House of Commons - Health

Select Committee on Health Second Report

CHILDREN LOOKED AFTER BY LOCAL AUTHORITIES

Health of Children Looked After

247. Local authorities have duties to ensure that the welfare of children looked after is properly safeguarded as regards their health, education and general quality of life. They are required to act "as good parents".[263] The Children's Act regulations make clear that "health care implies a positive approach to the child's health and should be taken to include general surveillance and care for health and developmental process as well as treatment for illness and accidents".[264]

248. SSDs have the following statutory duties in respect of looked-after children's health:

(2) to require a medical practitioner to make a written assessment of the child's health and needs for health care;

(3) to ensure that, during the placement, arrangements are made to provide the child with health and dental care; and

(4) to ensure that a written report is provided on the child's health once every six months before the child's second birthday, and once every 12 months thereafter.

A child of "sufficient understanding" is entitled to refuse to submit to a medical examination.[265]

249. Regulations provide that the Foster Placement Agreement which has to be made for every fostered child should contain information about the child's health history. The DoH describe the Agreement as "an important opportunity for sharing information about a child's health and health care needs when potentially serious problems such as allergies, asthma, etc. are increasing among the child population".[266]

250. The equivalent regulations governing residential homes require that homes should offer programmes of health education and health care. Children must be registered with a GP and with a general dental practitioner, and should receive any necessary immunisation and medical or dental attention. A health record must be kept in the home in respect of each child. This should build on earlier records (and where these are not available, efforts should be made to obtain them), should be kept up-to-date, and should be made available to whoever is to have subsequent care of the child.[267]

251. The Government's 1996 guidance on mandatory Children's Service Plans emphasised the need for inter-agency co-operation on matters relating to the health of looked-after children:

"social services departments, health and education authorities and the probation service need to work together if local authorities are to fulfil their role as 'good parents' to these children. This role includes looking after their health, including sexual health."[268]

252. Despite this array of statutory requirements, actual health outcomes for looked-after children are poor. Research commissioned by the DoH found that many looked-after children had undiagnosed chronic health conditions, including poor and uncorrected eyesight, significant weight problems and glue ear. It also found evidence of uncompleted immunisation programmes and courses of treatment.[269]

253. Mental health is a particular problem. Research in Hampshire found that young people in care are four times more likely to have a psychiatric disorder than others, with a rate of disorder of 67% amongst young people in both foster and residential accommodation, compared to one of 15% amongst their counterparts in the general population. 23% of those in care had a major depressive illness compared to 4% of children in the general population. A significant number of adolescents looked-after were found to be suffering from serious psychiatric disorders which had previously been undetected.[270]

254. BASW told us that the quality of psychiatric services for children in care had declined. They claimed that in the past there had been many local examples of multi-disciplinary services bringing together teams comprising a child psychiatrist, psychologist, child psychotherapist and social workers, but that "employing agencies have progressively withdrawn staff from these services". BASW asserted that collaborative arrangements between children's homes and health authorities used to result in easy access to child psychiatrists and other relevant health professionals, whereas the general pattern now was for such services to be only accessible for individual children, through GP referrals, often entailing long delays and an uncertain response.[271]

255. The joint submission from ACC and AMA also drew attention to a general lack of availability of psychiatric and psychological services.[272] The NCB told us that their research had found that waiting lists for psychiatrists could be so long (over two years) that children could leave care before they were assessed.[273] During our visits to children's homes, we received much anecdotal evidence about lack of psychiatric provision for severely disturbed youngsters. Our overall findings on this subject are consistent with the findings of our predecessors, in their report on child and adolescent mental health services (CAMHS) for the general population, that provision of CAMHS "is inadequate both in quality and in geographical spread", with specialist services particularly difficult to access.[274] The Parliamentary Under-Secretary, Mr Boateng, told us that he accepted that "child and adolescent psychiatry has not had the attention it deserves across the Department of Health".[275]

256. Research suggests that such health education and sexual education as is given to looked-after children is ineffective. A survey by a national drug and alcohol agency has found that 44% of their clients had been in care at some point in their lives, and over a third of these reported that they had started using drugs while being looked after.[276] At least one in seven young women leaving care are pregnant or have already had a baby.[277] The NCB commented that what is needed is not only sexual education but wider education in how to conduct relationships.[278]

257. DoH-sponsored research has found poor health supervision of looked-after children, even though such supervision is required by regulations. There is poor inter-agency co-operation between health and social services and difficulties with record-keeping.[279] The NCB commented that residential home staff are rarely trained in the health need of children, reflecting their overall lack of training. They also found that staff skills in health promotion were particularly poorly developed, and recommended that all relevant training courses should include training in health care, child development and accessing health services.[280]

258. The Who Cares? Trust carried out a major consultation process in 1995-96 with young people in care. They found that young people expressed concern that they lacked:

(2) access to confidential information and guidance on contraception, sexual health and drugs; and

(3) contact with trusted adults with whom to discuss personal health matters, and stress, loneliness and depression.

The young people expressed particular anxiety about confidentiality, in many cases saying that they did not trust their doctors to keep what they said or requested as confidential.[281]

The NCB told us they had experience of "some alarming breaches of confidentiality in relation to health—one girl's gonorrhoea was recorded in the daily log, for instance".[282]

259. We were told that some older children dislike the practice of compulsory six-monthly medical inspections, either regarding them as too perfunctory to serve much useful purpose,[283] or resenting them as an invasion of personal privacy to which children not in care are not subjected.[284] The requirement to conduct such examinations at every change of placement means that some young people have to undergo them very frequently.[285]

260. Looked-after children who are disabled encounter particular problems. Recent research commissioned by the Who Cares? Trust found there was a 'mindset' within SSDs which treated disabled children and looked-after children as though these were completely separate categories. Some disabled children were spending time away from home in short-term placements without any knowledge or involvement of the social services, and some on long-term placements were not being accorded the protection of the Children Act. There was little evidence of disabled children's "wishes and feelings" about their placements being "ascertained" (as required by the Act), and reviews of placements were overdue in a significant number of cases. There was a lack of information about disabled children receiving short- and long-term care away from home, about the services they were receiving and whether the services met their needs.[286]

261. The Council for Disabled Children confirmed to us that there are currently no reliable statistics for children with disabilities living away from home. They said that in recent years there had been an encouraging increase in the number of disabled children being fostered or adopted rather than looked after in residential care; however, they added that many such children experienced multiple failures in placements. They said there was anecdotal evidence that many disabled children "slide" into long-term care, having been multiple users of short-term care provision through the NHS, social services, or residential education. The Council strongly endorsed the use of Children's Service Plans to integrate community and residential provision, and said they wished to see disabled children who are looked after having their needs met within comprehensive local authority children's services, but with recognition that such children may require additional support.[287]

262. The RNIB submitted detailed evidence about the needs of visually impaired children within the care system. Such children need greater support in many ways, including provision of information about their personal histories and their rights, assistance in participating in recreation and leisure activities, and special precautions against abuse.[288]

263. The key factors in producing poor health outcomes for looked-after children appear to be as follows. Before entering care, children may have suffered serious neglect of their health, through poverty, poor housing and diet, and bad or inconsistent parenting. Absence or exclusion from school may have led to missed hearing and eye tests and other medical examinations.[289] Once they have entered care, these problems are compounded by frequent moves between placements, combined with poor record-keeping and transmission of records, over-reliance on formal medical examinations, lack of health education and confidential advice, and failures of co-operation between social services and the NHS. Overhanging all these is the absence of direct parental care. Parents will normally be intimately acquainted with a child's medical history, and are more likely than professionals to detect signs of illness or ill health at an early stage. The current system of public care leaves it unclear exactly who has responsibility for an individual child's health and health education needs.[290]

264. The Social Services Committee in its 1984 report recommended that "as a minimum requirement there should be a named medical adviser generally responsible for the oversight of the physical and mental health of children in care.[291] In its reply, the then Government made no undertaking to implement this recommendation.[292] In our inquiry, the RCN suggested that

"in completing a health plan for children in their care, local authorities should identify a named nurse for each residential home. It may be appropriate for this named person to be the school nurse whose catchment area includes the schools local to the residential home. A named nurse would help ensure that health needs are met, and may act as an advocate for vulnerable children."[293]

HEALTH OF CHILDREN LOOKED AFTER: CONCLUSIONS

265. The failure of local authorities to secure good health outcomes for the children and young people they look after is a failure of corporate parenting. The first instinct of a normal, caring parent is to secure the health and physical well-being of their child. We note that the DoH has acknowledged, in evidence submitted to us both before and after the General Election, that the health needs of looked-after children are at present neglected. The DoH therefore cannot deny its responsibility to set action in train to tackle this problem.

266. There are serious weaknesses in the current system of passing on information as to a child's medical history. We recommend that the potential of the Looking After Children records should be exploited as a means of ensuring continuity and focus in children's medical treatment. The obligatory medical examinations should be conducted within a framework set by the LAC materials. A foster carer or social worker familiar with those materials should always be present when the child attends for the medical examination, provided that the child consents to their presence.

267. Greater sensitivity needs to be shown towards children by the healthcare professionals who treat them. In particular, it must be recognised that transactions between children and doctors should normally be regarded as confidential. Children's views on the quality of the health care they receive should be taken into account, wherever possible through formal mechanisms such as children's forums.

268. Health education for looked-after children is at present regarded as a comparatively low priority. This is a very short-sighted attitude, given the problems caused for society as well as individuals by bad diet, obesity, drug abuse and under-age pregnancies. The statutory responsibility of local authorities to promote health education is clear, but as in so many other areas, there is currently no way of systematically monitoring the extent to which authorities carry out this duty, or of enforcing the duty on those authorities who neglect it. Voluntary bodies do valuable work, publishing material such as the Who Cares? Trust's Who Cares About Health?, a booklet published in 1996 and aimed at giving young people readily accessible information about food, exercise, drugs, sexual health and so on[294]—but the resources of such bodies do not allow them to provide a comprehensive service. We recommend that the DoH should report to us with proposals for ensuring that appropriate health education is provided to young people in the care system.

269. There is considerable evidence that the mental health of looked-after children and young people is particularly neglected, and that specialist services are increasingly difficult to access. Here also, preventive measures and timely appropriate treatment at a specialist level may do much to minimise personal unhappiness and problems for society in future years. This is one of the areas we are investigating as part of our ongoing inquiry into the relationship between health and social services. We believe that the current arrangements for providing psychiatric and other specialist services to children in care are grossly inadequate. It is a disgrace that children should have to wait as long as two years before even being assessed for treatment. We recommend that the DoH should investigate how more effective links can be created between SSDs and local health services, to ensure that the former can speedily access expert medical attention, including psychiatric care and guidance on sexual health, for the children in their care.

270. A further area where greater liaison between health and social services is called for is in relation to looked-after children who are disabled. Their needs should be born in mind in Children's Service Plans. It is unsatisfactory that no reliable statistics on such children are available; the DoH should take steps to acquire such information when it gathers data on the care system from local authorities.

271. We agree with the Social Services Committee's conclusion of 14 years ago that a named medical adviser should be responsible for the oversight of the physical and mental health of each child in care. We believe that the Government should accept this principle, and should consult widely on the best way of implementing it, considering options such as the RCN proposal that each residential home should have a named nurse with responsibility for such oversight, or that each home should be required to have a formal link with the local primary care team.

272. Recommendations elsewhere in this report, if implemented, will help to improve the overall health status of looked-after children. In particular, trusted adult friends[295] will have an important part to play in educating children about healthy living and lifestyle choices; and an increase in the number of looked-after children attending mainstream education will result in wider dissemination of the benefits of school-based health surveillance and education.[296] In addition to the recommendations we make above about training of residential staff,[297] we wish to endorse the call by the National Children's Bureau for NVQs, DipSW and in-service training to include training in health care, child development and means of accessing health services.

263 Ev p 124. Back

264 Ev p 120. Back

265 Ibid. Back

266 Ev p 121. Back

267 Ibid. Back

268 DoH, Children's Service Planning: Guidance, LAC (96)10, quoted in CLA 21, p 2. Back

269 Ev p 352 (Appendix 6); see also Ev p 396 (Appendix 20). Back

270 Ibid. Back

271 Ev p 93. Back

272 Ev p 7. Back

273 Ev p 381 (Appendix 13). Back

274 HC(1996-97) 26-I, paras 102, 117, 121. Back