A system falling short
When a child needs intensive care, their chances still depend on ethnicity and poverty, particularly if they are from an Asian background, as a major new medical study highlights. Journalist Anil Dawar breaks down the sobering research and looks at what needs to happen now.
When a child is rushed to a paediatric intensive care unit (PICU), families would assume that their loved one will get the same shot at survival as every other patient in the unit. That is a reasonable assumption but the statistics say otherwise. A new study led by Imperial College London (ICL) and published in the Lancet, found clear differences in outcomes linked to both ethnicity and poverty. Asian children face a much higher risk of dying than their white, Black and mixed ethnicity peers – a gap serious enough to demand urgent attention from hospitals, policymakers and communities.
PICUs care for the sickest children. Admissions are relatively rare but resource-intensive, and the stakes are extraordinarily high. The team analysed data from 245,000 admissions for 163,000 children between 2008 and 2021, drawn from PICANet, the UK’s national PICU audit.
They wanted to see whether a child’s ethnicity and the level of child poverty in their local area was linked with what happened after admission. Specifically, they wanted to know whether they survived their stay, how long they were kept in hospital and whether they needed to return within 60 days. Because the dataset is both national and long-running, it helps move us beyond anecdote and into a clearer, more sobering picture of who is at greatest risk and where the system is falling short.
‘Headline results are striking’
The headline results are striking. Across all admissions, sadly, 3.7 per cent (9,056) ended with a death in PICU – about one in every 27. This risk was not spread evenly.
For white children, mortality stood at 3.2 per cent, around one in 31. It was a similar number for those of Black ethnicity. However, for Asian children (Bangladeshi, Chinese, Indian, Pakistani and other) it was considerably higher at 5.1 per cent, or one in 20. That means Asian children had about 50 per cent higher odds of dying than their white and Black peers.
Where a child lives also matters. Mortality was 3.1 per cent in the least deprived areas (about one in 32), rising to 4.2 per cent in the most deprived (one in 24). Put simply, children from the poorest areas had a 13 per cent higher chance of dying.
When we break down the data for children from the most deprived areas, we see shocking disparities. Some 43 per cent of Asian children admitted to PICUs came from the most deprived areas, compared with 42 per cent of Black children, 28 per cent of those of mixed ethnicity, and just 19 per cent of white children.
A major caveat is that ethnicity data was missing for nearly one in five admissions. This gap limits accuracy and is itself an equity failure – if the system cannot record who it treats, it cannot design fair services.
‘Universal coverage does not erase structural barriers’
Many assume the NHS treats all patients equally, but universal coverage does not erase structural barriers. Ethnicity is social, not biological – these gaps reflect systemic disadvantages that shape access to care. Families in deprived or minoritised communities may face practical obstacles (transport, childcare, jobs) and barriers of trust or communication. Limited access to interpreters, culturally insensitive encounters and unfamiliarity with the system can all mean children arrive sicker, as well as shape the decisions families make under pressure.
The data highlighting the higher mortality odds for Asian children, even in planned admissions, cannot be explained simply by emergency severity. It raises questions about the design of pre-operative pathways, the quality of communication with families before surgery, the risks associated with certain procedures and the adequacy of post-discharge support. It also underscores the need for solutions tailored with Asian communities themselves, rather than generic measures that fail to account for specific lived experiences.
‘Children from the poorest areas arrive sicker, stay longer and are more likely to die’
The deprivation gradient tells a complementary story. Children from the poorest areas arrive sicker, stay longer and are more likely to die. This reflects not the level of service in a PICU but upstream determinants of health – housing, income, nutrition, environmental risk and the availability of timely primary care.
In other words, PICU is where inequality shows up most starkly, not where it begins. That makes the problem both broader and more solvable. Interventions cannot be confined to hospital walls but must also target the wider conditions in which children are born and raised.
What could change? Inside hospitals, equity basics need urgent attention: guaranteed access to interpreters, culturally safe communication and tailored safety checks such as follow-ups for families with language needs. Hospitals should also track outcomes by ethnicity and deprivation in real time, so inequities trigger immediate fixes.
Beyond the PICU door, access pathways matter. Families in deprived areas should not be left to navigate urgent care alone. Community-based navigation and rapid transport services can make the difference between a child arriving in time or arriving too sick. Condition-specific outreach, whether for asthma, serious infections or congenital conditions, needs to be delivered in the languages and formats families actually use. Aftercare must be strengthened too, with flexible follow-up clinics for children at higher risk of readmission, supported by travel assistance and out-of-hours options.
Above all, this research reminds us that tackling child poverty is itself a health intervention. Policies that raise family incomes, improve housing quality or reduce fuel poverty will save lives in PICU as surely as the most advanced medical therapies. That is why health equity must be pursued hand in hand with anti-poverty policy.
The study also demonstrates the importance of co-design. Solutions cannot simply be imposed from above. They must be built with communities. Asian, Black, mixed ethnicity and other minoritised families should be partners in mapping the barriers in their PICU journeys and designing fixes that actually work, from multilingual information packs to post-discharge check-ins that rebuild trust and confidence.
‘The implications are stark’
For those committed to racial equality, the implications are stark. Inequity in health outcomes is not an accident, nor is it the product of individual bias alone. It is a systems problem with measurable consequences for children at their most vulnerable. This study challenges the comforting assumption that fairness automatically begins once a child reaches specialist care. In reality, equity must be deliberately designed into every step of the journey – GP advice lines, ambulance dispatch, pre-operative clinics, bedside communication and post-discharge support.
The authors of the study end with the conclusion that disparities in PICU outcomes by ethnicity and deprivation are real, measurable and changeable. The gaps revealed here are not an indictment of the clinicians who work tirelessly in intensive care units. They are a map for action. If we address the barriers that push some children to the brink – late access, poor communication, unsafe discharge and the grinding weight of poverty – fewer families will face the worst-case scenario.
A child’s odds in intensive care should never depend on the colour of their skin or the postcode they live in. This study gives us the evidence to make that principle real. What remains is the will to act on it.
Anil Dawar is a journalist born in London to Asian and British parents. He specialises in home affairs and education issues.
The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect those of the Runnymede Trust.
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