Annual Report of the Chief Medical Officer 2012 - Population Health and Improvement Science

CHAPTER 4

Looked after Children and Young People

The Early Years Collaborative aims to improve wellbeing of children through care and nurturing from the womb to early school years. There are, however, a large group of children who are already experiencing the problems of failure of nurturing. These are those children and young people who are looked after because their family lives have not been able to provide for their needs.

If, as Antonovsky suggested, health creation depends on having the psychological and social resources which allow us to manage our way in the world and these resources include insight and intelligence, social networks, material resources and cultural anchors, then looked after children are in a difficult position. These resources allow an individual to feel that he has insight into the events of his life, that he feels he can influence them and that he can be optimistic that things will work out as well as can be expected. Too often, children experience adverse events that damage their capacity to manage challenging events. Looked after children are often at the extreme end of the spectrum of damaging experiences. As a result, outcomes for looked after children and young people are generally poor but need not be so.

Mental health of looked after children

In a report published in 2004 - The Mental Health of Young People Looked after by Local Authorities in Scotland' ^[7] , the authors studied a group of young people aged 5-17 years, looked after by local authorities. They found that:

• 45% were diagnosed with a mental disorder
• 38% had clinically significant conduct disorders;
• 16% were assessed as having emotional disorders - anxiety and depression
• 10% were rated as hyperactive.

In another study carried out in an English local authority, McCarthy and colleagues ^[8] found that:

• 40% of a sample of children looked after were experiencing significant difficulties in 3 of 4 key areas: home life, friendships, learning and leisure activities.
• They concluded that 'children and young people with multiple adjustment problems are at high risk of developing a range of very significant psychosocial outcomes in later adolescence and early adulthood'.

In another Scottish study, Minnis and Del Priore ^[9] found that looked after and accommodated children were more likely to have some form of attachment disorder, indicating that problems began in very early life.

Scott, Hattie and Tannahill ^[10] have produced a Health Needs Assessment for looked after children published under the auspices of the Scottish Public Health Network. They clearly found the task difficult. They concluded that, despite the fact that they represent a significant proportion of the general population of children and young people in Scotland (1.6%), there is no consistent or comprehensive health and wellbeing profile collected for them across all local authority areas.

This seems surprising given that it is likely that children and young people looked after in Scotland will have poor outcomes relative to the general population. In addition, they also have poorer outcomes than children and young people who have experienced similar levels of material deprivation. They seem to accumulate additional risk by being looked after and the consequences are significant.

There is some evidence of this poorer outcome in educational terms but there is a lack of consistent data across health and social care to provide the necessary evidence. Where there was appropriate multi-agency collaboration and data sharing for individual case management, services seemed to be effective. The researchers also pointed out that there is a great deal of health data within individual case records that is often duplicated across different agencies and is not collated. Accordingly, opportunities to identify problems and provide appropriate support are often missed. They commented that the lack of systematic information on needs of children and the limited capability to share information electronically across services is a real barrier to good practice.

Despite these difficulties they were able to use routinely published data to explore reasons for care in some areas of Scotland Children's Social Work Statistics (CSWS), published annually, provided some high level epidemiological information for the national population and by administrative area, including incidence and prevalence of local authority care. Both the Scottish Children's Reporter Administration (SCRA) and local authorities hold data on children and young people. From data on a point prevalence sample of all LACYP with Supervision Requirements (provided by SCRA) and data on a point prevalence sample of all children and young people looked after by Glasgow City Council (provided by Glasgow City Council Social Work Services) they were able to build a picture of the population of looked after children.

Conclusions

Combining the information from the literature and each of these data sources allows the following conclusions to be drawn:

• 1.6% of 0-17 year olds in Scotland are looked after (July 2011 data);
• the number and proportion of 0-17 year olds in Scotland who are looked after has been increasing over the last 10 years;
• children looked after at home (where the parental care of children at home is supervised by the local authority) are the biggest care setting sub-group nationally (representing 33.6% of LACYP in 2011);
• kinship care has seen the largest growth in numbers of any care setting sub-group since 2001;
• most recent data (2011) indicate that "lack of parental care" is likely to be the most frequent reason children and young people become looked after;
• material deprivation is likely to be a major upstream determinant of need for care;
• care setting sub-groups differ in terms of a number of important determinants of health including age, sex, reasons for care, parent's area deprivation and previous number of placements in care;
• health intelligence is least good for children at home, yet this care setting sub-group may be particularly vulnerable;
• it is likely that being looked after is associated with an increased risk of mental illness, particularly conduct disorder, although the extent to which this association is related to the causes rather than the consequences of care is not clear; and
• placement instability is likely to be associated with adverse health outcomes, yet may be relatively common for looked after children and young people in Scotland.

Unfortunately, neither the SCRA nor Glasgow City Council data sources explored in this study had health outcome data. Four NHS boards reported collating health outcome data for looked after children and young people. The majority of outcomes described were very high level and it was not clear how these were defined or measured. Clearly, there is an urgent need for health data to be used to establish the extent and pattern of health problems encountered by these children.

In addition, to measuring absolute health outcome frequencies for looked after children, there is a need to determine how much of the observed morbidity and mortality is in excess of that seen in children and young people from similarly deprived backgrounds and neighbourhoods. This comparison is necessary in order to assess the level of investment and intervention that would be proportionate to the needs of this group specifically.

Responses to the stakeholder interviews highlighted that national directives and performance targets are important in determining what data are collated at a local level. There is currently no such directive or target for health outcomes for looked after children, and while the challenges of introducing one are recognised, national leadership of this type is needed to ensure more systematic understanding of the needs of these children in Scotland, better targeting of intervention, and routine monitoring of progress.

In the absence of improved health intelligence it is of obvious importance to continue to meet the health needs of children and young people identified through individual health assessments. It is hoped that a planned NHS Greater Glasgow and Clyde health and wellbeing survey of 11 to 16 year olds looked after by Glasgow City Council will be helpful in improving understanding of health needs for this group.

The Looked After Children Strategic Implementation Group (http://www.celcis.org/lacsig) was set up in 2010 with the aim of "improving the way services work for looked after children, young people and their families. Focused primarily on service leaders, it facilitates the joint development and implementation of policy and innovative practice." It worked through the creation of "hubs" of activity which focussed on areas such as mentoring, aftercare and foster care. Clearly, these are important areas to get right. However, in the absence of properly constructed data, the hubs would find it difficult to monitor impact of their activities.

Recommendations

The Scottish Public Health Network Report made a number of specific recommendations on information.

1. Health boards and local authorities (or their integrated health and social care partnerships) should have systems which allow them to record and report on the health of looked after children information in a systematic way. Core indicators should by compatible, where possible, with those available for the general population of children and young people, thereby enabling quantification of any excess morbidity associated with being looked after. The multi-informant strengths and difficulties questionnaire (including impact questions) is recommended as a comparable, pragmatic measurement instrument for mental health. A recommended starting point is the incorporation of this core set of measures into the comprehensive physical and mental health assessment for looked after children.

2. A series of approaches should be considered to establish the routine recording of looked after status, and to enable linkage across different data sets. These include:

a. incorporating a looked after care setting code into existing child health data sets (e.g. Child Health Surveillance System, Scottish Immunisation Recall System, Special Needs System, relevant local surveys);

b. including looked after measures in national child health surveys (Growing Up in Scotland, as a prospective cohort, would be particularly useful);
c. using a single unique identifier across education, social care and health to facilitate record linkage; and
d. data linkage across agencies

3. In addition to a consistent set of health indicators, they recommended that a more consistent set of definitions of 'reasons for care' is developed. Currently, 'reasons for care' categories differ between agencies and the distinction between categories is sometimes unclear. A smaller number of categories, or a typology that could merge into broader categories, would enable analysis to be carried out in a way that helps direct preventative action.

4. To ensure progress on the above, they recommended that Directors of Public Health should assign a national lead for GIRFEC/LACYP health information, working with the Scottish Government and other national bodies to derive a strategy and timescale for delivering:

a. a standard minimum data set, and a means by which data can be linked across agencies for each child;
b. shared protocols and facilities for sharing good practice and experience; and
c. guidelines for regular local and national standard reporting.

5. At a local level, they recommended that Directors of public services should work together to share information on a systematic basis and report jointly on the experience and performance of services supporting looked after children.

Application of these principles consistently and at scale is likely to make a real difference to the lives of these children. Being looked after in childhood is a high risk factor for failure in later life. "A nation's greatness is measured by how it treats its weakest members" is a statement attributed to many people. Ghandi offered this version. Scotland has an opportunity to lead the world in its care of children. The will to change is apparent at all levels of society. In our application of improvement techniques, we have learned much about how to change complex systems. Putting the will for change and the method for change together will transform the lives of the most vulnerable young people in Scotland.