Children in Care

Introduction

Haringey’s Safeguarding and Children in Care Services had a joint Ofsted and Care Quality Commission (CQC) inspection. The findings from the CQC inspection contributed to the joint report published by Ofsted and enriched the information used to assess providers against the Essential Standards of Quality and Safety. A series of recommendations were made as a result of this inspection, including:

  • Ensuring there are robust systems in place to monitor the quality of healthcare provided to all looked after children and care leavers in all settings.
  • Ensure that the views of young people are heard strategically in the planning and development of health care services.

A rapid health needs assessment was therefore undertaken in Haringey.

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Key issues and gaps

  • The health of children and young people in care is often poor at the time of their entry to the care system, since it may reflect the impact of poor early life experiences, family influences and environmental risk factors.
  • Young people leaving care are a particularly vulnerable group, and research has consistently found that their health and well-being is poorer than that of young people who have never been in care (see footnote 1).
  • Many aspects of young people’s health have been shown to worsen in the year after leaving care. Promoting the health and wellbeing of looked after children - revised statutory guidance (external link).
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Who is at risk and why

Children in care are a group who can be particularly vulnerable to developing substance misuse problems; engage in risky sexual behaviours and experience high levels of mental health need which will adversely impact on their life chances (see footnote 2).

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The level of need in the population

At 31st March 2011 there were 613 children in care in Haringey, including unaccompanied asylum-seeking children.

Figure 1: Numbers of children in care year on year at 31st March 2011

Source: SSDA903 Children looked After by Local Authorities in England

As can be seen from Figure 1, there has been a steep increase in the number of children in care from 2008, with Figure 2 below comparing Haringey with the national and statistical neighbour average

Figure 2: Comparison of number of children in care

Source: SSDA903 Children looked After by Local Authorities in England

Age, gender and ethnicity

58% of children in care at 31 March 2011 were male and 42% female. A majority of children in care fall into the 10-15 year age bracket (36%)

Figure 3: Age and gender of children in care at 31st March 2011

Source: SSDA903 Children looked After by Local Authorities in England

44% of children in care at 31 March 2011 were from Black ethnic backgrounds. This includes Black British, Black African and Black Caribbean backgrounds. 35% were from white backgrounds, including White UK and other white European groups.

Figure 4: Ethnicity of children in care in Haringey at March 2011

Source: SSDA903 Children looked After by Local Authorities in England

Placements of children in care

Figure 4 shows that 62% of children in care to Haringey are placed with foster carers. A majority of them are placed outside the borough, but a high proportion of these are in neighbouring boroughs (e.g. Enfield, Waltham Forest).

Figure 5: Placements of children in care at March 2011

Source: SSDA903 Children looked After by Local Authorities in England

Health of children in care

Despite the wide ranging health needs of children in care, there is a statutory requirement for the local authority to collect data on only a small number of health outcomes: development checks, immunisations; dental checks and whether the child has had a health assessment.

Statistical returns in this area are based on children who have been in care for at least 12 months at 31 March 2011.

Developmental checks, immunisations, dental checks and health assessments

According to the London Borough of Haringey, 81 children aged 5 or under were due to have a review health assessment which includes a developmental check and 100% were up to date. 96% of children had up to date immunisations. 83% of children had an up to date dental check in the year and 92% had an up to date health assessment. All of these figures are an improvement on the previous year. The performance indicator is an average of health assessments and dental checks and the outturn for 2011 was 87.6%, compared to 85% in 2010. The London average for 2010 was 87% and the average of our statistical neighbours was 86%.

Figure 6: Percentage of immunisations, health assessments and dental checks completed in timescale

Source: SSDA903 Children looked After by Local Authorities in England

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Current services in relation to need

Age rangeServices
0-5 Years

Universal services:
Midwifery; Health Visiting; Parent Infant Psychology Service; Audiology; Children’s Centres; Speech and Language therapy services; GPs; Dentists; Optometrists; Accident and Emergency Department

Targeted services:
Children in Care health team; Tavistock-Haringey service; Family Nurse Partnership

6-11 yearsSchool nursing service; Open Door; Tottenham Hotspur Foundation (diversionary activities for young people aged 7-16)
12-16 yearsCOSMIC; HAGA; Insight; Third sector organisations; Hearthstone (Domestic Violence); 4YP sexual health services; Barnardo’s sexual exploitation advocacy service; Adolescent Outreach Team
16+ yearsAs per 12-16 plus:
Young Parents Team at Whittington Hospital; Family Nurse Partnership
Dentists; Optometrists (issues with paying for services post 16)

Children in care health service

The objective of the children in care health service is to ensure that all Haringey children and young people in care are physically, mentally, emotionally and sexually healthy and that they are able to make health choices that enable them to enjoy healthy lifestyles.

This is discharged by providing the statutory initial health assessment within four weeks of entering care and review health assessments:

  • Six monthly for children under the age of 5 years and
  • Yearly for children 5 to 18 years

All initial health assessments are carried out by the Designated Doctor for Children in Care. Since January 2011, all review health assessments are carried out by the specialist nurses for all Haringey children in care, no matter where they are placed. The initial invitation for a review health assessment is to attend an appointment in Bounds Green Clinic; if this is not possible the nurse will visit the child in their foster placement.

Substance Misuse

In Haringey, part of the health assessment includes substance use, including alcohol, drugs, smoking and other substances. Health education and promotion is included and is age and developmentally appropriate. Referral for treatment is to Insight (young people’s substance misuse service).

Sexual Health Services

During the health assessments the nurse’s health promotion includes sex education relevant to each individual child’s needs. Services provided include:

  • Opportunistic chlamydia screening
  • Condom demonstration and initial provision – as part of the C Card scheme
  • Pregnancy choices
  • Rapid direct referrals to sexual health services
  • Advocacy and support for Social Workers and foster carers
  • Young people can text the specialist nurse
  • Referral to the Family Nurse Partnership.

Tavistock Haringey Service – Mental Health & Emotional Well-being for Haringey Children in Care (Adapted from the paper presented to the Overview and Scrutiny Committee, January 2011)

The service is currently commissioned by Haringey Council to provide a mental health service for Haringey’s Children in Care.

The service aims to support children and young people in care by offering a flexible and tailored service which is able to respond speedily to the diverse needs of this complex group.

The service provides opportunities for social workers to discuss concerns and dilemmas regarding the emotional and psychological issues of the children and young people they work with through a variety of consultation surgeries within Social Services.

The team works with children and young people who are in transition between placements, where placements are breaking down, or where there are Court proceedings, as well as with children and young people who are more settled in Care. Clinicians and social workers aim to promote placement stability if at all possible.

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Service users and carers opinion

In June 2011, as part of a rapid health needs assessment, young people in care and leaving care were invited to a workshop facilitated by the Council’s Children and Young People’s Participation and Strategy officer to share their experiences of health and health services.

Ten young people aged 9 – 19 participated in the workshop and represented: young people in foster care, leaving care, asylum seeker backgrounds, young people accommodated by Southwark judgements, unaccompanied minors, those that had been in Children’s Homes, and young mothers.  The young people were asked a series of questions which they explored as a group:

  • What does being healthy mean to you?
  • What do you think of the information and advice you have received on healthy eating; smoking, drugs, alcohol; sex and relationships; oral health and mental health?
  • How do you feel about your health assessments? How involved do you feel? What could make them better?
  • What are your experiences of using health services? Did you feel listened to?
  • Who would you talk to if you had a problem?
  • How prepared were you for leaving care?

Overwhelmingly, the young people said that they had received little or no information on health issues. Many of the young people were critical of the health assessments, although it should be noted that all the young people had had their health assessments prior to the new system being put in place in January 2011, and therefore their comments do not relate to the current situation whereby all review health assessments are carried out by the Children in Care Health team based at Bounds Green Health Centre.

None of the young people in the focus group felt that they were prepared for leaving care and therefore further work needs to be undertaken to ensure that young people are equipped with the necessary skills and information before they leave the care system.

Professionals

  • A further workshop for professionals was held in June 2011. The aim of the workshop was to bring together local professionals who have a role in promoting the health and well-being of children in care.

Participants were asked to identify the key health issues faced by Haringey’s children in care. The following emerged overwhelmingly as the key issues facing children and young people in Haringey:

  • Sexual health including sexual exploitation and trafficking:
  • Drugs and alcohol
  • Emotional/mental health including behavioural problems; attachment disorder etc
  • Immunisations
  • Other e.g. chronic health problems etc
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Projected service use in 3-5 years and 5-10 years

There is currently a Children’s Service Action Plan that has been drawn up to look at the different groups of children in care and the long-term plans for them. This has resulted in a number of children returning home. Based on this work the number of children in care is expected to decrease slightly.

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Expert opinion and evidence base

Research has shown that children in care share many of the same health risks and problems of their peers, but often to a greater degree. They can have greater challenges such as discord within their own families, frequent changes of home or school, and lack of access to the support and advice of trusted adults. Children in care can show high rates of emotional, behavioural or mental health issues. This is largely due to adverse factors impacting on children prior to entry into care, in particular the effects of disrupted early attachments, grief and loss and resulting depression, especially for younger children. Poor emotional and psychological health and feelings of low self esteem can lead to ill health, depression and / or the use of escape coping mechanisms such as substance misuse and risk taking behaviours in older children and conduct disorders in younger children (see footnote 3).

In a study by Meltzer at al (2003) (see footnote 4) two thirds of children in care were reported to have at least one physical health complaint. Looked after children are more likely than their peers to experience problems including speech and language problems, bedwetting, coordination difficulties and sight problems. The health needs which occur most frequently are those relating to developmental/educational and emotional/behavioural issues; incomplete immunisations have also been highlighted as an area needing particular attention with unaccompanied minors.

The sexual health and behaviour of young people is a key priority. Young women and young men in and leaving care are more likely than their peers to be teenage parents, with one study finding that almost half of young women leaving care became pregnant within 18 to 24 months (see footnote 5), and another reporting that a quarter were pregnant or young parents within a year of leaving care (see footnote 6). However, it should be noted that for some young people, this may be a positive choice.

A national survey undertaken by Meltzer and colleagues for the Office for National Statistics (ONS) (external link) confirmed findings of earlier research about the high level of mental health need amongst looked after children, particularly those in residential care. 45% of children in care were assessed as having a mental health disorder, rising to 72% of those in residential care. Among 5-10 year olds, 50% of boys and 33% of girls had an identifiable mental disorder. Among 11-15 year olds, the rates were 55% for boys and 43% for girls. This compares to around 10% of the general population aged 5 to 15.

Clinically significant conduct disorders were the most common among children in care (37%), while 12% had emotional disorders (anxiety and depression) and 7% were hyperactive. Even when compared to children in a community sample from the most deprived socio-economic groups, children in care still showed significantly higher rates of mental health disorders.

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Unmet needs and service gaps

Gaps identified by professionals working with children in care in Haringey:

  • There is a delay in getting some services, particularly child and adolescent mental health services (CAMHS) for those children placed outside the borough.
  • There is a lack of preparation for young people on leaving care. This is reinforced by the young people themselves who stated that they were unprepared for leaving care.
  • There is a lack of clarity on the transition to adult services where this is necessary and concerns about the high thresholds for vulnerable adult services, meaning that many 18 year olds may no longer have access to services.
  • There are concerns about young people with long term conditions e.g. asthma, as often these conditions are not well managed by young people once they leave care.
  • Although children and young people are encouraged to access universal services, e.g. GPs etc, work needs to be undertaken with young people in particular to reduce anxiety about using health services and also with health professionals to ensure they understand the particular needs of looked after children and young people.
  • There is a lack of targeted health information for looked after children and young people and a resulting lack of awareness about services.
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Recommendations for consideration by commissioners

  • Commissioners and providers should work with the children in care and care leavers focus group on an on-going basis to regularly review services for looked after children and care leavers.  
  • Ensure that the mental health needs of looked after children and young people remain a high priority and that adequate provision is commissioned.
  • Commissioners could consider the potential for developing additional health outcomes data for looked after children and young people, beyond the statutory requirements, to provide a more comprehensive understanding of their health status.
  • Consider developing a resource (web based) providing looked after children and young people (and professionals) with a range of health information and local services available. In addition, develop an age appropriate welcome pack for children and young people on entering care.
  • Improve local practitioners’ awareness of services available to children in care and care leavers and ensure better communication between partners and agencies i.e. regular forum for professionals working with children in care to share good practice, experiences and to problem solve.
  • Consider developing regular brief intervention training for professionals working with children in care focussing on substance misuse to respond to young people’s comments about a lack of awareness in this area.
  • Commissioners could consult with the Clinical Commissioning Group (CCG) on the most effective way to improve access and provision for children in care.
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Recommendations for further needs assessments

  • Repeat the focus group with young people to assess if they have experienced any improvements in the quality of health provision.
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Key Contact

Sheena Carr, Senior Public Health Strategist, Children and Young People

sheena.carr@haringey.gov.uk

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Footnotes

  1. Department for Children Schools and Families, Department of Health. Statutory guidance on promoting the health and well-being of looked children. 2009
  2. Department for Children Schools and Families, Department of Health. Statutory guidance on promoting the health and well-being of looked children. 2009
  3. Department for Children Schools and Families, Department of Health. Statutory guidance on promoting the health and well-being of looked children. 2009
  4. Meltzer et al (2003) The Mental Health of Young People Looked After by Local Authorities in England, The Stationery Office
  5. Biehal N., Clayden J., Stein M. and Wade J. (1995) Moving On: Young people and leaving care schemes Barkingside, Essex: Barnardo’s (cited in Statutory Guidance on Promoting Health)
  6. Dixon J. (2008) Young people leaving care: health, well-being and outcomes. Child and family Social Work 13, 207-217 (cited in Statutory Guidance on Promoting Health)
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Attached Files