Starting Well – Children and Young People 2016 to 2020

The population of Hampshire's children and young people is changing:

• Nearly a quarter of the county’s population (23%) is made up of young people (0-19 years), which is slightly less than England as a whole (24%) but in line with our comparators (CIPFA neighbours)
• This varies across the county with young people (0-19 years) making up as much as 25% of the population in Winchester to as little as 20% of the population in the New Forest
• Where our children and young people live also varies; 13% live in Basingstoke and Deane while only 6% live in Gosport
• There are marginally more boys (51%) than girls (49%). This is slightly more pronounced for young people aged 10-19 years (at 52% to 48% boys to girls)

The number of live births across Hampshire increased year on year until 2011 but since 2013 has fallen below the 2007 figure.

Overall, Hampshire's population of Children and Young People (0-19 years) is predicted to increase by 4.8% over the next 5 years. However, there are differences within different age groups and by district:

The largest rises in the 10-14 year old cohort may reflect the increases expected in house building along with the larger birth rates in 2008-2011. The decreases in the 15-19 year old cohort are possibly due to the impact of young people moving away to attend colleges and universities outside of Hampshire, which is also seen in the 20-24 year old cohort where there is a 5% fall predicted over the next 5 years. The fall in the 5-9 year old cohort may be reflective of the fall in the birth rates currently being experienced.

Low mortality rates for babies are a predictive indicator for good health. The rate of neonatal deaths (deaths within 28 days of being born) and stillbirths per 1,000 live births has stayed fairly constant and is below both the national and regional rates. However, the rates are still higher than in other high income countries.

Infant mortality is defined as the death of a child in the first year of life. The infant mortality rate (IMR) is the number of babies born alive, who die in the first year of life per 1,000 live births (this allows us to compare different areas). There is a clear link between high levels of infant mortality, deprivation and poor health outcomes. It is therefore often used as a comparative measure of a nation's overall health as well as to predict where there will be significant health inequalities.

Infant mortality rates show large socio-economic and ethnic differences at national level. Reducing the variation in the IMR is a key national target for tackling inequality and requires initiatives to improve maternal health, child health and the wider determinants of health. Evidence from the RCPCH has shown that many of the well-established risk factors for death in infancy persist into older ages. These include the association between birth weight and premature mortality, the differential between those children of fathers in manual occupations and those children of fathers in non-manual occupations, and the age, country of birth, lifestyle choices (such as smoking in pregnancy) and marital status of the mother.

The most recent IMR for Hampshire (2013/15) was 2.9 per 1,000 live births, which is significantly lower than the national figure of 3.9 and lower than the regional figure (3.2) and the third lowest rate in comparison to Hampshire's CIPFA neighbours.

Royal College of Paediatrics and Child Health (RCPCH) – leading the way in children's health

Deaths in childhood (1-17 years) are very rare. A low rate indicates overall good child health. Historically the child mortality rate has been lower in Hampshire when compared to national rates but for the latest figures, Hampshire rates are comparable to national rates. The latest 3-year period suggests a small increase for Hampshire. This needs further investigation. While our infant mortality rates are low compared to national rates, national rates are high compared to our European neighbours.

The absolute number of infants that die each year is very small and there will be some deaths that are potentially avoidable. Through the reviews of all child deaths (through the Child Death Overview Panel) lessons can be learnt and trends identified to help inform prevention and early intervention initiatives. Understanding the causes of death in children and identifying whether these deaths are potentially avoidable is of value in developing interventions that can improve child outcomes. The causes of childhood mortality differ between age groups. The major causes of death for children (pooled three year data 2014-2016) are:

Although the numbers are small, in terms of prevention it is the causes of death for babies (less than one year old) and those in the 15-19 year old age groups that have the most potential to be avoidable. Nearly half of the deaths in the 15-19 year old age group are due to external causes, such as road traffic accidents and deliberate self harm.

Almost one in five pregnant women in the UK is obese. Maternal obesity can impact on women's reproductive health and that of their babies, with growing evidence suggesting that obesity is associated with increased morbidity and mortality for mother and baby. It is not possible to quantify the attributed effect of maternal obesity on infant and child mortality and morbidity on our young population, however research has found there are risk factors associated with increased maternal obesity which could focus prevention work these are:

• deprivation
• being from the White ethnic group
• aged over 35 years

A focus on the following would help reduce the numbers of premature deaths in infants and young people:

• lifestyle choices of women (such as stopping smoking and reducing alcohol intake pre-conception and while pregnant)
• the mental and emotional wellbeing of young people
• road safety in young drivers, cyclists and pedestrians

Reducing smoking and alcohol intake during pregnancy can reduce poor outcomes. The risks of smoking during pregnancy can be serious, from premature delivery to increased risk of miscarriage, stillbirth or sudden infant death. Smoking can affect an unborn baby's growth and development particularly their lungs and heart. Smoking when pregnant increases the risk of cot death by at least 25%.

There are no reliable prevalence figures for smoking in pregnancy but nationally it is estimated that between 1 in 10 and 1 in 6 women smoke in pregnancy. However there are more reliable figures for the number of women smoking at the time of delivery.

In Hampshire the proportion of women smoking at the time of delivery is lower than the national and regional averages and is continuing to fall, however latest data for 2015/16 show there are still over 1,200 babies born who were exposed to smoke during their gestational period.

Just as smoking during pregnancy can negatively impact on the health of the unborn baby, alcohol intake during pregnancy can also negatively impact on health. Foetal Alcohol Syndrome (FAS) results in mental and physical problems in the baby, babies are unable to process alcohol which passes through the placenta thus damaging their brain, spinal cord and other parts of their body. FAS is a relatively prevalent alcohol-related birth defect and is the commonest single cause of learning disabilities. It is the most severe and visibly identifiable form of foetal alcohol spectrum disorder (FASD). and completely preventable. Applying figures on the European prevalence of alcohol use during pregnancy (25.2%) from the Lancet study by Popova et al. to the number of live births translates to approximately 53 children being born with FAS in Hampshire.

Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis

Nearly half of teenage pregnancies are unplanned and around half of these result in a termination. While for some young women having a child can be a positive turning point in their lives, for many teenagers bringing up a child is extremely difficult and often results in poor outcomes for both the teenage parent and the child, in terms of the baby's health, the mother's emotional health and wellbeing and the likelihood of both the parent and child living in long-term poverty. Teenage mothers are less likely to finish their education, are more likely to bring up their child alone and have a higher risk of poor mental health than older mothers. The children of teenage mothers have an increased risk of living in poverty and poor quality housing and are more likely to have accidents and behavioural problems.

Infant mortality rates for babies born to teenage mothers are around 60% higher than for babies born to older mothers.

Risk factors for becoming a teenage parent include:

• poverty
• being a child in care
• children of teenage mothers
• low educational attainment
• truanting or exclusion from school
• 16-17 year olds not being in education, employment or training
• being a victim of sexual abuse
• mental health problems
• involvement in crime

There has been a significant reduction in teenage conceptions both nationally and locally since 1999. In Hampshire there are low levels of teenage pregnancy overall and the levels have been falling consistently since 2009. When we correlate higher levels of teenage conceptions to areas with lower levels of educational attainment and deprivation in Hampshire, there is an association but this is not uniform. Across Hampshire the local Family Nurse Partnership is working with teenage mothers and their babies to ensure positive outcomes for both mother and child.

In 2015 the under 18 conception rate for England was 20.8 per thousand women aged 15 to 17; this is the lowest rate recorded since comparable statistics were first produced in 1969.

In Hampshire, there has been a 53.8% reduction in teenage conceptions from 35.9 per 1000 women aged 15-17 in 1998 to 16.6 per 1000 in 2015.

While this progress is really positive, there remains significant variation in the under 18 conception rate in young women across the county. Gosport and Havant both have under 18 conception rates that are higher than the national average of 20.8 per 1000 and there have been slight increases in some district rates between 2014 and 2015.

Babies born with a low or very low birth weight have a higher risk of poorer health, dying prematurely and/or having developmental issues which can ultimately drive need and demand for intensive support in education and from  social care and the NHS. Low and very low birth weight can be used as an important predictor of future poor health. Low birth weight is defined as a birth weight of less than 2,500gm (very low birth weight babies are defined as less than 1,500gm).

Low birth weight is closely associated with deprivation, and often results from poorer maternal health including dietary intake, multiple births, babies being born prematurely and smoking during pregnancy. Across the population there is variation in levels of low birth weight; a high proportion of low birth weight births in an area could indicate poorer health in mothers, unhealthy lifestyles linked to deprivation and/or be related to the delivery of maternity services.

In Hampshire the proportion of low birth weight babies has remained fairly constant and is significantly lower than national rates. However the proportion of very low birth weight babies, although lower than national rates, is not statistically lower.

Poor diet and smoking/excess alcohol intake during pregnancy are significant risk factors for a baby having a low birth weight and therefore a risk for poorer child development. Giving women good dietary advice and supporting women to stop smoking before or during pregnancy is therefore important for the future health and development of the unborn child. Babies born to mothers at maternal age extremes, both young teenagers and older women, are also more likely to be of lower birth weight and need targeted support is needed for these women.

Exclusive breastfeeding for the first six months of life is internationally recognised as making good health as well as economic sense. Breastfeeding protects the health of babies and mothers, and reduces the risk of illness. In Hampshire 78.8% of mothers breastfed their babies in the first 48 hours after delivery (2014/15). The 6-8 week breastfeeding prevalence figures are based on the number of infants categorised as totally or partially breastfeeding, as a percentage of all infants at 6-8 weeks. Just under half of mothers (48.8%) were breastfeeding at 6-8 weeks (2014/15). This is significantly better than the England proportion of 43.8%, but still means that a large proportion of babies are not receiving the ongoing benefits of breastfeeding.

Perinatal mental health problems are those which occur during pregnancy or in the first year following the birth of a child. Nationally perinatal mental illness affects between 10% and 20% of mothers and covers a wide range of conditions. If left untreated it can have significant and long lasting effects on the woman and her family. Perinatal mental health problems can also have a major impact on children's emotional, social and cognitive development. There are a number of risk factors for mental health problems during pregnancy and after childbirth; many reflect those associated with mental illness in the general population and include:

• History of mental health problems
• Traumatic childbirth, stillbirth and infant mortality
• Domestic violence and abuse
• Poor social support
• Sole registrations of birth

Figure 16 estimates the number of women in Hampshire with mental health problems during pregnancy and after childbirth. Estimates are based on the number of women giving birth in Hampshire (Approximately 14,400 babies are born every year).

Around 26,041 (13.9%) of Hampshire school pupils (187,426) were identified as having a SEN based on the January 2016 school census, a decrease of 1,202 (4.4%) from 27,243 in January 2015. Of these pupils, 11.2% (20,925) were characterised as having 'SEN support', the new category replacing the previous 'School Action' and 'School Action Plus' categories. Around 2.7% (5,116) have statements of SEN or EHCP, lower than the average of Hampshire's statistical comparators (2.9%), the South East (2.9%) and the England proportion of 2.8%. Whilst figures have remained constant for England and the South East since 2008, Hampshire and its statistical comparators have experienced fluctuations in proportions of statemented pupils.

Percentage of pupils with Statements of SEN or EHCPs

Early and accurate identification of SEN and putting the right support in place is vital for achieving positive outcomes in education, employment and maximising independence enabling children with SEN and their families to have more choice and control over the support received and the ability to lead fulfilled lives. Work with schools is needed to incrementally increase the number of children with SEN accessing mainstream education and succeeding.

Proportions of pupils who have SEND and/or are disadvantaged, 2016

Achievement in Early Years is a good predictor of achievement later in childhood. In Early Years learning across Hampshire, boys and girls consistently achieve higher than the England average for attainment across all of the early learning goals.

However this masks inequalities in the system. The data for Early Years Foundation Stage (EYFS), both now and over time, suggests that, even from this early stage in school, there is a notable difference between the achievements of disadvantaged pupils and their non-disadvantaged peers, both locally and nationally, with the local difference being greater. The percentage of Year 1 pupils with free school meals achieving the expected level in phonics is significantly lower than nationally, and the gap increased between 2014/15 and 2015/16.

Educational attainment at the end of Key Stage 2 in reading, writing and mathematics is higher in Hampshire than in England (59% compared to 54% respectively).  Overall girls perform better than boys; this trend is comparable to national figures.

Pupils move to Key Stage 3 when they start secondary school. Educational attainment at secondary school level has traditionally been measured as the percentage of pupils with five or more GCSE passes at grades A*–C (including English and Mathematics) at the end of Key Stage 4. For 2016, new measures have been introduced in line with recent changes to the curriculum and to values placed on the subjects taken. Going forward the measure of attainment will be:

• Average ‘Attainment 8’ (A8) score per pupil which measures the average achievement of pupils in up to 8 qualifications (including English, Maths, three further qualifications that count in the English Baccalaureate and three further qualifications that can be GCSE qualifications or any other non-GCSE qualifications on the DfE approved list)
• Average Progress 8 score per pupil which measure the progress a pupil makes from the end of key stage 2 to the end of key stage 4, comparing pupils’ Attainment 8 score with the average Attainment 8 score of all pupils nationally who had a similar starting point
• Attainment in English and Maths (A*-C) which measure the % of pupils achieving A*-C grades in the two subjects

The measures of attainment are reported for all pupils to give some indication of how well the children of Hampshire are achieving overall and also for those who are eligible for Free School Meals (FSM) and/or are disadvantaged (disadvantaged children includes those eligible for free school meals (FSM) at any time within the last six years) which provides us with some understanding of the inequalities in outcomes that exist for our children and young people.

In 2016, the Attainment 8 for all pupils in Hampshire was 51.1 In this first full year of the new reporting of the educational attainment for Hampshire children, overall the Attainment 8 scores and % Attainment in English and Maths are better than both regional and national values.

However, whilst Hampshire performed better than the national picture for all pupils, this is not the case for disadvantaged pupils where there are lower Attainment 8 scores and percentage attainment for English and Maths compared to national values.  The average Attainment 8 score was 39.1 in Hampshire compared to 41.2 nationally.

The progress scores overall and for children eligible for FSMs is poorer than the national and regional progress scores (although in line with our statistical neighbours). The Hampshire average Attainment 8 score was 36.4 compared to 39.1 nationally. This suggests that children who are more disadvantaged have poorer educational attainment and potentially poorer outcomes but also that the good early development seen within primary education for this group of children may not be continued through into secondary education.

There are clear links between educational attainment, absenteeism and both current and future health outcomes for children and young people. Good educational attainment and skills are part of the key to breaking the intergenerational cycle of inequalities in income and employment opportunities which impact on health. Lack of further education and training can lead to poor basic skills and limited academic and vocational qualifications.

Absenteeism can be seen as a risk for poor attainment. Overall, across Hampshire the rates of absenteeism, both authorised and unauthorised, are significantly lower than the national average. However this masks differences between different groups of children.  Children defined as in need, or who are looked after, have significantly higher absenteeism rates than nationally or compared with Hampshire’s statistical neighbours.

From 2013, Raising of the Participation Age legislation placed a duty on young people to remain in education, employment or training (EET) until the end of the academic year in which they turned 18. Historically, the proportion of young people aged 16-18 (academic years 12-14 inclusive) who are not in education, employment or training (NEET) is below both national and regional averages.

Across Hampshire there are significantly more young people in education, employment and training than nationally.

The Health Survey for England (2015) focused on physical activity in children. Excluding school-based activities, only 22% of children aged between 5 and 15 met the physical activity guidelines of being at least moderately active for at least 60 minutes every day (23% of boys, 20% of girls). These proportions have increased since 2012, when 21% of boys and 16% of girls met the guidelines but the majority of children are too physically inactive. Worryingly this figure falls to only 9% of children aged 2-4 years meeting the Chief Medical Officer’s physical activity guidelines for their age group of three hours per day.

There is a reverse relationship between income deprivation and physical activity. The proportion of both boys and girls aged 5 to 15 years meeting the current recommendations was lower in the higher quintiles than the lower quintiles of equivalised household income.

The latest data for 2014/15 are only available at County level and show that only 14.8% of 15 year olds in Hampshire were physically active for at least one hour a day, seven days a week. This is comparable to the national figure. 68.6% of 15 year olds in Hampshire reported a mean daily sedentary time in the last week of over seven hours per day. This is comparable to the England figure of 67.8%. Although Hampshire is comparable to the national proportion, 68.6% of 15 year olds equates to almost 10,500 children in Hampshire who for 7 hours a day are inactive. How we address this and encourage our young population to be more active requires further investigation.

Physical activity and sedentary lifestyle in 15 year olds

Obesity has become one of the major public health challenges for the 21st century. The causes of obesity are complex, with behavioural, genetic, environmental and social components. The health risks associated with being overweight or obese include increasing risk of type 2 diabetes, cancer, heart and liver disease. The health risks increase with increasing weight. Child weight gives a good indicator of future health and development; overweight or obesity in children is a sign of malnourishment and is often linked to deprivation or poverty. This makes obesity a key health inequality issue.

In developed industrialised nations over the last two to three decades, childhood obesity has been increasing. In response, in 2006 the National Child Measurement programme was introduced across England to measure the height and weight of all 5 and 11 year old children, year on year, to monitor levels of healthy and unhealthy weight.

Data from the Hampshire programme  indicate that 22.6% of 4-5 year olds and 15.0% of 10-11 year olds are obese or overweight. There has been a significant increase in the levels of overweight 4-5 year olds between 2014/15 and 2015/16.  However, this increase is not seen in the 10-11 year olds. While Hampshire children at 10-11 years are generally less overweight or obese compared to other areas, there is a doubling of the obesity levels between Reception year and Year 6 children. This increase in the proportion of children who are obese is seen nationally. Locally we need to ensure that we minimise excess weight gain during the primary school years, working with and supporting families to achieve and maintain a healthy weight.

In terms of tackling childhood obesity, there is yet to be clear evidence of what works to reduce the increases we are seeing. However, we do know that higher levels of breastfeeding are linked to lower levels of obesity and better child health. Evidence demonstrates that improving exclusive breastfeeding rates at 6-8 weeks improves longer term health for children and both reduce risks of future disease and hospital admissions and attendances in primary care by protecting babies from common infections.

Substance misuse is associated with significant health risks including anxiety, memory or cognitive loss, accidental injury, hepatitis, HIV infection, coma and death. It may also lead to an increased risk of sexually transmitted infections. There are a range of factors that increase the risk of children or young people undertaking risk behaviours including substance misuse (drugs/alcohol/smoking).

Factors that influence substance misuse among children and young people

• Environment (for example, availability of drugs/alcohol)
• Family (for example, sibling and/or parental substance misuse, domestic abuse and lack of discipline)
• Individual experience/risk taking behaviour (for example, early sexual encounters, drinking, smoking and peer group pressure to misuse substances)
• Poor mental health (for example, low self-esteem, depression)
• Dis-engagement in education (for example truancy, persistent absence, exclusions, NEETs)
• Other socio economic risk factors: deprivation levels including children in poverty, homelessness, unemployment and violent crime

At risk groups of children and young people

• Children or young people who are or have been looked after by local authorities, fostered or homeless, or who move frequently – where there is a lack of stability in their home and school life
• Children or young people whose parents or other family members misuse substances
• Children or young people who are marginalised and/or from disadvantaged communities, including some black and minority ethnic groups
• Children or young people with behavioural conduct disorders and/or mental health problems
• Children or young people who have been excluded from school and/or truants
• Young offenders (including those who are incarcerated)
• Children or young people who are sexually exploited/involved in commercial sex work
• Children or young people with other health, education or social problems at home, school and elsewhere

Some of the risk factors that influence substance misuse among children and young people are reported nationally and are useful to help us understand the potential for substance misuse amongst Hampshire children and young people. Recent local analysis found:

• Vulnerable children and young people are particularly at risk when they are exposed to key factors associated with substance misuse. Local service data enable us to identify the families who have children; if the needs of these children are not met, a number of coping mechanisms can become evident including their own substance misuse
• Exploring key factors in Hampshire: 282 children were living with a parent (at least one night a week) who was an alcohol or drug substance misuse client. 2,586 children had been witness to domestic abuse violence, over 40 young people had been a victim of domestic violence and 30 young people were perpetrators
• Disengagement from the educational system and lack of aspirations are significant antecedents for substance misuse
• Separate data for vulnerable groups across Hampshire, such as Young Offenders and Social Services, show a large proportion of these children and young people have substance misuse issues which are having a detrimental effect on their daily lives
• There are significantly higher levels of drug use among those young people who belonged to more than one vulnerable group, however, it is not possible to identify the children who are known across multiple services or agencies
• It suggests that substance misuse problems predominantly start before the age of 15. Hampshire population forecasts show that the number of children aged 10-14 years are predicted to increase. Identification of the risk factors and of those children with vulnerabilities which make them more susceptible to substance misuse is key to effectively planning substance misuse services
• Substance misuse hospital admission rates are increasing. Alcohol was the main substance coded within the hospital admissions, however the range of drugs and substances taken are wide and varied and the possible side effects of those may be evident when exploring all primary diagnosis codes
• There is a strong positive correlation between areas of deprivation and substance misuse hospital admission rates
• In 2015/16 there were 370 children and young people (aged under 25 years) engaged with a substance misuse service
• The number of referrals into local substance misuse services from education, youth offending and domestic abuse services are low and ? disparate when compared to service data such as Youth Offending Team who report a large proportion of young people with a substance misuse concern.
• Alcohol, cannabis and tobacco are the main problem substances for Hampshire children and young people. Service data also found a larger proportion of children using stimulants such as cocaine, ecstasy and amphetamines compared to national data.
• The vulnerabilities of the young people in services were gender specific, with females being more vulnerable to self-harm and exploitation, whereas males were more susceptible to anti-social behaviour. More young people in Hampshire recorded mental health as a vulnerability compared to England.

Further work is needed to understand the impact of all risk behaviours for children.

Two thirds of smokers will start smoking before the age of 18 years.  Experimental smoking in childhood is highly predictive of regular smoking in adolescence. There are also several key indicators which can predict the likelihood of young people starting to smoke. These include:

• Truancy or being excluded from school
• Drinking alcohol
• Taking drugs
• Smoking parents/siblings

In Hampshire, an estimated 3.3% of children aged 11 to 15 years and 15.5% of children aged 16 to 17 years smoke compared to 3.1% and 14.7% in England respectively.

Figures 30 and 31 provide a breakdown of smoking prevalence for children aged 11-17 across Hampshire districts compared to England. It should be noted that both graphs show very wide confidence intervals meaning that no statistically significant difference in estimates can be observed.

A survey of Hampshire Secondary Schools was undertaken in 2015 by Hampshire’s Public Health Team. A total of 7,479 students from Years 7 to 11 took part from 19 schools within 10 districts of Hampshire.  The survey asked questions relating to smoking, drinking and drug use amongst students.  A summary of the key findings for smoking and alcohol are presented.

The following key findings were noted in relation to smoking prevalence which mirror national findings:

• 19% of 11-15 year olds have tried smoking and 3.7% of 11-15 year olds are regular smokers
• 8.4% of 15 year olds are regular smokers.  More 15 year old girls smoke regularly than boys (9.6% of 15 year old girls and 7.2% of boys smoke regularly). Hampshire girls are more likely to smoke than nationally (both 8% for girls and boys).
• All rates have reduced since 2012.

In response to questions regarding prevalence of e-cigarette usage:

• 21.2% of 11-15 year olds have tried an e-cigarette with no difference between boys and girls. 88.4% of regular smokers aged 11-15 have used an e-cigarette and 9.3% of 11-15 year olds who have never smoked have used e-cigarettes.

The survey identified the following key findings in relation to smoking prevalence:

• Most young people around the age of 13-14 try smoking because they are curious to see what it is like. However most young people do not continue to smoke but those that do are more likely to use cannabis, solvents, New Psychoactive Substances (NPSs) and other drugs and drink alcohol.

The rate of experimentation with e-cigarettes is higher than that for tobacco smoking, although the majority of users are current smokers. Knowledge about smoking and its health effects is generally good but there are some misconceptions about the causes of cancer.

Summary findings from the Hampshire Secondary Schools survey in relation to alcohol were:

• 49.2% of 11-15 year olds have had an alcoholic drink – this is higher than the England average (38%)
• Half of the pupils reported drinking alcohol
• The majority of students who drank obtained their alcohol from their parents and drank it at home
• The number of children being drunk and then ill increased with age and by 15 or 16 years, nearly half of the pupils had been drunk within the last 4 weeks.
• 6.7% of those who had been ill after drinking required help to recover (e.g. visit to hospital)

In Hampshire, between 2013/14 and 2015/16 there were 317 alcohol-specific admissions (admissions which were wholly attributable to alcohol), an average of 100 children admitted a year.

Published trend data for Hampshire for under 18 years alcohol-specific hospital admissions has historically shown a consistently lower admission rate than England. However, while the total number of admissions continues to slowly decline, over the last few years, the rate of reduction when compared to England has slowed. Latest data for Hampshire show the under 18 years admission rate is now comparable to England.

At a district level, between 2013-14 to 2015/16., Gosport and the New Forest’s under 18 admission rates for alcohol-specific conditions were significantly higher (worse) than England.

Immunisations aim to protect people for life. They often concentrate on young children as they are more vulnerable to many dangerous infections.  The childhood immunisation programme aims to protect against a number of preventable diseases, including polio, pertussis, diphtheria, measles, mumps and rubella.  High rates of immunisation reduce child morbidity and mortality.

High percentage immunisation coverage is required to achieve herd immunity, meaning that it is harder for the disease to pass between people who have not been vaccinated.  The more infectious the disease,  the larger the number of people who have to be vaccinated to keep the disease under control.  The general threshold is considered to be 95% of the population being vaccinated to break transmission.

Child vulnerability includes children with SEND, children affected by social factors including domestic abuse, sexual exploitation, children in need, children in care, children who have been neglected, children with disabilities (including autism).

Given the right support, children with SEND and other vulnerable children can thrive and develop. Recently published statutory guidance provides comprehensive details of services and support to be provided by all public organisations who work with children who have special educational needs or disabilities.

The guidance highlights the need for organisations to work jointly and base the development of their services on local needs. To implement this guidance it is important to understand the local needs, assets and gaps for this population to improve outcomes. Although the guidance is statutory only for SEN and children with disabilities, it is good practice to apply this approach for services to all vulnerable children.

Mental and emotional health is fundamental to good health and wellbeing. There are strong links between emotional wellbeing of children and young people and their personal and social development and educational performance and it is an important factor in ensuring that they achieve their full potential. Emotional wellbeing includes confidence and self esteem which contributes to an ability to form good relationships with family and friends. Poor emotional and psychological health or mental health problems may result in educational underachievement, family disruption, anti-social behaviour and offending. Unrecognised and untreated mental health problems create distress not only for children and young people, but also for their families and carers, continuing into adult life and affecting the next generation.

Social, emotional and behavioural difficulties are common and affect 30–40% of children and young people at some time. Normal development will include behaviour of concern to adults. Young children may show poor concentration, aggression, lying, stealing, tantrums, toileting or bedtime problems, food fads, specific fears or anxiety; teenagers may have relationship problems, poor anger control and conflict with adults over appearance, school progress or household rules. Mostly these are transient reactions to a particular life event, but for some they may be more prolonged.

Risk factors which increase the likelihood of a child experiencing poorer mental health can arise from:

• Wider environment, e.g. poverty, social housing, homelessness, refugee status or social isolation/loneliness
• Family, e.g. parental unemployment; family poverty, family breakdown, poor parenting, and circumstances which can result in a child being looked after by the Local Authority
• Child, e.g. physical disability, chronic health problems, learning disability
• School e.g. bullying and several of the above risk factors may result in relative social exclusion at school which may further increase the risk of bullying

Providing the best start in life can maximise children's health, educational, social and emotional development. This can be done by providing good quality universal preventative and early intervention services before the age of five. Evidence suggests that mental disorder during pregnancy can affect the wellbeing of the woman, the foetus and the infant and is likely to be associated with poorer long term outcomes for children. It has been estimated that 10% of new mothers suffer from post-natal depression and this has been associated with cognitive delay and emotional and behavioural difficulties in young children. Identifying and managing poor maternal mental health and poorer health and wellbeing development of children are two of the six high impact areas where health visiting service interventions produce a high return on investment in terms of improved outcomes.

Currently there is very little comparative information of the mental health and wellbeing of older children and young people. However there is a national profiling tool that presents local authority level indicators. The tool provides commissioners, service providers, clinicians, services users and their families with the means to benchmark their area against similar populations and gain intelligence about what works. The indicators are presented under the headings Risk, Prevalence, Health, Social Care and Education. In the current absence of detailed data on treatment and outcome the tool focuses on those services that support children with, or who are vulnerable to, mental illness.

Key indicators where Hampshire is higher than the national and/or benchmarked areas that warrant further interrogation include the following:

Indicators where Hampshire performs worse than regional or national comparators

Given the benefit and potential return on investment in improving the emotional health and wellbeing of young people, information and indicators need to be developed so that early intervention and prevention initiatives can be properly targeted.

Work on a detailed emotional wellbeing and mental health needs assessment has started. This will inform a new emotional wellbeing and mental health strategy for Hampshire's children and young people.

Overall Hampshire is a prosperous area, ranked the 12^th least deprived upper tier authority in England (out of 150). However this masks some inequalities. Within Hampshire there are 32 areas (LSOA) that rank amongst the 20% most deprived areas in England. The most deprived areas have been identified in Havant, Rushmoor and Gosport.

In terms of deprivation for children, the Indices of Deprivation Affecting Children Index (IDACI) shows there are 9 areas that are in the 10% most deprived areas and 47 that are in the 20% most deprived areas in England. View the IDACI Hampshire map.

The Marmot Review (2010) suggests there is evidence that childhood poverty leads to premature mortality and poor health outcomes for adults. Reducing the number of children who experience poverty should improve these adult health outcomes and increase healthy life expectancy.

"A New Approach to Child Poverty: Tackling the Causes of Disadvantage and Transforming Families' Lives" set out the Government's approach to tackling poverty. It was published during the Coalition government, looking ahead to 2020. This strategy meets the requirements set out in the Child Poverty Act 2010, focuses on improving the life chances of the most disadvantaged children, and sits alongside the Government's broader strategy to improve social mobility. Currently the measure of child poverty is the percentage of children under 16 in low income families (children living in families in receipt of out of work benefits or tax credits where their reported income is less than 60% median income).

Overall in Hampshire there are significantly lower rates of children in poverty than the national and regional averages. However this does mask considerable inequality across the county. Between 2013 and 2014 there appears to be a slight increase in the number of children in poverty, and although, in itself this is not indicative of an increasing trend it is recommended that this is monitored.

Children from homeless households are often the most vulnerable in society. Homelessness is associated with severe poverty and is a social determinant of health. Homelessness is measured by the number of households eligible for assistance (1996 Housing Act) that are unintentionally homeless and in priority need. Priority need categories of household include dependent children or pregnant women.

Family homelessness across Hampshire increased by nearly 50% in 2014/15; 535 families identified as homeless compared to 361 in the previous year (2013/14), showing a much bigger rise than national rates. Again it is recommended that this is monitored.