Memorandum submitted by National Children's Bureau's Healthy Care Programme
Changes that will make a difference to the health and well-being of children and young people in care include
· National and regional leadership, and advocacy for the health and well-being of looked after children
· Primary Care Trusts (PCTs) as part of the Corporate Family
· Named health commissioner for looked after children
· Children and young people's voices being included in service planning and reviews
· Partnership working to support children and carers
· Multi agency teams with a shared understanding of emotional health and well-being
· Review and update of 2002 Department of Health Guidance as a statutory responsibility for health services
· Guidance to OFSTED and SHAs on quality indicators
· Core training for carers and social workers to promote health and well-being
· Core training for all foster carers and residential workers to include a component on promoting emotional health and well-being, including for children bullied or bereaved
· Support and encouragement for children and young people in care to take up positive leisure activities including arts, culture and sport
The Healthy Care Programme in the National Children's Bureau developed the National Healthy Care Standard and has been working over the last six years to improve the health and well-being of children in care. Funded originally by the Department of Health and latterly since 2004 by the Department for Education and Skills/Department for Children Schools and Families, it has developed a tried and tested multi-agency framework that uses partnership working to deliver improved health and well-being for children in care and young care leavers. Over ninety local Healthy Care partnerships are now in existence and their experience and learning have contributed to this paper.
out more about the Healthy Care Programme at: www.ncb.org.uk/healthycare
When children and young people were consulted by Myrtle Theatre Company and the Healthy Care Programme to respond to Care Matters children said:
"There's nothing wrong with us, it's just that our parents don't want us."
"They do want us, they can't cope."
girl at school, she said that I'm spoilt and I said shut up, and she said well
at least I've got a proper mum."
1.1 The health and well-being needs of this group of children and young people are high. Statistics continue to tell us that the main reason for children becoming looked after is because of neglect and abuse. The evidence that neglect and abuse of children causes physical and mental health problems is well documented, and some of these problems will be enduring throughout childhood and may continue to impact on physical and mental health and well-being into adulthood. Care Matters (DfES 2007 p10) states:
"The task of improving health should be approached holistically - it is not the concern of the NHS alone. Factors such as secure attachment, friendships and engagement in positive leisure activities also promote health and wider well-being".
1.2 This approach is applauded by the Healthy Care Programme and the ninety local Healthy Care partnerships supported by the programme. The Healthy Care Programme has shown that local and regional multi agency partnerships are a sound basis for translating policy into effective child focused practice that places children and their carers at the centre of improved services to promote health and well-being and address the consequences of early neglect, abuse and need.
A recent England wide study reported:
· Two thirds of all looked after children were reported to have at least one physical complaint
· 45% of looked after children aged 5 to 17 years were assessed as having at least one psychiatric disorder
· Two thirds of those living in residential child care were assessed as having a mental disorder.
Looked after young people are more likely to engage in self harm and risky life style behaviours such as the misuse of drugs and alcohol and are at greater risk of young parenthood, poor sexual health and bullying.
1.3 Looked after children are more likely to have missed out on routine child health surveillance, to have unmet health needs and undetected and untreated health problems such as:
· missed immunisations
· missed developmental checks
· undiagnosed sight and hearing problems
· speech and language delays
· no preventative health care
· no dental checks or treatment and poor oral health.
This is likely to be in addition to the effects of neglect and abuse, the loss of their parents, family and home, which often cause children emotional, behavioural and mental health difficulties. Also their health records are likely to be incomplete and difficult to trace leading to gaps and delays in carers and professionals knowledge about a child's health status and needs, including food and drug allergies.
1.4 The emotional needs of children who have needed to leave their parents requires the careful support of foster carers and residential children's workers and their social workers. There is need for effective training and support for carers to ensure they are providing safe and nurturing care as well as encouraging confidence, aspirations and enjoyment. Local authority children's services and partner agencies in health, education, arts and leisure and youth services have a vital part to play in building services that support children in care and their carers.
1.5 The Healthy Care Programme Handbook Healthy Care Briefings and Promoting the Health of Looked After Children describe a considerable body of evidence about the significant health needs of looked after children and young people.
A young person in care wrote the poem below to tutors who provided a music workshop
The music workshop has helped me plan my life ahead,
years ago I wished I was dead.
I've had a tough life now it's about to turn right
so I'm thanking you for helping me along the way
because I'm going home after my SATs in May
On my block every life is but a dream
hard times is all we see
every block is kinda mean but on our block we still pray
for people like you to come along.
So one day we won't be scrubbing pots for breakfast
and can buy people things for Xmas.
I really hope we can meet again because I'll always feel the same.
2. Changes that will make a difference to health improvement
2.1 National Children's Bureau has been pleased to develop, support and sustain good practice in the ninety local Healthy Care partnerships, and to work with Regional Government Offices, Strategic Health Authorities, Care Services Improvement Partnership and national and regional arts and leisure providers to ensure sustainable partnership working and effective models of practice.
2.2 National funding from Department of Children Schools and Families for development, coordination and support for the Programme by NCB ceased in November 2007; continuation funding was provided by Regional Government Offices and the Care Services Improvement Partnership. NCB is negotiating with Regional Government Offices and the Care Services Improvement Partnership to provide future funding to continue national advocacy, leadership and development to ensure the necessary momentum for change.
2.3 Good physical and mental health enables children and young people to benefit from education and other opportunities that lead to successful and happy adulthood. Looked after children and young people need significant support as well as appropriate treatment and input from preventative health services if they are to achieve the Every Child Matters 'Be healthy' outcome. There is much good practice around the country, which demonstrates, tried and tested ways of tackling the health inequalities experienced by this group of children.
2.4 Based on the learning from Healthy Care Partnerships (multi-agency groups that provide a framework for agencies to work together on improving the health and well-being of looked after children and originally developed by the Healthy Care Programme) the Healthy Care Programme proposes that the following should be considered by the Children, Schools and Families Select Committee's Inquiry on looked after children:
2.4.1 National and regional leadership, advocacy and support for local authorities, PCTs and other partners to work together effectively on improving the health and well-being of children and young people in care, sharing best practice and providing a high quality evidence base. National leadership and coordination of regional Healthy Care partnerships and the inclusion of health and well-being in regional pledges and other strategic mechanisms supported by Regional Government Offices, Strategic Health Authorities, public health and the Care Services Improvement Partnership will support local partners in health and local authorities achieve improved outcomes.
2.4.2 PCTs can be part of the Corporate Family. Clarify and confirm the responsibility and contribution of PCTs to the Corporate Parent role. Evidence from the Healthy Care Programme shows that PCTs with executive level leadership and advocacy for health improvement for children in care has resulted in stronger and more effective local partnerships and targeted services for this group of children.
2.4.3 Require all PCTs to identify a named commissioner for looked after children and identify the responsibilities of the commissioner in the revised Promoting the Health of Looked After Children Guidance. The commissioner should have a strategic role in ensuring that the Primary Care Trust is pro-actively engaged in meeting the health needs of looked after children and young people and in working in partnership with the local authority and others to do this. The strategic championing of looked after children should ensure continuation of the public health specialist nurse role for looked after children and young people, important for quality "looked after" health services.
2.4.4 Keep Listening to Children. There is a need to keep re-enforcing the importance of listening to children and young people in care and those of their carers. They know what will make a difference to their lives but are often the last to be asked. Putting children's voices at the centre of service development will ensure services are responding to needs. A Public and Patient Involvement manager worked with the local looked after children's nurse and Children in Care council to design the looked after health service and young people's Drop In centre.
2.4.5 Joint Services Needs Assessment should include the involvement of children and young people in care within its user groups. Directors of Public Health and Directors of Children's Services and Directors of Adult Services should then report their progress toward delivering their corporate parenting responsibilities (as 2.4.4 above)
2.4.6 Focus on improved interagency work to promote health and well-being, supporting carers and children and young people in care and their families. There is a need for improved cross agency understanding amongst strategic and operational service managers that all services need to work together to provide a healthy care environment. Messages from local Healthy Care partnerships indicate that some areas think "health is Health's business", and in other areas local Children's Services cannot engage PCTs to identify designated Doctors and health practitioners. An example of effective Healthy Care partnership is included as Case Study 1.
2.4.7 Review and update the 2002 Department of Health Guidance 'Promoting the Health of Looked After Children' and make the guidance statutory for Primary Care Trusts (PCTs) and Strategic Health Authorities (SHA's) as it is for Local Authorities as indicated in Care Matters (DfES 2007). Healthy Care partnerships have identified a number of issues that need to be addressed by the review and updating of the guidance and these are listed Appendix 1 of this document.
2.4.8 Issue guidance to OFSTED on quality indicators about health assessments, health plans and public health policies such as sex and relationships and alcohol and smoking.
2.4.9 Issue guidance to Strategic Health Authorities on quality performance management of PCTs in regard to their roles and responsibilities for meeting the health needs of looked after children and young people. The National Healthy Care Standard revised audit tool provides evidence to ensure access to effective healthcare, assessment, treatment and support, which could advise such Guidance.
2.4.10 The core training for all foster carers should include a specific component on how to promote the health and well-being of looked after children and young people to support work on the revision of National Minimum Standards. The Healthy Care Programme has developed such a programme, that is used by many looked after children's nurses and children's services. Many local Healthy Care partnerships have also developed additional specific training for carers on key health topics.
2.4.11 Training and resources for foster carers and residential workers and social workers in ensuring improved social and emotional well-being. Measuring improved well-being of children who have serious difficulties caused by neglect and abuse is hard. The Goodman Strengths and Difficulties Questionnaire is being piloted as an aggregated measure for Local Authorities and health partners to assess improvement, provide an opportunity to highlight the importance of emotional well-being and address practice in the setting where the child is cared for. Healthy Care Programme has developed training to improve the emotional and social well-being of children in secure settings. NCB Healthy Care Programme is well placed to develop a further training programme and carer resource.
2.4.12 Opportunities for children and young people and their carers to build relationships that nurture and sustain their attachment, and that are supported by effective teams of health, mental health, public health, youth services, arts, sport and leisure, who understand the emotional needs of this vulnerable group of children. Current Arts Council/NCB work on examining how to embed creativity in the lives of children in care indicates that there is need for enhanced support for children, and training for carers and practitioners, to enable looked after children to make use of opportunities to engage in positive activities.
2.4.13 Additional support to access positive activities including the forthcoming Cultural Offer for all children Arts Council England 2008. More work is required to ensure that young people growing up in care, and the families and individuals that support them, can benefit from engagement with the arts and creative.
The use of the personalised education allowance identified in Care Matters (2007) should be identified for use by all looked after children to help attain and support their education and developmental needs, and be used to support access to positive activities such as sport arts and leisure.
NCB was pleased to devise and write the Care Matters national template for Things to Do to encourage positive activities, arts and leisure. Arts and creative opportunities can promote health and well-being by providing opportunities to
· Build positive relationships with carers and other adults
· Promote self expression, confidence and skills
· Engage and motivate for further learning
· Contribute to service planning
· Improve physical and mental health
It is clear from NCB work on the Things to Do Template and Healthy Care Creative Participation of looked after children and young people across the country that this group of children need additional support to encourage them to take part in arts and leisure activities. This can take the form of funding, carer encouragement, acknowledgment of progress and support for transport or opportunity.
Cross government programming is needed to help children and young people in care take part and contribute in arts, sport and leisure activities. NCB is well placed to build on current Arts Council partnership working to ensure looked after children and young people are placed to accept opportunities provided through positive activities and the Cultural Offer for all children and young people.
National Children's Bureau Healthy Care Programme supports the approach to looked after children's health and well-being and the measures suggested within Care Matters 2007. We believe that the policy intent will need cross government leadership and focused regional support from Regional Government Offices and regional health bodies. The Healthy Care Programme in NCB is well placed to continue to support this work, when funded to do so.
Review and update the 2002 Department of Health Guidance 'Promoting the Health of Looked After Children' and make the guidance statutory for Primary Care Trusts (PCTs) and Strategic Health Authorities (SHA's) as it is for Local Authorities. Healthy Care Partnerships have identified a number of issues that need to be addressed by the review and updating of the guidance and these are In particular the review should be asked to examine and include revised guidance on:
1. The multi-agency framework required to enable health and local authorities to work together as partners to meet the health needs of looked after children and young people (Healthy Care Partnerships provide a tried and tested model as described in Time for Change p96)
2. The role and responsibilities of PCTs in relation to meeting the health needs of looked after children including appointing a named commissioner for looked after children to oversee and coordinate how the PCT will meet the health needs of looked after children in its area (see section 2.4.3).
3. Work with public health teams in promoting education and support on sexual health and relationships, promotion of mental health including dealing with issues such as loss and bereavement, bullying, healthy eating and physical activity and alcohol and drug education, screening and support.
4. The roles of the designated doctor and designated nurse for looked after children Evidence from Healthy Care Partnerships is revealing a worrying trend for the looked after children's nurse role to be subsumed into the work of Safeguarding Teams with a focus on child protection. It is important that the valued work and advocacy provided by looked after children's nurses and their expertise is not undermined or diluted.
5. Good practice for joint working between PCT's and local authorities in promoting the health and well-being of children in care. There are many examples of good practice from around the country that demonstrate how effective joint working is resulting in improved health outcomes for children and young people in care. It would be good to include such examples in the revised guidance. Case study 2 demonstrates effective partnership working and its positive effect on a child.
6. How to assess a child/young person's physical and mental health and well-being holistically including speech and language needs, with examples of good practice and the need for these assessments to be shaped around the child rather than one size fits all. This could include a range of examples from around the country such as that used in Southampton where health assessments are provided by a health team set in the leisure centre which also houses other services such as young peoples sexual health clinics. This enables young people access health advice and be encouraged to take part in a range of leisure activities
7. Who is the appropriate person/s is to carry out health assessments, and the qualifications, experience and training of health professionals to carry out health needs assessments that are child and young person focused. Young people have told us how the consistent support of a specialist doctor or nurse who provides consistent support can be important to them in an otherwise unstable life.
8. The timeframes by which health needs assessments should be carried out and health care action plans written - the plan which describes how the child's health needs will be met. A review of this plan should be included within the child's annual review, and necessary action taken by the Independent Reviewing Officer.
9. Examples of child/young person friendly and effective health action plans.
10. Who is responsible for writing the health action plan, its implementation and monitoring and how these will be aligned with the child's care and placement plans.
11. The provision of health needs assessments and health action plans, including speech and language therapy needs for children who are placed outside of their home authority including identifying who is responsible for carrying out the assessment, writing, implementing and monitoring the health action plan.
12. The inclusion and support of the needs of children with disabilities and their parents and carers. Work should be done to ensure that disabled children are heard and their needs met within health planning and review.
13. Clarity about the specific health needs of looked after children from black and minority ethnic groups. NCB is currently funded by Department of Health to identify and address the additional health needs of these children and their carers.
14. Systems for speedy data collection and management of information relating to looked after children and young people's health. Healthy Care Programme has reports of looked after children's nurses spending much valuable time "chasing" health records.
15. Training and support for Independent Reviewing Officers about how to ensure health needs are identified and met and how they can work with health teams to ensure this.
16. Systems for ensuring carers receive health information about children and young people as soon as possible and in an appropriate format.
17. Systems for ensuring care leavers are supported to make the transition to using adult health services and that transition to adult health services is covered in their pathway plans. A recent review of care leavers health by NCB indicated that emotional health and loneliness were key concerns for young care leavers, alongside debt, housing and employment.
18. Ensuring adult health services are responsive to the needs of young care leavers - for example this could be through involvement and/or linking with the local multi agency partnership for looked after children and young people's health
Case Study 1
North Lincolnshire Healthy Care Partnership
North Lincolnshire Healthy Care partnership has strong representation of health partners including the looked after children's' nurse, Teenage Pregnancy Coordinator, and Drugs Agency, as well as representatives from Children's Services including foster carers and care leavers. The partnership also includes the Youth service, Connexions worker, arts and culture organisations, and an employability scheme for children in care and care leavers. The Be Healthy Turning the Curve and Children in Care Health Action Group are chaired by health staff and provide a multi-agency approach to improving health outcomes for children in care and care leavers.
The partnership carried out its Healthy Care audit, and developed an action plan identifying how all services work together and contribute to improving health outcomes of children in care and care leavers. It is has now re-audited work for a further year. Arrangements are underway for North Lincolnshire PCT Head of Joint Commissioning to share accountability with the Lead for improving outcomes for Children in Care to the Children's Board. Annual Performance Assessments have recorded improvement, including the development of a mini choices clinic and drug and alcohol service at the Children in Care Support Centre, where all staff receive training in sex and relationships education. A fast track referral service to CAMHS and therapeutic services has been developed. All children and young people in care have a health plan. The health of children in care was identified as an important outcome when the Children and Young People's Plan was reviewed in the Local Area Agreement.
The commitment to the Corporate Parent role is demonstrated in action by a range of service providers including the Leisure services who provide free sports tasters and swim passes for children in care and care leavers. Children and young people's participation is well developed through their involvement in the Children and Young People's Plan, and has enabled children in care and care leavers to shape how health services are delivered from the Children in Care Support Centre.
Case Study 2
An effective Healthy Care Programme delivering the ECM outcomes
Tony is a 14 year old looked after child placed in residential care. He has been in the same placement for just over one year, having been admitted to the looked after system because his parents were unable to cope with his behaviour within the home. Tony initially presented as an angry young person who was disengaged from education and had been on the edges of offending behaviour although he had no criminal convictions.
Tony has particularly benefited from the initiatives that have arisen through the Healthy Care multi-agency partnership for looked after children in a number of particular ways.
Firstly, he has always had an interest in sport and particularly in football. Following a partnership between the local Primary Care Trust, Bradford City Football Club, Bradford Youth Offending Team and the Social Services Department, Bradford City Football Club arranged some Saturday mornings sessions for young people in residential care which Tony attended. These sessions consisted of some input in relation to healthy living (exercise, healthy diet, not smoking etc.) followed by free tickets to watch the football match on that afternoon. In relation to sport and recreation Tony was also able to receive a passport for leisure to allow him access to leisure centres and he has been a regular attender at the recreation centre near where he lives.
Secondly, in relation to this education the residential home in which Tony lives places a high emphasis on school attendance and as a result Tony has been actively encouraged to go into school. The school and his social worker have used the personal education plan as a way of identifying Tony's need and the type of support that he needs to meet those needs. One particular issue that arose was that Tony would benefit from the use of a computer and this was able to be purchased for him as a result of some joint funding between the Education Department and Social Services Department. Tony is now more engaged at school and is thinking about commencing his GCSE courses.
Thirdly, health. Following his admission to the looked after system Tony was allocated his own health nurse through the Primary Care Trust and an assessment of his health needs was undertaken within one month. During the course of the assessment concern was raised regarding his emotional well-being. Through the multi-agency partnership the CAMHS services have identified two workers to work specifically with Looked After Children and one of these was able to provide Tony with some individual counselling and support in relation to his emotional well-being. It was possible to provide this support quickly in a way that meant that Tony was able to address some of his feelings soon after his placement in the residential unit. The CAMHS service also provided consultation to the staff at the residential unit which helped them find strategies for supporting Tony.
Finally, Tony has been able to have some involvement with Seen & Heard, a Barnados run project which provides advocacy and consultation for Looked After Children. This service was commissioned by the Local Authority and Barnados are an active member of the multi-agency partnership. Tony has been involved in several events with Seen & Heard including a question time event where, along with other looked after young people, Tony met with senior managers from all partner agencies at which he was able to express his views and raise queries and concerns. As a direct result of this the residential unit in which Tony lives received satellite TV after the young people raised that as a wish with the managers involved. Tony was also involved with a number of other young people in re-designing the child in care review form to facilitate greater participation of young people at their reviews. Tony is just about to commence a training course so that he can be involved interviewing staff and managers who will themselves then work with Looked After Children.
The advantage of the multi-agency partnership for Tony is that it consists of managers from all partner agencies who are then able to ensure contributions are made towards all of Tony's needs - his education, health, emotional well-being as well as his need for opportunities to express his views and be involved in developments that will impact upon his and the lives of other looked after young people.
Summary of local Healthy Care Programme development work to achieve the five outcomes
 Melzer and others (2003) The Mental Health of Young People Looked After by Local Authorities in England. Office of National Statistics. The Stationery Office.
 Department for Education and Skills (2005)
 Department of Health (2002) Promoting the health of looked after children