Examination of Witnesses (Questions 169-179)
HELEN CHAMBERS,
SUE DUNSTALL,
DR RITA
HARRIS AND
DR CATHERINE
M. HILL
28 APRIL 2008
Q169 Chairman: I welcome Helen Chambers,
Sue Dunstall, Dr Rita Harris and Dr Catherine Hill to our deliberations.
It is a pleasure to have you here and the quality of your expertise,
to help us get under the skin of the health dimension of the provision
of health services for looked-after children. When starting these
fact-finding sessions, we tend to do two things. First, we revert
to more informal terms, so I hope it is all right if I use your
first names and not your titles. Secondly, I am the warm-up act,
but before I ask any questions and the team drill down on particular
sections, could you say something—you do not have to repeat
your CV—about what you think are the big issues facing health
provision for looked-after children?
Helen Chambers: I think that the
healthy care programme, of which I am the national leader, within
the National Children's Bureau demonstrated that the promotion
of the health of looked-after children and the meeting of their
health needs requires more than the health community. The health
services have specific roles based on the assessed health needs
of children entering care. Health assessments of children in care,
healthy, nurturing care and the opportunity to enjoy feeling good,
joined up by interagency planning and delivery, are vital elements
of corporate parenting. Members need only think of their own children
to know that it is parents who care for the health of their child
and that it is often only when they are ill or sick that we contact
health professionals. It is the same for looked-after children.
The carer and home environment are central to the child's health
and well-being on a day to day level. Their care, support and
nurture within a positive relationship are key to their well-being.
Healthy care needs to be a philosophy embedded within corporate
parenting, promoting secure attachment, health lifestyle and self-esteem.
So it is essential that local authority children's services ensure
that the care environment promotes health and well-being. I have
been delighted to be the lead for the healthy care programme developed
by the NCB, and funded by the Department for Children, Schools
and Families, until November 2007, because it provides a practical
means of improving the health of looked-after children in line
with the Department of Health's guidance of 2002. That national
funding has now been discontinued, so we rely on regional support
to improve looked-after children's health and well-being. Yet
again, that leads to a potential inequality in health outcomes.
It is probably within those areas where the health of looked-after
children is best recognised that continuation and focus will occur.
To summarise, the health and well-being of looked-after children
requires good joined-up services between children's health services,
together with youth services, leisure, arts, cultural services
and sports. It requires foster carers and residential care workers
who are well equipped to promote the health and well-being of
the children in their care. Some people talk in terms of a therapeutic
model of foster care, and that requires effective training and
support. Looked-after children need access to positive activities
that give them the opportunity to develop their interests and
talents. Finally, we need national, regional and local championing
of a group of children who are experiencing great inequality.
Sue Dunstall: My name is Sue Dunstall
and I am policy adviser for the National Society for the Prevention
of Cruelty to Children. Thank you for inviting me to present evidence
here today. The arguments about the need for health agencies to
work well with all other agencies are well rehearsed in many arenas.
As an agency, we provide therapeutic services in some 34 locations
in England, Wales and Northern Ireland. Around 50% of the children
whom we work with in those therapeutic services are looked-after
children. The looked-after children group is very varied. We know
that 63% of children in care are there for reasons of abuse and
neglect, and that 45% of children who are taken into care have
some form of mental health disorder. The importance of some form
of mental health support or input cannot be stated too strongly.
Our prime concern is the rescue, recovery and repair of some of
these children who are very damaged when they enter care. The
thresholds for entry into care are very high. It is not just about
social care and putting things right in a social aspect; it is
also about restoring self-esteem and emotional well-being and,
in some cases, repairing mental health. We believe that there
has been a general lack of priority and recognition in society
about the recovery needs of children who have been abused. In
particular, we believe that current health assessments for looked-after
children do not focus sufficiently on their emotional and mental
health needs, and that contributes to the paucity of these services.
It is important for a range of child-centred services to be made
available, not only from CAMH services, but also from other providers
to provide both therapeutic services and assessments. One of the
key issues is to identify the extent of unmet need within the
system—something that we currently do not do. That is probably
all I need to say in my introduction.
Chairman: You will get lots more opportunities
in a moment.
Dr Harris: My name is Rita Harris.
I am clinical director of the child and family department at the
Tavistock and Portman NHS Trust, which is a mental health trust
in north London. I am here to represent mental health services,
but also as part of The Care Matters Partnership, which is between
BAAF, the Coram Family, and the Tavistock Clinic. I am speaking
with three hats.
Q170 Chairman: What is BAAF?
Dr Harris: The British Association
for Adoption and Fostering
Chairman: Excuse my ignorance; sometimes
I help Hansard.
Dr Harris: Is it worth saying
that CAMHS is Child and Adolescent Mental Health Services?
Chairman: I think we have got that.
Dr Harris: Emotional understanding
is central to care, and opportunity alone is not enough. From
a mental health point of view, the profound impact of early trauma
on children—such as the trauma arising from separation and
loss—just cannot be overestimated. We know that people have
a built-in propensity to react to new experiences as if they were
like previous experiences, and they do not necessarily interpret
good intentions in the way in which they were intended. A child
may react to very good care by experiencing it as quite damaging
and rejecting. The profound effect of trauma and loss on children
also profoundly affects adults and those who care for them. Children
will often identify with their abusers and be physically and verbally
abusive to carers. They can communicate feelings of inadequacy
and worthlessness. Carers often end up wondering why they have
lost all the confidence that they had gained with their own child
to parent a child. Placements often break down because of carers'
feelings of inadequacy and impotence. Children can also experience
great conflict about loyalty. If they become attached to a new
carer, they may feel that they are abandoning or rejecting their
own birth parent. The main point that I want to make is that they
are complicated children to look after. We know that in order
to make stable and good relationships and to have good attachments,
children and young people need stable and consistent relationships.
If those are ones that they inadvertently damage, they are a very
complicated group to care for. Therefore, support, training and
supervision for carers and the professional work force that works
with this group of children is essential when it comes to service
provision. Also, these children have complex needs and require
complex services. There is a danger that structures and services
get set up in a rather defensive way, in the same way that children
can have very defensive controlling strategies to deal with their
distress. They can be moved around systems in a way that prevents
the adults from thinking about the distress, guilt and anxiety
that children who have been so badly abused can provoke in adults.
In order to help such children, the set-up of networks and systems
around them needs to be worked out very carefully. The last point
that I want to make is that the needs of such children are long
term. Short and quick measures do not work with these kids; they
have needs that last a lifetime. Helen mentioned our own children;
parenting is a lifelong exercise. Quite often, looked-after children
are the most damaged in society. They need long-term services
and have long-term needs. They probably do not need to leave home
at the age of 18 and have nowhere to go back to. We can think
of what our own children would be like if they did not have our
emotional and physical resources to fall back on. Whatever services
CAMHS or other professionals provide, they have to be long term.
Sometimes they need to be active and sometimes watchful, but we
are talking about a long period of care for these children. I
think that the work force is central, as is looking after the
carers and giving them decent support, training and advice to
understand the meaning of children's behaviour. Often, children's
distress is demonstrated in some of the most difficult and challenging
ways. Those are my priorities.
Dr Hill: Thank you for inviting
me. I am Catherine Hill. I am here principally in my capacity
as chair of the health group advisory committee for the British
Association for Adoption and Fostering. The group has been established
for 45 years and principally supports practitioners in the field
by developing guidance and good practice and providing individual
support for people such as doctors and specialist nurses working
with looked-after children. I am here in two other capacities
as well. One is as a practitioner myself. I have worked as a consultant
paediatrician with looked-after children for almost 10 years.
For some of that time, I have been designated doctor of a unitary
authority and also adoption adviser to a shire county. I have
a post as senior lecturer in the University of Southampton, so
I have had some research interest in the health of looked-after
children—what threatens it and what promotes it. A lot of
what I would like to say has been said—that is always the
advantage of going last. I shall not reiterate at length the nature
of the health problems of looked-after children, other than to
make two simple points. Sometimes, people simplistically see health
as freedom from disease, and I think that everybody sitting on
this side of the table is signed up to the concept that it is
much broader than that. There is also a time dimension that we
ought to remember, and that is the time dimension looking back.
These children come into care with inherent vulnerability. That
vulnerability comes partly from their background genetics and
from their experience in early childhood. We must also look forward,
and in the present time they are vulnerable through health risk
and I am sure that we shall engage in discussion on that today.
I would like to make a few points about the White Paper and the
Children and Young Persons Bill specifically, which I hope we
can discuss. The first is a positive reflection—there are
enormous positives that health professionals would fully support,
particularly around an increased focus on the competency and support
for foster carers and the primacy of that parenting role. The
second is the enhancement of positive discrimination in education
for these children and the promotion of positive participation
outside school. All that is very good, but in the rush for Time
for Change, it is crucial that we also look back at what is
good and what is excellent, so it is also time to take stock.
From where I am sitting and from looking at the army of health
professionals on the front line who are phenomenally dedicated
to health advocacy for these children, we need to look at what
works well and what we need to shore up and reinforce. I have
great concerns that the Bill seems to be neglecting, or at least
deferring, the concept of a statutory role for health professionals,
while supporting, as I do, the statutory role for a designated
teacher. I hope that we can explore that further. As a health
professional who has to wrestle for thinly spread resources within
the NHS, there is another issue, that of performance indicators.
We love them and hate them on the front line, but it has to be
said that performance indicators help to dictate and support where
resources go in the health service. It has been a long-standing
concern of mine that we do not have performance indicators at
present that the health services are directly accountable for—they
are accountable in partnership with their local authority. I would
like to see performance indicators for which PCTs are directly
accountable; that would enormously improve my role. The other
discussion I hope we can have is around the vulnerability of children
when they move in care, particularly when they move distances
across boundaries, and the need for enhanced communication between
health professionals. In summary then there are enormous positives
in Care Matters, but we must not neglect the gains
that we have made in looking at what works well and let them fall
by the wayside as we progress.
Q171 Chairman: I thank all of you
for that excellent introduction. Many members of the Committee
have more of an education background than a health background,
although not all of us. On the other hand, we are not only educational
in experience; we are also constituency MPs. I frantically phoned
Kirklees PCT to find out whether we had psychotherapy services
when I saw that part of the briefing said that most of the psychotherapy
services seemed to be in London and the south-east, with not much
in the north, so I quickly had to check on that. The interesting
thing for the Committee is finding out where health does and does
not play. Some of us find that when we visit a children's centre,
for example, they say that health is the weaker partner. If you
want a holistic approach to the needs of children—children
full stop, but looked-after children in particular—health
is the more difficult side to engage. Catherine, I know you have
just finished and you said that there was a penalty for coming
last. Is the criticism that we pick up on fair? What is this missing
dimension of health care? Is there one?
Dr Hill: That is a surprising
comment and I find myself instantly rising in defence of the excellent
practice that I see around the country. If you are talking specifically
in the context of looked-after children, which we are doing here,
there are, at the very minimum, statutory requirements that we
have to work to. Subsequent to the Quality Protects initiative
and the 2002 document on promoting health, there has been impressive
development—to call it an explosion would, perhaps, be a
bit dramatic—in many localities of health teams that are
dedicated to working with looked-after children. I think they
would be horrified by the concept that health is not an equal
partner. I think you are probably picking up on inequity across
areas. From one PCT to the next, there may be an enormous difference
in the provision, not only in terms of man and woman hours but
in terms of diversity—that is, whether a health team is
a lone nurse or whether it is a group of nurses, doctors, clinical
psychologists etc. It is worth asking why that should be. That
comes back a little bit to the point that I was trying to make
in my introduction about what promotes excellence of services
in local areas. Some of it will, of course, be must-dos—we
have a statutory must-do—but when we are talking about really
achieving health, we are talking about two things. Quality comes
through the must-dos, plus the local champion. The group on behalf
of which I made my defensive response are those many people who
are strong champions for children in the care system. That is
not to be naive and say that health is all about health professionals
and statutory assessments, because it is absolutely not, although
those are some of the crucial foundations that I was referring
to. It is about a much more multi-dimensional approach that engages,
particularly, health issues in the broadest sense, including participation,
self-esteem and positive mental health.
Dr Harris: I agree with what Catherine
has just said. I was reflecting, as she was speaking, on the patchiness
of the provision. It is fair to say that there is less consistency,
certainly in terms of mental health, about which I can speak more
clearly. The commissioning process is critical to this. In boroughs
where the local authority and health commissioners work closely
together, and the balance between health and local authority commissioning
is thought about carefully and in partnership, in my experience
the needs of looked-after children tend to be met better by mental
health services than where a balance is slightly less equitable.
We do not have the same statutory regulation, whereas local authorities
have joint area reviews and inspections. They may be powerful
players in the commissioning process. Certainly, where I am based,
in Camden, there is good joint commissioning for child and adolescent
mental health services across all the funding streams, with one
person responsible for them who is employed by the local authority,
but accountable to the PCT. For us, that is a lever in terms of
frameworks that we do not have but local authorities do. So commissioning
is one of the elements that makes a difference.
Helen Chambers: I was just thinking
about two elements of that. I absolutely agree in respect of the
inequity across the country and, thinking about the approximately
90 healthy care partnerships across England that work as partnerships
between health and children's services, that is true. I think
that health is well engaged, but, going back to what colleagues
have said, the commissioning of services varies hugely. The West
Midlands regional government office is currently carrying out
an evaluation of the Healthy Care Programme. One of the early
key findings has been that it is really important for the whole
corporate parent, including health, to sit around a table and
consider the child-focused needs of our population of looked-after
children, and to build services responsive to those needs, so
that commissioning is informed by the child and by Ofsted—or
the joint area review, as it has been—and information is
brought together in one place. The Government office for Yorkshire
and the Humber has been working with us on healthy care, and one
of the key points that has gone into the regional pledge is that
the regional government office should have a challenge and support
role in looking at the multi-agency looked-after partnerships
or healthy care partnerships that operate to improve health and
well-being. Like Cathy, I feel that, at practitioner level, some
of our greatest champions—in fact, they were called champions
of looked-after children—are our looked-after children's
nurses. They are fantastic, and I can think of many who are virtually
beaten into the ground by trying to provide for the needs of looked-after
children operationally and strategically. In other places, such
as Worcestershire, there are wonderful multi-disciplinary teams,
focused on the emotional health of looked-after children. There
are some great models of practice. A problem is how often plans
develop, and services are considered, too easily and separately.
Healthy care has been one mechanism, and children's trusts are
another, but there is something about people actually focusing
on the breadth of need for these children and how, together, we
can make a difference. With a corporate parent that may be made
up of 16 or 20 staff, that is very difficult. I would certainly
say that the health community has done a great deal, but there
is a lot more to be done.
Sue Dunstall: I absolutely endorse
everything that has been said, but I think that there is a big
difference between the excellent networks on the ground among
practitioners and the rather less excellent partnerships at commissioning
level. My sense is that we are leaving looked-after children with
the presence, or absence, of creative and committed individuals—the
champions that we are talking about. I am not at all clear that
it is good enough to have champions at network level. We must
have those champions at partnership level, where we have senior
people, who actually hold the money streams and can commit to
services that will be consistent and of high quality. What will
drive that quality of commissioning is the performance indicators
that my colleague Dr Hill talked about.
Chairman: Right, we have got started,
and now I will hand over to David to start drilling down.
Q172 Mr Chaytor: Can I pursue the
question of performance indicators? What else is needed? From
next year, local authorities will have an enormous list of 158
compulsory indicators and another 50-odd priority targets. What
else needs to be included in that list of indicators to strengthen
the position of children in care? What more needs to be done in
the indicators on the health service side of the partnership?
Sue Dunstall: For me, there needs
to be a much clearer drive to focus on the indicators, which unquestionably
exist, particularly in the local authority indicator set. At the
moment there is no level of comfort that those indicators will
be chosen, and considerable comfort that indicators such as obesity,
which will be a much softer target for local authorities and health
agencies to meet, will be focused on. Indeed, obesity features
heavily in the health authority performance outcome framework.
It seems to me that there is a clear drive towards obesity, for
example, in the health indicators. Nor is there, as my colleague
Dr Hill pointed out, a clear indicator specifically for looked-after
children. There are some generalised materials—my two medical
professional colleagues may give you more details—on the
emotional well-being of children generally, but not specifically
on looked-after children. As we have said, these are particularly
vulnerable children, and I argue that they have particular needs.
Q173 Mr Chaytor: National indicator
58 relates to the emotional behavioural health of children in
care. Is not that enough? What else do you want for children in
care? That indicator seems reasonably specific.
Sue Dunstall: I want something
much more specific. That is a local authority indicator, combined
with something much more specific on the health indicator side.
Dr Hill: For me, it is about not
more indicators, but accountability. It is as simple as that.
At the moment, accountability is fairly firmly placed with the
local authority. While there are clearly duties of co-operation
between the partners, and some good examples of good partnership
working, the indicators by which the PCTs are currently monitored
are not specific. They must be specific for looked-after children
because there is a food chain in the PCT, and children are quite
a long way down that food chain in my experience. Vulnerable children
are a wee bit further down and looked-after children are embedded
even further down. Unless you bring them up the food chain in
the performance monitoring framework, they will remain lost and
embedded among the various social inequality local area agreement
targets and so on. Some PCTs bring them into those frameworks,
but for me it is to do with bottom-line accountability.
Helen Chambers: Perhaps I could
add that before coming here, I asked how many local authorities
in one region—the south-west—had addressed the health
of looked-after children in their local area agreements, which
is the key way of putting the joint strategic needs assessment
at local level into action. My public health colleague in the
south-west told me that not one local authority had identified
the health of looked-after children in their LAA. My observation
nationally is that, as Cathy said, they are just not high enough
up the agenda and there are many other priorities. The local area
agreements and national indicator sets go beyond children, so
local authorities must make difficult decisions on the key 35
indicators that they will choose.
Sue Dunstall: May I be absolutely
clear that it is not just up to the local authority. Unless the
health agencies are prepared to sign that local area agreement,
it will not go forward as the local area agreement. It is not
just about the local authority identifying performance indicator
58, it is about the health agencies agreeing to identify that
as well. It really is important not to lodge this solely in local
authorities' laps, because that is where we have gone wrong in
the past.
Dr Harris: I was going to underscore
that by saying that I would be interested in looking for a statutory
responsibility for health to co-operate with the local authority,
because that is what is lacking. It feels like good will rather
than a statutory responsibility.
Q174 Mr Chaytor: To what extent are
the relative issues that you are describing due to the fact that
the original 2002 guidance on the health of looked-after children
did not give statutory responsibility to health agencies? Rita,
do you think that is central to that?
Dr Harris: Yes, I agree with that.
It is guidance, and there is no statutory responsibility, so it
depends largely on PCTs' interpretation, and there are no measures
against which they can be measured in terms of both co-operation
and the services that they deliver.
Q175 Mr Chaytor: Catherine, on the
statutory and non-statutory issue, you said earlier that we need
a statutory role for health professionals, but when you were being
defensive following the Chairman's remarks, you said that the
NHS has statutory requirements. How do you reconcile that? Can
you be more concise?
Dr Hill: To clarify, there is
a statutory requirement that looked-after children receive a health
assessment—both an initial health assessment when they are
first received into care and review health assessments, either
six months later for under-fives or annually for over-fives. That
should be done by a registered medical practitioner. That it a
process issue that is attended to by a health professional and
is nothing to do with the broader role of a designated doctor
or nurse for looked-after children. That obviously relates a strategic
clinical leadership, governance role that is quite separate.
Q176 Mr Chaytor: Finally, on the
process of assessing the health needs of looked-after children,
what are the most common gaps, and how do children fall through
the gap between health and social care in terms of their assessment?
There are statutory time limits in which children should be assessed
in relation to health care once they are taken into care. Do you
have any view on that?
Helen Chambers: From the breadth
of work we have seen within the Healthy Care Programme, I would
say that there are a variety of difficulties. One difficulty is
that a looked-after child might be invited to a medical by a doctor
and when they hear that they have to take their trousers down,
they decide they will not go. The foster carer or residential
social worker then says, "I don't blame you," and that
is the end of the story. That is what might happen at one end
of the spectrum. In Southampton, where Cathy is lead physician,
there is a very good model because there is a weekly drop-in health
centre for looked-after children at the Quays leisure centre.
In addition to a health assessment, all sorts of great things
happen there. In between those two examples there is a huge diversity.
I have experience of some health services providing a health assessment
by telephone, which does not feel like a good-quality health assessment.
Other local authorities will provide a medical assessment or health
promotion literature, which is another model. Some of the most
effective health assessments are provided by skilled, trained
paediatricians and a range of other practitioners, including nurses,
mental health workers and others, who see the child face to face
and probably spend some time with them over a consistent period.
One of the clear issues for looked-after children is consistent
placement, and when we have talked to looked-after children and
young people about consistency, the designated doctor or nurse
who they have got to know through health assessments and support
is really key to their sense of well-being.
Q177 Mr Chaytor: Does that mean that
there is no formal national guidance about what form the health
assessment should take and that people can get away with either
just distributing a few leaflets or a quick phone call?
Dr Hill: This is absolutely core
and central to the work of the BAAF health committee. In fact,
preceding the 2002 guidance—but galvanised by that—we
have had a number of working groups consisting of people who between
them have extensive professional expertise in the area, and who
have developed pro forma formats, which, to some extent, dictate
the structure and content of a health assessment. The really important
thing to get away from is the concept of a medical. That is history,
the old "freedom infection medical" what I call the
veterinary stethoscope and testes approach—that is not there
anymore. Such an approach might be an important part of an assessment
for a child—and we know that some of these children need
diagnostic skills as they have neglected health problems—but
the issue is also about a much broader understanding. It is about
understanding attachment, the impact of neglect on brain development,
how you legitimately access family history and how you package
all that up to look into that child's future. Those are very different
skills from any of those I learnt in my standard paediatric practice.
On top of attempting to improve the model for conducting health
assessments, we know that the forms we have developed and that
we distribute via the BAAF organisation have been adopted by two
thirds of local authorities nationally and additionally by primary
care trusts. We know that they are very broadly used; in fact,
they have been put forward in the "Connecting For Health"
child health programme as a model for how health assessments should
be conducted and the data collected. Of course, what you cannot
dictate are the skills and competency, sensitivity and flexibility
of the individual conducting the assessment. Those are factors
that we are also looking at. With the Royal College of Paediatrics
and Child Health, which we are a specialist interest group of,
we are developing competencies for paediatricians in practice
and I hope that that process will move on in due course, via the
Royal College of Nursing, to establish similar competencies for
nursing professionals. There are two other points I want to make.
First, I cannot understate the fact that this is not a veterinary
medical. Secondly, the people engaged in this work are skilled.
We surveyed about 50 nurses in 2002. The average post-qualification
training time for those nurses was 21 years; these were, and are,
experienced senior nurses. Among our medical colleagues, who were
surveyed last year, we know that 85% of them are senior paediatricians;
they are consultants or associate specialists. So these are people
who have a lot of skills and expertise between them. I think that
this role and the quality of the health assessment need to be
reinforced. However, for children, assessment needs to be efficient
and it needs to lead to resources and support.
Q178 Mr Chaytor: That is my follow-up
question. What is the link between the results of these individual
health assessments and the commissioning process? How does the
position of the individual child feed into the commissioning of
services?
Helen Chambers: It should feed
in to inform a Joint Strategic Needs Assessment (JSNA), which
a local authority does in partnership with health and children's
services. I think that there is often the difficulty that commissioning
on strategic working does not necessarily hear adequately the
needs on the ground. In a sense, the opportunity should be there.
Q179 Mr Chaytor: Am I right in thinking
that the known specific indicators for children in care in the
core data set off the JSNA?
Helen Chambers: This is a new
way of working; it is in the Care Matters implementation
plan. The indicators that are chosen between local authorities
and health services will be overseen by the director of public
health, the director of children's services and the director of
adult services. I do not know how this new way of working will
pan out. My understanding is that the needs of vulnerable groups
should be heard within this way of working and I see looked-after
children as one of the constituents. However, I am not aware that
there is any obligation for them to be heard.
Dr Harris: No, there is not; I
think that that is the problem. One of the issues is being able
to ring-fence funds within the health pot, if you like, to meet
some of these needs. Further, one of the problems that health
often has, certainly within mental health, is conflicting priorities.
The priorities of looked-after children do not necessarily jump
higher than a crisis intervention because somebody has got an
early psychotic illness or something like that. Our priorities
do not match, if you like, and I think that there is something
about identifying those priorities and being able to protect the
funding. You will probably be aware that the CAMHS grants that
were available for developing services have gone into local authority-based
budgets. Some of these have been protected and some have not been.
Some of them will be protected for looked-after children and some
of them will go into a much wider range of services over which
health has no say. So, it is complicated, and the pressures on
the health services—certainly speaking for mental health
services, once again—are, as I have said, to meet performance
targets around waiting lists, quick interventions, or quick throughputs
of children. These children do not go through quickly.
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