Changes that will make a difference to the health
and well-being of children and young people in care include:
The Healthy Care Programme in the National Children's
Bureau developed the National Healthy Care Standard[1]
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 90 local Healthy
Care partnerships are now in existence and their experience and
learning have contributed to this paper.
When children and young people were consulted
by Myrtle Theatre Company and the Healthy Care Programme to respond
to Care Matters children said:
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:
1.2 This approach is applauded by the Healthy
Care Programme and the 90 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.
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:
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.
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 90
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 the Department
for 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.
CONCLUSION
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.
APPENDIX 1
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.
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 p 96).
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 to access health
advice and be encouraged to take part in a range of leisure activities.
7. Who is the appropriate person/s 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 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 morning 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
|
National Outcomes
| Local activity and services |
| Be healthy | — Dedicated "looked after" nurse service.
— Dedicated CAMHServices.
— Sport and healthy lifestyle link including football club membership.
|
| |
| Stay safe | — Child centred support and consultancy service for staff in residential units.
|
| |
| Enjoy and achieve | — Education support team.
— Provision of computers and IT support in residential homes.
— Leisure passport providing free entry to leisure provision.
|
| |
| Make a positive contribution | — Advocacy service supporting young people's involvement in service review and planning.
|
| |
| Achieve economic well-being | — Universal and targeted services provided through effective strategic partnerships to ensure looked after young people have improved life opportunities.
|
February 2008
| |
1
The National Healthy Care Standard see: www.ncb.org.uk/healthycare
or
http://www.ncb.org.uk/Page.asp?originx_7194cp_58543156822553f74l_20067313739a Back
2
Melzer and others (2003) The Mental Health of Young People
Looked After by Local Authorities in England. Office of National
Statistics. The Stationery Office. Back
3
Department for Education and Skills (2005). Back
4
Healthy Care Briefings (2005 and 2006) www.ncb.org.uk/healthycare
search under healthy care resources then healthy care briefings. Back
5
Department of Health (2002) Promoting the health of looked
after children. Back
