Memorandum submitted by the NSPCC

 

EXECUTIVE SUMMARY

 

Approximately 90,000 children and young people will experience a period in care in any 12 month period. At any one time, there are approximately 60,000 children and young people in care, and 40,000 children and young people will experience care for a continuous period of 12 months or more.

 

The single most common reason for a child or young person to be in care is because of abuse and/or neglect. At any point in time around 60 per cent (c.37,000) children and young people will be removed from their family because they are experiencing acute or chronic abuse and/or neglect.

 

Removing a child or young person from his/her family is not done lightly. The thresholds for doing so for reasons of abuse and neglect are, arguably quite rightly, high. However, the impact of such high thresholds is that a child taken into care is likely to have experienced high and/or sustained levels of maltreatment, with the mental and emotional trauma with which this is associated.

 

45 per cent (c.27,000) of children and young people in care are assessed as having some level of emotional or mental health disorder. In 2006-2007 only 10,000 received support from Child & Adolescent Mental Health Services (CAMHS). Up to 17,000 children and young people, known to have emotional or mental health needs, received no support at all.

 

Corporate parenting is the responsibility of all the agencies who must come together to provide a stable and caring environment for the children and young people in their care. There are many excellent and committed practitioner networks, providing and supporting excellent and caring support for these very damaged children, but they cannot do this, and they cannot do it with consistency, without accompanying strategic support from corporate partners.

 

The NSPCC's key concern is that the emotional and mental health needs of children and young people in care should be adequately assessed and that services should be available to respond to the identified needs. We do not consider that the current performance framework for health agencies and local authorities provide a sufficiently strong imperative to drive an appropriate level of strategic support from corporate partners.

 

For this reason, the NSPCC considers that the conduct of health assessments, and the availability of appropriate services for children in care must be supported by legislative change - a sustainable lever to drive reform.

 

 

 

 

 

Summary of recommendations

 

1) New regulations are required placing a statutory duty on the relevant health bodies to proactively co-operate with local authorities in improving health outcomes for children in care.

 

2) The regulations must specify the relevant qualifications, post-qualifying training and skills and competencies required to undertake each domain of assessment: physical health; mental health and emotional wellbeing.

 

3) Statutory provision must be made for a health assessment of children receiving 'kinship' care and/or being cared for under 'special guardianship' arrangements.

 

4) Regulations must specify the timescale within which assessments are required to be conducted.

 

5) The provision of a health assessment must remain the joint duty of health agencies and the local authority even in circumstances where a child or young person has been accommodated.

 

6) Regulations must provide for the inclusion of joint arrangements by the relevant local authority and health commissioner for the physical, mental and emotional health care of the child in the child's care plan.

 

7) there should be a clear expectation that appropriate support for children and young people will be jointly commissioned - to include the provision of therapeutic support alongside, or as the most appropriate alternative to, mental health services for children who have experienced abuse and/or neglect and have been assessed as needing this care.

 

 

INTRODUCTION

 

1) The National Society for the Prevention of Cruelty to Children (NSPCC) is the UK's leading charity specialising in child protection and the prevention of cruelty to children. The NSPCC aims to end cruelty to children by seeking to influence legislation, policy, practice, attitudes and behaviours for the benefit of children and young people. This is achieved through a combination of service provision, lobbying, campaigning and public education.

 

2) The NSPCC has more than 180 services. These services aim to:

 

a) prevent children being abused by working with parents and carers in vulnerable families to improve their knowledge and skills in safeguarding, and giving children and young people someone to turn to through ChildLine and the There4me.com online advice service.

 

b) protect vulnerable children and young people from abuse by providing direct services in a number of settings, including schools and young people's centres. We also protect them by providing Listening Services for adults to ensure they have someone to turn to with their concerns; by ensuring that abused children and young people are identified and effective action is taken to protect them, and by working with young people and adults who pose a risk to children and young people to reduce the risk of abuse.

 

c) overcome the effects of abuse by helping children and young people who have been abused achieve their potential.

 

3) This evidence is presented in the context of our whole-hearted support for the aspirations of the Care Matters White Paper (DCSF, 2007). It is intended to support and reinforce those aspirations, and in addition to fulfil the entitlements of children in care as outlined in the National Healthy Care Standard (HM Treasury, 2003); to strengthen and reinforce the commitments of the Department of Health Operating Framework for the NHS in England 2008-2009 (DH, 2007); to achieve the Government's Every Child Matters outcomes for children and to fulfil the Government's National Service Framework for Children & Young People (Core Standard 9), and the Care Matters Implementation Plan (DCSF, 2007).

 

Emotional Wellbeing

 

4) Approximately 60 per cent of children in care are there for reasons of abuse and/or neglect. Research into the effects of abuse and neglect consistently shows serious and lasting damage to children. Cawson et al (2000) found that 16 per cent of all children had experienced sexual abuse; 25 per cent of all children experienced one or more forms of physical violence during childhood and six per cent of children experienced frequent and severe emotional maltreatment.

 

 

5) Statistics indicate a disproportionate number of formerly looked after children in young offender establishments (CrimeInfo, 2008); among the homeless and/or experiencing mental and physical dysfunction (Crisis, 2006) long into adulthood.

 

6) Children in care who have experienced abuse or neglect are less likely to recover from their experiences than children in care for other reasons (Heath et al, 1994). Without help to overcome their pre-care experiences positive outcomes in all areas of their lives will continue to be compromised for this very damaged group of children.

 

7) However, abuse does not always or necessarily result in a mental health disorder. Nor is the impact of abuse likely to be obviously or immediately apparent. More likely is some level of emotional distress, often concealed, which therapeutic assessment and support is designed to reveal and to ameliorate.

 

8) The NSPCC provides therapeutic support in over 30 locations in England, Wales and Northern Ireland to help children overcome their experiences of abuse. Using a variety of therapeutic models, from cognitive behavioural therapy (CBT) to therapeutic play and integrative arts, our practitioners work with children and young people who have experienced abuse to restore and improve development that has been adversely affected by abuse.

 

9) We use recognised assessment tools[1] which help to inform the practitioner's therapeutic assessment and their subsequent planning for a case. The tools are also used in an evaluative way in considering change during the course of the work undertaken with the child or young person.

 

10) Of the 338 cases closed by the NSPCC in the quarter closing December 2007, 85 per cent of users responding "felt helped" by the NSPCC's therapeutic support services. In the professional judgement of our practitioners (supported by use of the TSCC/TSYP assessment tools), 61 per cent (172) of clients had derived benefit from therapeutic support.

 

 

FACTUAL INFORMATION

 

Background

 

1) The Government has made a significant and commendable commitment towards improving the mental health and emotional well-being of children and young people[2].

 

2) Considerable additional resources have been made available for pilot projects including:

 

a) multi-systemic therapy to prevent children being taken into care;

 

b) improvements in capacity and facilities for children and young people requiring inpatient mental health services to protect them from unsuitable environments and ensure the best possible treatment, and

 

c) the development of the Improving Access to Psychological Therapies (IAPT) project, although this includes only one pilot site in the community for young people.

 

3) There is no similar or explicit commitment to the significant cohort of children already in the care system, many of whom require support to help them to overcome their experiences before entering care.

 

The extent of identified unmet need

 

1) Research and statistical monitoring tell us that :

 

a) Approximately 90,000 children will experience a period in care (DfES, 2006)

 

b) Approximately 60,000 children and young people are in care at any one time (ibid)

 

c) Over 40,000 children will be in the care system for a continuous period of 12 months or more (CSCI, 2006);

 

d) approximately 63 per cent (c. 37,000) children and young people are in care for reasons of abuse and neglect (ibid).

 

e) An estimated 45 per cent (27,000) of children in care are assessed as having an emotional or mental health disorder (Meltzer et al, 2003; DfES 2007);

 

f) In 2007 approximately 10,000 children and young people in care received support from CAMH services (Barnes et al, 2007);

 

g) No statistical information is available to tell us how many children and young people received some form of therapeutic support from a service other than CAMH, Thus, up to 17,000 children and young people in care, known to be suffering some level of emotional or mental distress, are likely to have received no support at all.

 

h) The startling discrepancy between assessed need and service provision may, at least in part, be accounted for by:

 

(i) perceived differences between, and responsibilities for, emotional wellbeing and mental health, and

 

(ii) the extensive anecdotal evidence we have received concerning very high thresholds for referral for a mental health service. In many areas, if there is no voluntary agency therapeutic service provision, children and young people who have experienced abuse do not receive any support at all.

 

The Health Assessment

 

1. Health assessments are currently a statutory duty for the local authority. Health agencies have a general duty to co-operate in the safeguarding and welfare of children (Children Act 1989, Children Act 2004 respectively).

 

2. The content of assessments, and the qualifications and experience of those undertaking them, are subject to local variation. There is no national framework within which locally specific needs might be accommodated, thus there is no consistency. A child assessed as requiring an intervention in one authority may be assessed differently in another. For a looked after child this is important. Not only is a looked after child disproportionately likely to have an emotional or mental health disorder, they are also disproportionately likely to cross jurisdictional boundaries.

 

3. The Government is committed to revising and making the guidance 'Promoting the Health of Looked After Children' (DH, 2002) statutory for health agencies, and we are assured that this can take place under s.10 of the Children Act 2004. The content of this guidance is important. Nevertheless, it fails to place a duty on health agencies to proactively co-operate in the provision of an initial health assessment that includes a rigorous examination not only of physical and mental health, but also of emotional wellbeing.

 

4. It is evident from both official statistical information and from the wealth of anecdotal reports we have received that additional and specific measures are required if the health and wellbeing of children and young people in care is to be a priority for all the relevant agencies.

 

The Performance Frameworks for Children in Care

 

"Our vision for improving the lives of children and young people in care is underpinned by the Government's Public Service Agreements (PSAs) and the National Indicator Set for local government." (DCSF, 2008)

 

5. The performance frameworks for local government and health services, help to shape the design and delivery of local services and can act as a driver for partnership working. However children in care are not universally recognised as a priority group across the spectrum of performance frameworks, creating a disincentive for agencies to work in partnership. Furthermore, the direct incentives that do exist to promote the health and well being of children in care are flawed and inadequate.

 

6. The Government has put in place a number of drivers for reform, most notably Public Service Agreement 12 on improving the health and well being of children and young people. The indicators to measure performance against this will act as key drivers for improvement over the next three years. Specific indicators relating to this PSA and in the local government (LG) national indicator set (NIS) include one on the emotional and behavioural needs of all children (see footnote 2 above) and one on emotional and behavioural health of children in care.

 

7. Within the health system the NHS Operating Framework 2008-2009 includes a welcome section on the health and wellbeing of children, and is supported by Operating Plans 2008-2009 - 2010-1011 but fails to give any explicit recognition to children in care or identify associated indicators.

 

Barriers to co-operation

 

8. Lack of an incentive to prioritise the health and wellbeing of children in care

 

8.1. There is no explicit indicator for children in care in the NHS Operational Plans 2008-2009 to 2010-2011 (the 'vital signs' - National Planning Guidance). One of the 'vital signs' is "Effectiveness of Children and Adult Mental Health Services (CAMHS) (percentage of PCTs and Local Authorities who are providing a comprehensive CAMHS) ...". Performance will be judged against the proxy indicators outlined above[3]. Scarcely a pressing imperative for children in care.The failure to adequately recognise children in care through the NHS framework creates a barrier to co-operation on children in care.

 

9. There is no doubt that co-operative drivers across the performance systems can be found in other crosscutting policy areas. For example tackling obesity:

 

9.1.1. The LA NIS 52 concerns assessing the increase in healthy eating among children and young people.

 

9.1.2. In the context of children, The NHS Operating Framework 2008-2009 (DH, 2007a) is predominantly about obesity.

 

9.1.3. There is, then, a clear shared driver for partnership working, and it is likely to act as a lever for a generic public health target around obesity/healthy eating which is mirrored by co-operation at a local level between local authority and health agencies.

 

Unfortunately, there are no similar shared drivers for children in care.

 

Weakness in existing indicator

 

10. Local Area Agreements (LAAs) will set out the shared priorities for each local area and will be signed up to by all agencies with responsibility for achieving the target. The LA NIS indicator no. 58 does provide for the emotional and behavioural health of children in care. However, Local Authorities and their partners must identify only 35 of a total of 198 indicators for inclusion in the LAA.

 

11. The indicator is, in any event, problematic for a number of reasons, as follows:

 

11.1. There is no explicit indicator for children in care in the NHS Operational Plans 2008-2009 to 2010-2011 (DH, 2007). One of the 'vital signs' is "Effectiveness of Children and Adult Mental Health Service (CAMHS) (percentage of PCTs and Local Authorities who are providing a comprehensive CAMHS) ...". Performance will be judged against the proxy indicators outlined above[4]. Scarcely a pressing imperative for children in care.

 

11.2. The LA NIS indicator no. 58 provides for the emotional and behavioural health of children in care. However, the indicator is problematic for a number of reasons, as follows:

 

11.3. Local Authorities must identify only 35 of a total of 198 indicators for inclusion the Local Area Agreements (LAA). There is no certainty that this is an indicator the LA will choose, particularly since there is no directly complementary indicator for health agencies;

 

11.4. The indicator fails to address the issue of a robust and comprehensive health assessment with associated service provision, at entry into care. It will be assessed through the use of Goodman's Strengths and Difficulties Questionnaire (SDQ). Data will be collected by 'primary carers' for all children aged 4 - 16 (inclusive) who have been in care for at least twelve months.

 

11.5. We understand from senior practitioners that the tool:

 

11.5.1. is not designed to identify issues around emotional trauma (a matter of central significance for many children in care);

 

11.5.2. does not address the needs of children under the age of four years;

 

11.5.3. does not identify issues for older young people;

 

11.5.4. does not address the needs of children and young people who spend significant periods of time in care, but are not in continuous care for any 12-month period;

 

11.5.5. The indicator is an outcome measure - it is not about thorough assessment or service provision.

 

12. In short, the indicator, and the proxy against which it will be measured (even if it is selected), do not address the need to assess robustly and thoroughly the assessment of physical, emotional and mental health of children at entry into care.

 

Generic CAMHS Indicators

 

1) In terms of generic mental health, NIS51 provides for the effectiveness of CAMH services.

 

2) CAMHS indicators are:

 

a) a full range of child and adolescent mental health services for children and young people with learning disabilities

b) appropriate accommodation and support provided for 16/17 year olds

c) 24-hour cover to meet the urgent mental health needs of children and young people with specialist mental health assessments undertaken within 24 hours or the next working day, where required, and

d) early intervention support jointly commissioned and provided by and with universal and targeted services for children and young people experiencing mental health problems.

 

3) There is no explicit mention of services for children in care. It is true that targeted service provision has improved, though there is still a long way to go, and there is no certainty that targeted teams, many of which were developed as pilots, or for limited periods subject to continued commissioning, will be sustained

 

4) Finally, the extensive agenda for reform which the health service is currently experiencing is focused around the forthcoming review by Lord Darzi, the formation of Foundation Trusts and the embedding of world-class commissioning. In the midst of such a demanding agenda, and in the absence of clearly stated, shared and appropriate performance indicators, it is unlikely that a small group of highly vulnerable children and young people will receive the attention they not only require, but that they deserve.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECOMMENDATIONS

 

The NSPCC considers that:

 

1) new regulations should be put in place making clear that health bodies have a duty to proactively co-operate with local authorities in improving health outcomes for children in care;

 

2) such regulations should specify the relevant qualifications or post-qualifying training required to undertake each domain of assessment: physical health; mental health and emotional wellbeing, thereby enabling those undertaking assessment to identify issues requiring referral to the appropriate specialist service;

 

3) statutory provision should be made for a health assessment of children receiving 'kinship' care and/or being cared for under 'special guardianship' arrangements;

 

4) such regulations should specify the timescale within which assessments are required to be conducted;

 

5) should unavoidable delays occur in the provision of a health assessment, such that a child has been placed in foster care, the statutory responsibility for conducting a health assessment should continue to reside in the joint powers of health agencies and the local authority;

 

6) the regulations should provide for the inclusion of joint arrangements by the relevant local authority and health commissioner for the physical, mental and emotional health care of the child in the child's care plan;

 

7) there should be a clear expectation that appropriate support for children and young people will be jointly commissioned - to include the provision of therapeutic support alongside, or as the most appropriate alternative to, mental health services for children who have experienced abuse and/or neglect and have been assessed as needing this care.

 

REFERENCES

 

1. Barnes. D, Parker. E, Wistow. R, Dean. R and Thompson. C (2007). A profile of Child Health, child and adolescent mental health and maternity services in England, 2007. Durham University, UK. School of Applied Social Sciences

 

2. Cawson, P et al. (2000) Child maltreatment in the United Kingdom: a study of the

3. prevalence of child abuse and neglect. London: NSPCC.

 

4. Commission for Social Care Improvement (CSCI), 2006. Social Services Performance Assessment Framework: Children. Retrieved 4 April 2008 @ http://www.ofsted.gov.uk/portal/site/Internet/menuitem.eace3f09a603f6d9c3172a8a08c08a0c/?vgnextoid=5149f32414804110VgnVCM1000003507640aRCRD

 

5. CrimeInfo (2008). Young People in Prison: England & Wales. Retrieved 4 April 2008 @ http://www.crimeinfo.org.uk/servlet/factsheetservlet?command=viewfactsheet&factsheetid=83&category=factsheets

 

6. Crisis (2006). Statistics About Homelessness. Retrieved 4 April 2008 @ http://www.crisis.org.uk/pdf/HomelessStat.pdf

 

7. Department for Children, Families & Schools (2008). Care Matters: Time to Deliver for Children in Care: An Implementation Plan. Retrieved 4 April 2008 @ http://www.teachernet.gov.uk/publications

 

8. Department of Health (2007). The NHS in England: the Operating Framework for 2008/09. London, DH / NHS Finance Performance & Operations

 

9. Department of Health (2007a). Operational Plans 2008-2009 - 2010-2011 (Implementing the 2008-2009 Operating Framework) National Planning Guidance and 'vital signs'. London, DH/NHS Finance Performance & Operations

 

10. Department of Health (2002). Promoting the Health of Looked After Children, London, The Stationery Office

 

11. Department of Health (2004). National Service Framework for Children & Young People (Core Standard 9)

 

12. Department for Education and Skills (2006). Care Matters: Transforming the Lives of Children and Young People in Care. Cm 6932, London: The Stationery Office.

 

13. Department for Education & Skills (2007) Care Matters: Time for Change. Cm 7137

 

14. Heath, A.F., Colton, M.J, and Aldgate, J (1994). Failure to Escape: A Longitudinal Study of Foster Children's Educational Attainment. British Journal of Social Work. 24 pp 241-260.

 

15. HM Government (2003) National Healthy Care Standard. London, HM Treasury.

 

16. HM Government (2007). PSA Delivery Agreement 12: Improve the health and wellbeing of children and young people. Retrieved 4 April 2008 @ http://www.hm-treasury.gov.uk/media/9/6/pbr_csr07_psa12.pdf

 

17. HM Government 2007a. The New Performance Framework for Local Authorities and Local Authority Partnerships: Single Set of National Indicators. Retrieved 4 April 2008- @ www.communities.gov.uk

 

18. HM Government (2008). Care Matters: Time to Deliver for Children in Care. London, HM Stationery Office.

 

19. Meltzer, H; Gatward, R; Corbin, T; Goodman, R and Ford, T (2003). The Mental Health of Young People Looked After by Local Authorities in England. London: The Stationery Office.

 

April 2008

 

 

 



[1] Cotmore, R (2006). A Toolkit forThe Trauma Symptom Checklist for Children (TSCC) and the Trauma Symptom Checklist for Young People (TSYC) (a widely used measure in both practice and research). London, NSPCC

[2] PSA 12, Indicator 4 - Emotional health and wellbeing and child and adolescent mental health services (CAMHS) measured by the percentage of primary care trusts (PCTs) and local authorities who together provide a comprehensive service for this area, using four proxy measures:

Development and delivery of CAMHS for children and young people with learning disability;

Appropriate accommodation and support for 16/17 year olds;

Availability of 24 hour cover to meet urgent mental health needs;

Joint commissioning of early intervention support.

 

[3] See footnote 2, page 6

 

[4] See footnote 2, page 6