Health Review Committee

Health of our Children and Young People

Report 27 January 2004

Appendix B

Health of Children Looked After in Hampshire

Recommendation report for the Health of Children Looked After in Hampshire

1. Scope

1.1. This review commenced in June 2003 after several preliminary meetings had been held to discuss background and project planning. The working group was comprised of:

_ Councillor Mrs Banks (Chairman)

_ Councillor Beagley

_ Councillor Mrs Dickens

_ Councillor Mrs McNair Scott

_ Councillor Mrs Randall

_ Councillor Searle

_ Carole Bennett, Social Services

_ Gill Horrobin, Social Services

_ Graham Linecar, Policy Unit, (Review Team Leader until November 2003)

_ Pete Marsh, Education

_ Penny Velander, Policy Unit, (Review Team Leader from November 2003)

1.2. The theme for this review was scoped to cover the physical, social, emotional and mental health of children looked after through foster and residential care. The main question the review set out to address was `how should children who are looked after access health care'.

1.3. The stakeholder analysis identified key staff in health, social services and education, foster carers and looked after children.

2. Methodology

2.1. From the stakeholder analysis it was apparent that a great number of agencies and initiatives were offering support for children who are looked after. The working group agreed that the review approach would be to examine the efficiency of existing services and invite comments on how the service could be improved in light of the recommendations made in the Care Standard Act.

2.2. Once the stakeholders had been identified the working group decided that the most efficient method to collect initial information, experiences and concerns would be through questionnaires. Five stakeholder groups were established and each group sent a personalised questionnaire. The questionnaires gathered quantitative and qualitative information

2.3. It was recognised that the approach used for gaining the thoughts and comments of children looked after would need to be more accessible and user friendly. The Care Action Team (CAT) was approached and agreed to coordinate this task. A carefully worded questionnaire was sent to all children looked after and for those replying there would be the opportunity to win prizes. The questionnaire was followed up with telephone interviews to those young people who indicated that they were willing to be further involved

2.4. Responses from all questionnaires were collated, analysed and combined into an issues report (Annexe B1) that was circulated to all stakeholders. Those unable to attend the stakeholder event were invited to send postal responses commenting on the report as a whole and three `prompt' questions which invited ideas for improving the service for the future.

2.5. A half-day stakeholder event was held on 24 November at the Marwell Hotel, Colden Common, Winchester. The aim of this event was to invite further responses to the issues report and pose the same three prompt questions.

2.6. The deadline for all responses was 5 December 2003. All feedback was considered and informed the final report

3. National information on Children Looked After

3.1. Children and young people who are looked after are amongst the most socially excluded groups in England and Wales. They have profoundly increased health needs in comparison with children and young people from comparable socio-economic backgrounds who have not needed to be taken into care. These greater needs however, often remain unmet. As a result, many children and young people who are looked after experience significant health inequalities and on leaving care experience very poor health, educational and social outcomes.

3.2. The legislative framework supporting the care of children looked after originates from:-

_ The United Nations Convention on the Rights of the Child

_ The Children Act 1989

_ The Care Standards Act 2000

_ The National Service Framework for Children (due out 2004 once recommendations from the Green Paper, Every Child Matters, are incorporated


The regulatory framework provides for an annual health assessment of each child over five to ensure that health needs are properly assessed and appropriate health care intervention provided. However these assessments have been regarded as annual `medicals' with undue attention not being paid to the whole of the child's well being.


The Care Standard Act outlines the responsibility of agencies and carers in promoting the health of children who are looked after. It contains revisions to the regulatory requirements. Key changes are:-


_ The first health assessment should be carried out before placement, or as soon as possible after. It is required to be undertaken by an appropriately qualified registered medical practitioner and should form the basis of the child's health care plan.

_ Health assessments need to be based on a health promotion model and take a holistic approach to the child's health eg immunisations, mental health, medical conditions, diet, sexual health, and dental history

_ Annual review assessments may be carried out by an appropriately qualified nurse

_ Children under 5 will now be required to have 2 assessments per year

_ Notification is now required to both the PCT in the area from which the child is leaving and the PCT area to which the child is moving

3.3. National figures from the Department of Health show that 3.3 children per 1,000 aged between 0-17 are being looked after at any one time. Children in care are recognised as being seriously disadvantaged in all walks of life. National statistics show that:

_ 41% of children in care are aged 10 or under

_ 80% enter care because of abuse, neglect or family reasons - less than 10% because of their own behaviour

_ Almost 70% of children looked after live in foster care and 10% in children's homes

_ 25% live outside their `home' local authority

_ 27% have a statement of Special Educational Needs compared to 3% of all children

_ Children in care have poor results in all Key Stage Standard Assessment Tests (SATs)

_ In 2001-2, only 8% of children in care achieved 5 or more GCSE grades A*-C compared to half of all young people

_ Only 1% go to university

_ Only half as many care leavers are in education, training or employment at age 19 compared with their peers

_ Young people who have been in care are more than twice as likely to be teenage parents and twice as likely to have a mother who was in care

_ More than 25% of rough sleepers were in care

_ Around 25% of adults in prison spent some time in care

3.4. Research shows that children and young people who are looked after dislike the annual `medicals' and feel disengaged from their own health issues. In addition they regard them as stigmatising especially if they are carried out during school time

3.5. Preliminary research for the Social Exclusion Unit has estimated the total cost of social exclusion among adults who have been in care. If those leaving care who do not go into education, employment and training had the same pattern of activity as their peers, the saving over three years would be in the order of £300 million

4. Children Looked After in Hampshire

4.1. The number of children looked after in Hampshire is slightly above the national average with 3.7 per 1,000 children (compared with 3.3 nationally). The number of children looked after in Hampshire has risen significantly within the last year despite a drop in the overall population between 0-17.

4.2. A corporate team for the education of children looked after was set up in January 2003 with two Education and three Social Service staff. By January 2004 this had expanded to include designated Education Welfare Officers, Education Psychologists and Learning Support Assistants

4.3. The County Council maintains 12 children's homes.

_ 5 homes where children, usually from the locality, are placed short term for up to six months.

_ 3 homes which provide short-term respite care for children with disabilities

_ 4 homes for long term placement, this includes 2 for children aged 9-13 and 2 for young people aged 13-18

4.4. In Hampshire there are 650 Foster carers of which 121 offer Family Link respite care for disabled children; 260 have general approval to foster and approximately 90 are registered for specific care

4.5. Hampshire key statistics:

_ 13.3% of children looked after have been in continuous care for 4 years or more and with the same foster carer for at least 2 years

_ 16.4% of children looked after have been in three or more placements in the last year

_ 57% have had annual health check and medical in the last year

_ Social Services still work with over 300 care leavers

_ 6.9% of children looked after during past year have missed 25 days of school

_ There are 556 designated teachers for children looked after. 476 have received training for the role and a further 80 are awaiting training. Each school should also have a designated Governor but there are no records on numbers

_ The number of permanent exclusions for 2002-03 were 9 compared with 13 for the previous year

_ GCSE results for children looked after for 2003 show that 51.7% passed 1 A*-G; 8% passed 5 A*-C; 30% passed 1 A*-C

_ 26% of year 11 children looked after did not sit GCSE's and 16% have significant learning difficulty

_ Three celebrity events per year are organised where children looked after receive books and certificates for achievement. These could be for attendance, sport, academic achievement etc

5. Survey of professional stakeholder groups

5.1. The main questionnaire was sent to 5 stakeholder groups:-

_ Foster carers

_ Managers of registered children's homes

_ Primary Care Teams eg General Practitioners (GPs) Practices

_ Directors of Public Health

_ Designated teachers for children looked after


Each raised issues drawn on their own experiences of working with or caring for children looked after. The full report is attached as annexe B1

5.2. The main issue raised by foster carers was the lack of communication prior to a child being placed with them. This includes background information and the history of the child's mental and emotional health

5.3. As expected the managers of children's homes responses varied according to the type of service they were managing. However, overall their experiences mirrored those of foster carers with them identifying the need for more information at placement and additional details of emotional and mental health.

5.4. The responses made by GPs suggest that they are aware that this is an issue and an area where they might make improvements. Several indicated that the very fact of being asked questions about whether they have a `lead' and what information is included in practice records has prompted them to think about what might be done. In addition responses show that nearly three quarters of GPs are not alerted to a child being looked after and few practice records show who is able to give consent for a looked after child to receive treatment.

5.5. Responses from the Directors of Public Health show that all recognise children looked after as a specifically identified patient group however record keeping on this group is patchy. Anecdotal information recognises that children looked after have greater mental and emotional health needs than children in general

5.6. Responses from designated teachers of looked after children were very high, which reflects schools' recognition of the important needs of children who are looked after. In most schools the record system recognises that a child is looked after and limited medical information is maintained on that child. The majority of schools responding routinely share information with other agencies and see Social Services as the main focal point for information exchange

6. The Children's survey undertaken by the Care Action Team

6.1. The responses to the initial CAT survey were encouragingly positive, indicating that young people feel that those caring for them take their health issues seriously, provide the opportunity for healthy eating and that, for most of them, there is someone they can approach and talk to about health issues that may be worrying them. However the main issue for those responding was the annual assessment or `medical'. They'd like it undertaken more quickly, with less waiting and with simple, straightforward questions.

6.2. This is reinforced through the telephone interviews, which reported that many children who are looked after are not aware of how the medical assessment should work. They knew they were compelled to see a doctor once a year even if they felt there was no need. Many stated that they felt singled out and only wanted to see a GP when they were ill like other children. The full CAT report is attached as Annexe B2. The four key recommendations from the report are:-

_ `Make the medical assessment procedure less stigmatising. Maybe change the name to something much less off-putting than a `medical', allow GPs to carry them out and allow designated nurses to take on a bigger role.'

_ `Ensure that children looked after (CLA) always have some influence over their menu while ensuring that they are given the opportunity to have a balanced diet'

_ `Ensure that CLA always have someone to whom they can turn to for guidance. They need consistency, and should ideally be able to speak to someone outside the authority, who is not bound by the professional etiquette of social services. This also involves creating a much more user friendly complaints procedure'

_ `Involve the youth service more in offering advice on sexual health issues. It is essential that all young people, even as young as eleven or twelve, have a basic understanding of important issues such as contraception and safe sex.'

7. Stakeholders event

7.1. The aim of the stakeholder event was to bring together professionals, including carers, from a variety of backgrounds who are involved in supporting children and young people who are looked after. Colleagues from Social Services and Health gave background presentations to set the scene and then three multi agency discussion groups were established to carry out two set tasks. Task one was the opportunity to add further comments to the issues report. Task two was to discuss and feedback on three prepared questions which would help to inform changes that need to be made for the future of the service. The three questions were:-

_ How can we engage with young people to help them understand about health promotion

_ What are the obstacles that would stop Q1 happening and how could they be overcome

_ What are the three key issues that we need to tackle

7.2. There were 55 attendees at the stakeholder event representing Social Services, Education, Health, foster carers and children who are looked after. Many commented that this was the first time they had all been brought together to share their professional knowledge and experiences.

7.3. Feedback from the three task groups, despite being varied, had many common themes. These have been grouped together to create a pair of overarching principles and six main issues. The principles should be considered the bedrock running through all of the issues.

7.4. The two principles are:-

i. All services should endeavour to create a culture which values children and young people

ii. All children who are looked after should be at the centre of a truly multi-agency, needs-led approach that is co-ordinated across the county

7.5. Issue one - Choice for young people.

i. They should be made aware of and be able to access health care and preventative services as and when they are needed

ii. An adult mentoring scheme should be established which develops professionals from a range of backgrounds to support children who are looked after. This would respond to their wish to have a consistent person to care for them and confide in.

iii. Children and young people should be more involved in the placements that are made. It is important to them not to be moved away from their community, school and friends

7.6. Issue two - Transfer of information

i. This is an area that needs major overhaul and attention. The system needs to be tighter, speedier and more efficient to make sure that all necessary information follows transition and is immediately available to carers. Information needs to be honest and clear about any risks involved

ii. Children and young people should have ownership of their own hand held records where practical

7.7. Issue three - Clearer guidance to GPs

i. Children who are looked after should be registered as permanent patients. This is not always the case.

ii. GP practices may not close their books to children who are looked after. They are a vulnerable group and must be taken on

iii. Consideration should be given to provide same sex GPs for health checks if requested.

iv. Change the name to something more everyday eg `check-up'

v. There is a need for GPs to have a greater awareness of emotional well being

vi. GP practices should be made aware of good practice regarding children who are looked after

7.8. Issue four - Access to specialist services

i. There should be a range of specialist services available to children who are looked after provided with them in mind eg CAMHS, counselling, peer support, often provided by the voluntary sector

ii. Contrary to the issues report accessing NHS Dentists was seen as a problem

iii. The image of professional services needs to be more approachable, child friendly and accessible

7.9. Issue five - Focus on health promotion for diet and physical activity

i. Concern was expressed that children who are looked after are not receiving adequate health promotion information. On reflection this was felt to be relevant to all school age children and concerns mirrored general points identified in the Health of School Age Children report recommendations three and four (Appendix C)

ii. Special provision needs to be made for children and young people living in children's homes to have cookery lessons and opportunities to cook

7.10. Issue six - Professional support

i. Appropriate training available for foster carers, mentors, peers, GPs and other professional staff.

ii. A toolkit of good practice and advice for mentors and peers made available

iii. A support network that all carers and professionals can access as and when they need it. (Perhaps electronic - website and chat room)

iv. Improve communication

8. Postal responses

8.1. Several postal responses were received from people who were unable to attend the stakeholder event. The three main messages arising were:

i. Better communication between all involved in supporting children who are looked after

ii. Quicker access to services especially for emotional and mental health

iii. Increase personal support and respect for children who are looked after to maximise their self confidence and self esteem

9. Conclusions

9.1. Children and young people who are looked after are one of the most vulnerable and socially excluded groups in our society. Their greater needs however, remain unmet. As a result, many children and young people who are looked after experience significant inequalities in all areas of life

9.2. All children looked after are required to have an annual health assessment. Revisions to the regulatory framework have introduced significant changes to this procedure

9.3. The number of children in care in Hampshire is slightly above the national average. This number is rising despite a slight drop in the overall population of 0-17 year olds

9.4. Consultation with stakeholders shows that procedures and services vary from area to area across the county; this causes disparity of opportunity. Hampshire has a large network of professionals, including carers, who would like to work closer together to have a more joined up approach to support children who are in or about to enter care

9.5. Children who are looked after dislike the existing `medical' and feel it stigmatises them from other children. They want to have a greater say in all aspects of their health and so need quality information and support to enable this to happen.

9.6. This review has highlighted a large volume of good practice and support for children who are looked after in Hampshire. However, there is still room for real improvements through support, information and multi-level parenting to empower them to make the choices they face in life.

10. Recommendations

Please see over for Recommendations and Action Plan

Review Recommendation and Action Plan

Health of Children Looked After