general practitioners in areas of deprivation tend to have larger patient list sizes than those in areas of relative affluence. In the UK it has been noted that GP practices in deprived areas tend to have lower quality scores on evaluations and poorer patient satisfaction results (Fisher et al., 2020). Also, any public spending reductions disproportionately affect disadvantaged areas and services provided in those areas.
4. “Poverty gets under your skin”
Being born into and growing up in an environment of poverty has notable effects on the metabolic, endocrine and inflammatory systems in the body (Jensen et al., 2017, Carroll et al., 2011, Hostinar et al., 2017, Lupien et al., 2001). As seen in Figure 2, this can have direct impact on health and development of the growing child and can contribute to the development of many life-long health issues.
Figure 2 The potential impacts of child poverty (Schmidt et al., 2021)
Solutions
The American Academy of Paediatrics developed a policy statement on child poverty and heath in 2016 (reaffirmed in 2021) that summarised actions that were necessary to try to address the challenges of child poverty including “tax policies and direct financial aid, access to comprehensive health care, early childhood education, nutrition support, home visiting, family and parenting support in the medical home, early identification of families in need of services and interventions for adolescents and parents of young children” (PEDIATRICS et al., 2016). These wide-ranging suggestions drew on evidence from successful policies and initiatives that had been taking place mostly in the United States.
Similarly, Lee et al. (2023b) recommend starting to tackle child poverty by working at a number of different levels (see Fig 3). They recommend beginning by talking to parents who are experts in their own experiences of poverty, other professionals and stakeholders with local power about child poverty and the health consequences. With parents, they recommend routinely asking about financial status and challenges to destigmatise these discussions and truly understand the context that patients are living in. They also caution against only asking parents from specific areas about financial challenges, and that instead this ‘screening’ should happen for all parents. Showing solidarity and empathising with these parents is extremely important.
Figure 3 A framework for healthcare institutions to address child health inequalities (Lee et al., 2023b)
Structural changes will not come about without speaking to other professionals policy-makers, however (Lee et al., 2023b), and it has been noted that “inequalities cannot improve without repairing the inherent problems in society and health services.” Therefore, when speaking to other stakeholders including policy makers and healthcare leaders our input as clinicians must include relevant evidence as well as our experiences. Networks of like-minded parties with similar goals are important in order to bring issues to prominence and when trying to address major structural issues. Explaining the point that “the benefits of addressing child poverty cut across the board—there are financial, resource, moral, ethical and environmental benefits if children do not live in poverty” is vital, as well as highlighting that “poverty increases the risk of childhood mortality” helps to express the urgency of the situation.
Child poverty in Ireland
Context
The Central Statistics Office Survey on Income and Living Conditions (SILC) 2023 figures showed that 559,850 people in Ireland were living in poverty, of which 176,912 were children. It was also noted that 145,561 people living in poverty were in active employment - the “working poor” (Social Justice Ireland, 2024). The government has recently published figures on a variety of childhood indicators relating to health and poverty, including the numbers of children living in homelessness and estimated unmet healthcare needs (see Fig 4).
Figure 4 – Selected indicators on child poverty and child well-being (Department of Taoiseach, 2025)
In the Irish context the most commonly used measures of poverty are (Maître et al., 2025):
• Income poverty – coming from a household where disposable income is less than 60 per cent of median income
• Material deprivation – where a family cannot afford at least two of five basic costs like paying household bills on time or heating their home.
The ESRI have noted that while child income poverty has continued to decline consistently in Ireland since 2004, for most of that time income poverty rates were higher for children than for any other age group in the Irish context (Maître et al., 2025). We also know that the households with the highest risk of child poverty include (Maître et al., 2025):
• Households with three or more children
• Households led by lone parents
• Those living in rental housing, with those in the social rented sector having the highest risk
• Households where at least one person is classified as having a disability
• Households where there is no working-age adult at work
It was in this context that the Child Poverty and Well-being Programme Office was established in the Department of the Taoiseach in 2023. The subsequent Programme Plan entitled “From Poverty to Potential: A Programme Plan for Child Well-being 2023-2025” sought to catalyse cross-departmental working on key areas that were felt to be most beneficial and pressing in terms of the needs of children in poverty (Department of Taoiseach, 2023). The six priority areas for action were:
• Income Supports and Joblessness
This includes child benefit and working family payments
• Early Learning and Childcare
• Reducing the cost of education
This includes Back to School Clothing and Footwear Allowances and free school meals programmes.
• Family homelessness
Rebuilding Ireland is the national policy in this area
• Consolidating and integrating Family & Parental Support, Health and Well-being
• Enhancing participation in culture, arts and sport for Children and Young People affected by poverty.
The Department are now working to co-ordinate and focus government action on these six areas, and evaluation of the renewed and targeted efforts is awaited. The Government have also enhanced specific health initiatives such as the Slaintecare Healthy Communities Programme that forms part of the Healthy Ireland framework that seeks to improve the health of the population as a whole but includes specific projects targeting children and families in deprived areas. These include the Healthy Food Made Easy, Parenting Programmes and Social Prescribing initiatives. In recent months, they have published a progress report on the work of the Child Poverty and Well-being Programme Office and they have set out the enhancement of Family Support Services and specific focus on the needs of ‘excluded groups’ including children in homelessness as key priority areas for work in the coming year (Department of Taoiseach, 2025).
It is with this international evidence in mind and an understanding of the Irish context that we developed the round table meeting for DE Ireland members aiming to explore the ideas on how GPs working in areas of deprivation can support children living in poverty and their families around the country.
Child Poverty In Ireland - the workshop
List of Speakers
• Jackie Austin, Director of Public Health Nursing for North Dublin
• Naomi Feely, Senior Research and Policy Manager for the Children’s Rights Alliance
• Anna Visser, Principal Officer, Child Poverty and Wellbeing Unit
List of Attendees
Dr Bridget Kiely, Dr Christabell Cavey, Dr Mark Murphy, Dr Bronte Cloete Wakefield, Dr Orlaith Whelan, Dr Niall Compton, Dr Chiadika Uzor, Dr Deirdre Carroll, Dr Fiona Monahan, Dr Vivienne Wallace, Jackie Austin, Dr Mary Favier, Prof Susan Smith, Dr Bríd Shanahan, Dr Patrick O’Donnell, Dr Finola Minahan, Naomi Feeley, Dr Edel McGinnity.
Chair of discussion: Professor Susan Smith
Advice from Panel to inform final recommendations
• The panel recommended that the group assess existing structures and explore how they could be adapted to be more effective or to address key areas of concern. This tends to be a more favoured approach than creating entirely new structures.
• The distribution of health professionals should be dependent on need, as deprived areas face significant challenges due to high caseloads and the complexity of cases.
• We must address GP needs in order to mitigate risks – burnout is a huge issue for GP teams due to overwhelming caseload and the complex patient needs. This often leads to further retention issues and disrupts continuity of care.
• A clear roadmap for implementation is essential. Identify what the ‘first step’ is in order to make it easier when posing policy recommendations.
• Securing government commitment to policies addressing child poverty is vital. Legislative measures to reduce child poverty rates should be prioritized, ensuring consistency in approach across multiple budget
Child Poverty In Ireland - Deep End Ireland Recommendations
1. Resources to Address Child Poverty Need To Be Allocated According to Need
There needs to be increased staffing for GP and Primary Care teams in deprived areas. Working in areas of deprivation is often more demanding, requiring higher staff-to-patient ratios. Recognising the intensity of the work and providing adequate support is critical to meeting community needs effectively. Increased funding is essential to attract and retain staff in these areas. A Deis-like model of funding for practices in deprived areas could provide targeted financial resources, enabling practices to offer competitive salaries, enhanced training opportunities, and improved working conditions. Improved staff to patient ratios would result in a more equitable standard of care for the complex patients living in areas of deprivation.
Deprived areas often experience high staff turnover and low staffing ratios, which disrupt continuity of care and relationship-building with family units. Allocating sufficient resources to support long-term care relationships is essential.
There also needs to be a commitment to comprehensive provision of services in areas of deprivation. Policy makers should ensure that all GMS contract holders provide vital services, such as childhood vaccinations, combined antenatal care and supports for maternal health.
2. Address issues with GP recruitment and retention in areas of deprivation
High patient volumes and complex health profiles in these areas lead to stress and burnout, which contribute to retention issues. Mitigating these challenges requires targeted interventions such as implementing caps on list sizes, weighted by levels of deprivation, to balance workloads. Also, offering structured time for professional development or interests, such as teaching or research, to prevent burnout and enhance job satisfaction.
Newly qualified GPs require tailored support to thrive in challenging environments. Investments in moralebuilding initiatives, peer support opportunities, and mentorship programmes can strengthen retention and improve patient outcomes. Additionally, newly qualified GPs should be supported to set up new practices in underserved areas. Using vacant HSE plots to provide buildings for new practices could reduce barriers to entry and help establish essential healthcare infrastructure where it is needed most.
Exposure to deprived communities during training is vital. Providing placements in these areas ensures GPs develop the skills and understanding needed to work effectively, reducing stigma and building confidence in addressing complex health needs.
3. Expand the Social Prescriber Remit to Include support for Children and their Families
GPs need additional support when referring patients to supports, services, and resources, as it is impossible to have comprehensive knowledge of all available services in a given area. One potential solution is to leverage the existing social prescriber framework to include centrally accessible family support co-ordinators who can streamline referrals and provide clear guidance for families for parenting supports as well as support services for children such as counselling, play therapy, youth clubs etc.
4. Central referral Pathway for Children’s Services and Family Supports
An ideal solution would be a central referral pathway for all children’s services, operating under a "no wrong door" policy. This would ensure that families can access appropriate services regardless of their initial point of contact.
A pilot project in CHO9 is currently trialling this approach for CAMHS, CDNT, and MDT services. Under this system, a single referral form is used, allowing referrers to tick one or more services. If a selected service determines that it is not the appropriate provider, the responsibility falls on them to redirect the referral to the correct service, rather than rejecting it outright.
However, this model has some limitations. It does not include supports such as voluntary sector services, parenting supports, Tusla, or Assessment of Need. Expanding this approach to include all relevant services and ensuring that no referral is left without a clear pathway to support would be essential in making this system truly effective.
Additionally, there should be a centralised, regularly updated list of social care services to ensure accessibility and transparency. To enhance visibility, it should be a requirement for all social care providers to be included in this directory as a condition of offering their services.
Case Studies
Child A is a 14-year-old girl living in a two-bedroom apartment with her mother and four siblings, three of whom are under the age of three. She has her own bedroom, while two of her siblings share a room. Her mother sleeps on the couch, and the two youngest children sleep in travel cots in the living area.
Child A has always been prone to anxiety. She was first referred to psychology at age six, but by the time an appointment became available a year later, her symptoms had improved, so her mother chose not to attend. She was referred again at age 11 due to ongoing concerns about anxiety. A year later, psychology services contacted her GP to report that her mother, who was pregnant at the time, was struggling to find time to engage with them.
Academically, Child A excelled and attended a well-regarded secondary school. However, her behaviour began to deteriorate two years ago, at age 12, following the birth of her twin siblings, who arrived within 12 months of another baby. She refused to attend school and began vaping.
A year ago, her GP referred her to a teen counselling service and recommended that she join a local youth club staffed by trained key workers. When the GP saw her again six months later, she had attended only two days of school in the first ten weeks of term. Although she had received counselling appointments, the service did not allow younger children to accompany parents, making it impossible for her mother to bring her. She also refused to attend the youth club.
Her GP contacted her school and spoke to the home-school liaison officer, who was attempting to transfer her to an inner-city school that was deemed to be better equipped to support children with behavioural difficulties. Her GP also submitted another referral to primary care psychology and referred the family to Tusla, as her mother was struggling to cope with all the children at home.
Her GP spoke with her mother last week. Child A will not be sitting her Junior Cert this year and will be transferring to a new school. Her mother has yet to hear from Tusla. Given this, her GP is now making a direct referral to the Tusla family support service. Her GP has also written multiple letters advocating for more appropriate housing for the family.
At age 10, this child had a bright future. Now, there is a strong possibility that she will not complete school. This could have been prevented if more intensive whole-family supports with outreach, had been available earlier.
Child B is a 5 year old boy from the Roma community. He was first referred to CDNT by his GP at 2 and a halfyears old due to speech delay and fine motor difficulties.
At age 4, his mother returned to the GP with ongoing concerns. The child had very few words in Romanian and no words in English. The GP contacted CDNT to check on the referral status, only to be informed that the referral had been refused two years earlier. A letter had been sent to the child’s mother at that time, advising her to discuss a referral to Speech and Language Therapy (SLT) with the GP. However, this letter was written in English, despite the original referral stating that the mother did not speak English. She had not understood the letter, and the GP had not been copied in on the correspondence.
Upon learning this, the GP referred the child to SLT, and six months later, SLT confirmed that the child did, in fact, require assessment by CDNT. The GP formally requested that CDNT reinstate the child’s place on the waiting list from the date of the original referral, but this request was denied.
Meanwhile, the child had started primary school, where his difficulties became more apparent. The headteacher contacted the GP, raising concerns about his development. Both the GP and the school sent further letters to CDNT, advocating for urgent assessment.
Despite these efforts, the child still has not been assessed.
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