Dr Alice Lee and Professors Dan Hawcutt and Ian Sinha describe how a dedicated Clean Air Clinic implemented at Alder Hey Children’s Hospital Trust links health outcomes with housing and environmental conditions, providing actionable reports to improve respiratory health.

Respiratory illness remains the leading cause of hospital admissions among children in the UK, with the highest burden falling on families in deprived areas.

A major driver of this inequality is the environment in which children grow up. Air pollution and poor housing quality, particularly in social and private rented accommodation, continue to take a serious toll on child health.

The tragic death of toddler Awaab Ishak in 2020, following prolonged exposure to damp and mould in his family’s social housing flat, highlighted with devastating clarity the consequences of environmental neglect. Against this backdrop, tackling ecological and housing-related triggers must be seen not as an optional extra, but as a core clinical intervention in paediatric respiratory care.

The Clean Air Clinic model

Founded in 2021 by paediatric respiratory consultant Professor Ian Sinha, our Clean Air Clinic at Alder Hey Children’s Hospital Trust is the first dedicated service of its kind. What began as evening consultations for children identified during routine respiratory clinics soon expanded into a formalised service for patients whose recurrent illness is suspected to be linked to environmental exposures.

Referrals typically involve children with recurrent wheeze, asthma or respiratory infections. While some cases are linked to outdoor air pollution or industrial emissions, most are related to poor housing conditions – particularly damp and mould.

The structure of Clean Air Clinic appointments

Each consultation weaves together three strands:

  1. Detailed clinical history: all healthcare encounters across community, emergency and hospital settings are collated. This includes a comprehensive review of medication history, investigations and other risk factors for poor respiratory health
  2. Environmental history: a review of environmental exposures across the child’s life, including homes lived in during pregnancy. Each address is cross-referenced with traffic information and local air quality monitoring data. Appointments are virtual, enabling parents to share a detailed picture of housing conditions including damp, mould, ventilation, pests, and heating while showing the property via video and sharing photographic evidence of areas of concern. Although indoor air monitors were trialled, routine monitoring was not found to be useful in individual cases due to the absence of established legal limits for indoor air quality
  3. Integrated assessment and report: clinical and environmental findings are combined to identify how environmental triggers are influencing the child’s health. The family receives a tailored report outlining current health effects, future risks and recommendations for remediation.

Beyond addressing immediate medical optimisation, the reports created in the clinic serve as advocacy tools – concrete, evidence-based documents that are shared with councils, landlords and housing associations, either by the families themselves or by the clinic directly, to trigger environmental interventions.

Working with councils and communities

The success of the Clean Air Clinic has hinged not only on clinical expertise but also on carefully building relationships with councils, housing associations and communities. This collaborative approach represents a cultural shift: paediatric clinicians stepping outside the hospital walls to tackle the root causes of illness in partnership with the systems that shape children’s environments.

Initial challenges in the clinic included reports being delayed or overlooked within complex bureaucracies, and disagreements over the role of housing in children’s health outcomes. Engaging proactively with councils and housing teams has ensured reports reach senior decision-makers who can act swiftly. Establishing trust is important for reducing delays for vulnerable families.

The clinic also partners with Respiratory Parent Champions – trusted individuals based within local children’s centres who act as referral pathways and advocates. In one case, a family with two children under the age of two was found to be living in a one-bedroom flat that the fire service had condemned. Identification through this pathway enabled rapid clinical assessment and urgent housing intervention.

Beyond individual patient care, the clinic plays a role in broader environmental advocacy. Professor Sinha has worked with communities affected by landfill sites, including serving as medical expert in a landmark case where a five-year-old boy took legal action against the Environment Agency over toxic emissions. The case garnered national attention and prompted increased scrutiny of environmental regulations.

Looking to the future

Alder Hey’s Clean Air Clinic is now part of a broader regional initiative. Together with councils, housing associations and the integrated care board, Professor Sinha has co-founded the North West Paediatric Respiratory Health and Housing Taskforce. It aims to drive systemic change across the region, recognising that rehousing a family into another substandard property solves nothing.

Liverpool’s housing stock poses a particular challenge, with thousands of families living in damp and substandard conditions. The clinic advocates not only for individual repairs but also for improved regulation, consistent enforcement and stronger national policies. Awaab’s Law, which came into effect on 27 October 2025, now requires landlords to address hazards such as damp and mould within strict timeframes – a vital step that must be rigorously implemented.

Real-world case examples from the Clean Air Clinic

Types of referrals

  • Children referred from the emergency department, particularly preschool children with recurrent bronchiolitis or viral wheeze where environmental triggers have been identified
  • Referrals from other respiratory clinics, commonly for children with bronchopulmonary dysplasia or asthma
  • Referrals from health visitors or general practitioners for young children with recurrent viral illnesses or frequent antibiotic use, or older children with asthma managed in the community.

Housing issues identified

  • Damp and mould throughout the property, affecting clothing and bedding
  • Severe rat infestations
  • Poor heating and/or ventilation
  • Proximity to areas of high outdoor air pollution
  • Overcrowded living conditions (multiple children with limited space; often not recognised as statutory overcrowding under current UK housing legislation).

Outcomes achieved

  • Families moved up housing priority bands within Property Pool systems.
  • Landlords required to remediate damp and mould
  • Support provided to enable relocation to temporary accommodation.

Conclusion

Paediatric respiratory illness will remain a leading cause of admissions unless its root causes are tackled. The Alder Hey Clean Air Clinic model provides a blueprint for replication across the UK, reframing treatment and prevention by integrating healthcare with environmental action.

Its success highlights the importance of partnerships between hospitals, councils, housing providers and communities, and demonstrates how addressing the social determinants of health can transform outcomes for the most vulnerable children.

Authors

Dr Alice Lee
Clinical research and innovation fellow

Professor Dan Hawcutt MB ChB (Hons) MD MRCPCH
Professor of child health

Professor Ian Sinha MBBS MRCPCH PhD
Paediatric respiratory consultant

All of Alder Hey Children’s Hospital Trust, and the Institute for Life Course and Medical Science, University of Liverpool, UK