Promoting the Health and Wellbeing of Looked After Children

Held in Birmingham Tuesday 19 April 2005

Report written by Linnie Price, Research Officer, research in practice

Introduction

The aim of the symposium was to present research evidence and examples of evaluated practice that demonstrate the value of preventive methods for promoting the health and wellbeing of looked after children and young people. It began with a presentation on the Healthy Care Programme, focusing on using the evidence-base to build services. This was followed by an exploration of the public health context for health and wellbeing of children and young people. A third presentation discussed the impact of research on health. Finally, six agency-led sessions provided a forum for discussion of agency initiatives.

Speakers

Neelam Bhardwaja is Head of Children and Families Social Services, Poole Children and Families. She is a member of ADSS Children and Families Committees and involved in a number of national projects and consultations. Neelam chaired the Symposium.

Helen Chambers is Principal Officer in the Children’s Development Department of the National Children’s Bureau, and lead officer for the Healthy Care Programme. She described the use of evidence in building the Healthy Care Programme.

Becky Pollard is a public health specialist (children’s lead) at the South West Public Health Group, and is a member of the Government’s Office for the South West’s Children’s Forum. She spoke about the public health context for the health and wellbeing of looked after children.

Diane DeBell is Director of the Centre for Research in Health and Social Care and Professor of Policy in Health and Social Care. She spoke about the impact of research on health and wellbeing.

Presentation 1: Healthy Care Programme: using the evidence base to build services that help improve the health and wellbeing of children and young people. Presenter: Helen Chambers.

Helen Chambers described the Healthy Care Programme, which is concerned with promoting the holistic health and wellbeing of looked after children and improving their life chances. It is a child needs centred National Standard and support programme that is evidence based, locally delivered and nationally and regionally co-ordinated. It works within a multi-agency partnership framework and includes an audit tool, a carer training programme and implementation documents which address public health inequalities targets. The Programme includes an information service, an email network and a newsletter. It encourages the creative participation of looked after children and young people and their carers in local authorities.

While “Be healthy” is one of the five Every Child Matters outcomes, the speaker emphasised that none of the other outcomes is likely to be achieved in the absence of health and wellbeing, and it is therefore important to think creatively and holistically about the targets. The programme was informed by children and young people’s views of what a healthy care environment would be; that is one “Where someone gets to know us and what we feel strongly about”.

Key data were presented on looked after children, of whom there are 60,800 in the UK. Of these, 68% are in foster care and 10% in children’s homes. Sixty-two per cent of looked after children have suffered abuse or neglect, 11% have experienced family dysfunction and 4% are refugee or asylum seeking children. Research suggests that between 33% and 90% of looked after children and young people have a mental health problem.

A number of looked after children have multiple problems, a consequence of the experience of separation and change, and their wellbeing and providing a healthy environment should be at the forefront of the system. To provide a healthy environment for children, the important questions to ask are:

• Do they have they a supportive personal relationship?
• Does the environment encourage curiosity and achievement?
• Can they exercise choice – including in what they eat?
• Is there the opportunity to live free from violence or fear?
• Is it a safe environment where they can contribute and feel valued?

The views of looked after children and young people, carers and professionals went into the healthy care standard, which informed these questions. The standard states that a child or young person living in a healthy care environment is entitled to:

• Feel safe, protected and valued in a strong committed relationship with at least one carer
• live in a caring, healthy and learning environment
• feel respected and supported in his/her cultural beliefs and personal identity
• have access to effective healthcare, treatment and support
• have opportunities to develop personal and social skills, talents and abilities and to spend time in freely chosen play, cultural and leisure activities
• be prepared for leaving care by being supported to care and provide for him/herself in the future.

The importance for children and young people of shared leisure, play and creative arts was a major emphasis. An example of good practice here is the ‘Wellbeing, Creativity and Play’ training programme, which developed the magazine ‘Carers Can’ which is circulated to carers and which all local authorities will receive.

Improvement in Healthy Care Programmes will be achieved through respect for the rights and responsibilities of looked after children, by having well trained and supported carers committed to the wellbeing of children, having the involvement and participation of children and carers, through strategic and multidisciplinary planning, and by providing services that meet children’s needs. Achieving active and meaningful participation from all members of Healthy Care partnerships is likely to be a challenge. Healthy Care multi-agency training for carers has been provided locally, but there has been some difficulty recruiting carers to participate in training programmes, raising issues of payment for skills, mandatory training and training support. Helen stressed the importance of children and young people participating in policy and practice development, which is empowering, encourages them to take responsibility, promotes a sense of ownership and involvement in their environment, and so helps enhance self-esteem and promote wellbeing.

The Programme has been piloted across the country. Messages from Pilot areas are:

• Use and build on existing partnerships
• influence strategic partners, particularly health
• pilot status and enthusiasm has motivated multi-agency working
• capacity, leadership and advocacy are key
• think ‘outside the box’
• Healthy Care is ‘obvious’. Everyone should be doing it.

An example of good practice is from Telford and Wrekin, one of the pilot areas, who formed a local ‘Task Group’ of senior members, managers, foster carers and children, who met every quarter, with an appointed lead officer. The group formed sub-groups and made links with Healthy Schools. These were focused, for example on children with disabilities, short break residential care, and arts and leisure.

The programme included children and young people in the assessment and audit. Telford and Wrekin stressed the need for enthusiasm for the programme, creative thinking and application, and establishing quick wins combined with deeper practice developments and breaking down the programme to tangible aims and outcomes.

Regional Healthy Care partnerships have been set involving Regional Government Office stakeholders, including DfES Public Health, Teenage Pregnancy, CAMHS and Art and Leisure colleagues. Strategic health authorities have also provided useful support. Early learning from the regional partnerships includes the importance of networking and support, having a strategic lead or support person, trouble-shooting, developing regional initiatives, compiling a regional children’s profile to contribute to the national picture, and effective evaluation.

Young people have participated in the Healthy Care Programme at all levels. Nationally, they were involved in helping to draft the Standard and in feasibility studies. At local levels young people participated creatively in music, poetry, drama, cookery, visual art and photography activities. These reflect the Programme’s stress on the relationship between wellbeing and creativity as part of a whole child approach to promote life chances and ensure the sustainable development of local services. This in turn provides opportunities to succeed and celebrate and can provide opportunities to have fun with supportive adults, all of which can be reflected in academic achievement and greater placement stability. The Carers Can! Magazine was designed to help carers to feel more confident in using simple creative activities and encourage leisure pursuits.

For more information on the Healthy Care Programme, contact Helen Chambers, National Children’s Bureau. hchambers@ncb.org.uk. 0117 3179606

Questions and discussion on the presentation

Audience question: Given the emphasis on partnership working, why was the audience predominantly from Social Services departments. Why was there not more representation from other services such as education and health ?

Speaker response: Participation at this Symposium reflects research in practice membership which is predominantly from social services. Other meetings targeted different services such as libraries and leisure departments. The heat is on for all services to join up and deliver the five outcomes.

Audience : Celia Atherton of Research in Practice urged partners to offer their allocated Symposium places to other services as they saw fit.

Audience An audience member pointed out that the audience was more heterogeneous than the delegate’s list suggested.

Audience question : How will Healthy Care Programmes link with education?

Speaker response: That will depend on the Healthy Care co-ordinator. In Telfoed and Wrekin the Healthy Schools co-ordinator was a member of the Task Group.

Audience question : Did the pilot projects look at risk and risk management? Today’s risk culture discourages a lot of activities.

Speaker response: Young people do practice risk-taking behaviour, including their sexual behaviour and substance misuse. There are risks involved in just taking children out, but cutting back on ‘risky’ programmes such as sport is detrimental to children’s health and wellbeing. Looked after children and young people need opportunities to participate in appropriate risk activities through leisure programmes. Taking risks is part of development. Telford and Wrekin overcame some of the problems by having a standing consent form covering the duration of care.

Presentation 2: The public health context for health and wellbeing of looked after children: Becky Pollard

In addressing the question ‘Why Children’, Becky Pollard began her presentation with a quote from Al Aynsley Green. ‘Children are the life blood of the nation, they’re absolutely vital for our future success as a country.’ Healthy children make healthy adults; much adult disease has its roots in childhood.

She outlined some of the epidemiological approaches. The life course approach to health suggests that we are the product of critical life-events and accumulated risks, with the need to promote health and protect against ill-health at each critical stage. Low birth weight, for example is now associated with adult coronary heart disease. The extent to which adult diseases have their origins in childhood is beginning to be recognised. However the work of Richard Wilkinson on ‘social capital’ suggests the need to invest in communities.

Of 11 million children in the UK, three to four million are vulnerable, three to four thousand are in need, 60,000 are looked after and 17.000 are on the child protection register. If these figures are modelled as a pyramid, with the latter group at the apex, health needs increase up the pyramid.

Looked after children experience significant inequalities in health. Lacking power, they are one of the most excluded groups in our society, and hence have special needs. They are removed from the democratic process and dependant on others for their health and social care. It is important to take a positive, holistic view of health as not just the absence of disease, in line with the World Health Organisation definition of health as ‘a state of complete physical, mental and social wellbeing’. Such a view would include feeling well and full of energy, having good social relationships, having control over life and living conditions, being able to do things one enjoys, having a sense of purpose in life and experiencing a connectedness to community. It is important to include such factors in considering what is a healthy environment.

The ‘Choosing Health’ White Paper was influenced by the ‘Dove Ring’. In this model, influences on health such as individual life-style behaviours, social and environmental factors, and socio-economic factors such as housing and occupation radiate out from fixed factors such as age and sex, over which we have no control. All these levels, from the individual up to governmental responsibility must be taken into account. Policies must enable healthy choices to be a collective, as well as an individual responsibility.

In considering the health of looked after children, there is some key research which highlights the physical and mental health problems experienced by this group. Most commonly reported conditions were psychiatric disorders (45%), asthma (10%), bedwetting (10%), coordination difficulties (10%), eye and sight problems (16%) and speech and language problems (14%). This has implications for primary care trusts and GPs as well as for local authorities. In addition, looked after children have unhealthy lifestyles, particularly in relation to smoking, alcohol and diet. There are issues of low self-esteem, emotional and behavioural problems, homelessness and unemployment. These problems are compounded by inequality of access to services and an over medicalised model of health standards for looked after children, which does not take into account the wellbeing factors contained in the holistic model.

The educational achievement of looked after children is also poor. Only 56% sit one GCSE compared with 96% of the general population, and they are more likely to be absent or excluded from school. Seventy-five per cent of care leavers have no educational qualifications and 50% are unemployed. Thirty-eight per cent of prisoners and 30% of homeless people have been in care, and 17% of young women leaving care are pregnant or already mothers.

Promoting the health of looked after children goes beyond providing healthcare. There is a real need to talk to young people and to empower them so that they have an understanding of their right to good health, and the skills to communicate and relate to others and to take responsibility for themselves. There are a number of models for achieving this. Four approaches are to:

• Provide information
• develop personal and social skills
• provide healthy environments
• offer preventive services.

Effective interventions address all levels of society (individual, community and government), actively involve children and young people and their carers, make services relevant to their needs and work in partnership with others. These challenging goals are based on research evidence.

Research on how looked after children express their own needs suggests these are for:

• Reliable and trustworthy carers
• information about services
• to be listened to and heard
• support after leaving care
• confidentiality
• respect
• privacy
• paticipation
• choice
• support
• advocacy

These need to be checked for constantly.

With Every Child Matters, children have been precipitated up the policy agenda both locally and nationally, with the emphasis on partnership working and integrated services. The National Service Framework for Children, Young People and Maternity Services is very inspiring, and provides a lever for NHS workers to keep children high on the Primary Care Trusts agenda, which can be a real battle in the light of NHS priorities which can favour acute over preventive services. The Choosing Health White Paper recognises lifestyle factors in health, but also promotes healthy environments. It devotes a whole chapter to promoting the health of looked after children. The Choosing Health delivery plan stresses access to good quality and confidential services. It points out the high prevalence of sexually transmitted disease among looked after children. It will also provide guidance on involving carers in fostering play and creativity. In the Public Service Agreements (DfES, Home Office/DfES, DH) each department has signed up to deliver the health improvement targets.

To summarise, looked after children experience social exclusion and poorer outcomes than their peers. Effective public health programmes must be holistic and encourage partnership working at all levels. Looked after children are reflected in current policy which provides opportunities to promote their health and reduce inequalities.

Questions and discussion on the presentation

Audience question: There was little in the policy documents on asylum seeking children or young people in the prison system. Social attitudes to children and young people are very negative and preoccupied with social control measures such as asbos. Does this lead to the danger of losing some groups? Also, the high proportion of children with mental health problems could be an artefact of the measures used, which tend to rely on a psychiatric/medical model.

Speaker’s response: Regarding the first question, it is important to have a dialogue to identify the needs of these groups. The ‘crime agenda’ is high on the agenda. It is important to look at the whole person when working with young people.

Audience question: How do you keep the health and wellbeing of looked after children and young people on primary care trust agendas?

Speaker’s response: Strategic partnerships with strong relationships and a wider knowledge of each other’s roles bring an integrated, more balanced service. This works best in unitary authorities with shared boundaries. It is particularly challenging where boundaries are complicated. Key factors are relationships, trust, a common language and agenda and a clear sense of overlap with joint agendas. It takes time and investment, and often depends on individual personalities.

Audience response: There is a need to steer the team away from the term ‘child protection’ toward ‘safeguarding children’. ‘Safeguarding’ can include safeguarding against offending behaviour. This could bring looked after children into the mainstream.

Audience response: Use every opportunity to put your hand up and say ‘and children’. This does work.

Speaker’s response: This is excellent, but takes a lot of energy so we need good support mechanisms. Directors of Public Health in primary care trusts have responsibility for improving health and reducing health inequalities. Find out who they are.

Audience question: Re tobacco – working in the residential service. The tax on cigarettes is now so high that they are out of reach financially, but looked after children are addicted. There has been a trend towards criminal behaviour and cannabis use to feed the tobacco habit.

Speaker’s response: Very interesting. No research on this, and need to know more. There is evidence that raising tax reduces prevalence, but this might not be the case for this at risk group. Stop smoking services are effective, but not generally for young people. There has been some discussion on listing nicotine replacement therapy as harm minimisation. It comes back to the whole person approach. Why are looked after young people attracted to substance abuse? We need to look for other ways to manage their issues.

Audience question: Is there any research that looks at positive aspects of health?

Speaker’s response: No. There is the problem of the hierarchy of evidence. Money and resources often go into quantitative research, so there is less qualitative research. But there is the work on resilience, and some on pets and peers, and Bob Broad’s work on children as researchers. I have raised this with NICE.

Presentation 3: The 21 st Century Child: The impact of research on health and wellbeing: Diane DeBell

Diane DeBell began by proposing a definition of childhood. She then talked about the main theories that researchers are currently using to explain health inequalities, giving examples of how her own research has helped to inform practice. She described studies of young people with a close family member in prison, of inter-agency CAMHS support, school health services, Sure Start Programmes, Person-Centred Planning for young people with learning disabilities, studies in young people's sexual health needs, and an evaluation of a Community Mothers Programme. Throughout her talk, she focused on the vulnerability of children -- what makes them vulnerable and what can help to protect them.

Children and young people are 22% of the UK population, yet take up 40% of health and social care resources. This has implications for the cost effectiveness of service delivery and its planning.

Childhood, in western developed countries, is defined in terms of the developmental period from birth to adulthood. Children are not just miniature adults, either physically or psychologically. They are also vulnerable and need protection. Children are disenfranchised members of specific cultures. Yet, at the same time, they have reserved human rights under the UN Convention on the Rights of the Child (1989). Within the Convention, children have the right to be heard and to have their views taken seriously. There is much rhetoric about "listening to children" but it is ethically and methodologically difficult as well as highly resource intensive to include children's voices in service planning and in research. The National Children’s Bureau, exceptionally, has achieved this successfully. With very little prompting, children will draw and write such that we can understand what it is they know and feel. For example, children's drawings and writing give us access to their complex and sophisticated understandings of their own health and well being. Childhood is a long period of development and children inhabit a world that is closed to adults. Yet childhood is defined by adults. Critically, childhood is also the platform on which adult health and wellbeing is based.

What are the determinants of health and wellbeing? We focus on personal health related behaviours yet it is the ‘accidents of birth’ that fundamentally matter. Who are the parents/carers, where do they live, what is the educational achievement, and the level of income of the child's family group? For example, if we look at international profiles of mortality, we instantly see these differences. There are enormous inequalities in health between countries. Life expectancy for a baby born in 2005 in Norway is 78.9 years, for example, whereas in Sierra Leone it is 39 years. There is a similar disparity within countries. Male life expectancy is ten years longer in Belsize Park than it is in Kilburn. When we look at children’s health prospects, common determinants focus on factors such as income, parenting, child labour, culture and religion, and neighbourhood, with poverty the primary risk factor for poor health. The persistence of inequalities in health is variously explained by theories of genetics, life-course explanations, the "status syndrome" and the social gradient, and by psycho-social explanations. No single theory is able to capture the full explanation for such wide diversities in health and well-being.

The speaker proposed a more complex model, in which hard structural factors such as income inequality are mediated by more experiential factors such as perceived fairness, social reciprocity and civic engagement (i.e., “social capital”). This model is highly relevant to the health and wellbeing of looked after children. Cross-country studies show that there is a broader gap between the health of rich and poor when there is low social reciprocity and there is less health inequality when social reciprocity is high. Examples to demonstrate this include very poor countries such as Cuba and Costa Rica as well as wealthy countries such as Norway.

The speaker moved on to describe some of her own studies of children with mental health problems. In a study of young people aged 12-17 with a close family member in prison, poor mental health was identified as a risk factor. The family circumstances these young people are seeking to manage are generally hidden from public view because of the fear of stigma. Few local authorities have an explicit policy to assist these vulnerable children in the school environment. Yet children in these circumstances may be coping with distressing experiences (e.g., the stress of the remaining carer, sudden loss of family income, visits in difficult penal environments, a change of carer, loss of contact with the family member).

In a study of Family Support Teams in Norfolk (multi-agency teams with practitioners from social services, education and health) during 2001 to 2003, her team of researchers carried out action research that assisted in the process of service development itself. The Norfolk project won First Prize from the Department of Health in 2003 for Access.

Research she conducted in 1996-97 helped to re-orient school nurse services across the UK. In 2000, DeBell and Jackson published a National Strategy for Practice for school nursing and this is now the base upon which new service development is proceeding (DeBell and Jackson 2000).

Evaluations of Sure Start have been, and continue to be conducted in locations across the country. Yet systematic comparisons have been impossible because of the diversity of research approach. A national evaluation based on longitudinal studies is now underway and this should provide us with evidence of the impact of this major investment in child health.

Diane DeBell concluded by warning against policy that is based on population level research only without taking individual-level and delivery system factors into account. “My anxiety levels rise when policy shoots out of a government office without any context”.

Questions and discussion on the presentation

There was not enough time to allow for discussion after this presentation.

Agency-led parallel workshops

Title and description

Involving Young People and their Carers in the Implementation of the National Healthy Care Standard

The session focused on how young people and carers have been actively involved in producing the NHCS Action Plan, and how the presenters felt it was making a difference to health outcomes for looked after children. There were practical examples of their work such as a health information leaflet designed by young people and a “passport” system for sharing information about young people with their prospective carers and vice versa.

Vaughan Tudor-Williams. Policy Development Manager, Portsmouth City Council Social Services.

Improving the Health of Looked After Children in Newham

Newham has taken a creative and holistic approach to improving the health and wellbeing of their large population of looked after children in the borough – 700 children including a large number of asylum seeking children. This workshop demonstrated the evidence for and benefits of this creative approach. Newham have produced a DVD to support their approach which was on view during lunch.

Anjum Mouj, IHOLAC Project Consultant, Newham Social Services

Parenting Puzzle. “Parents are not the problem, parents are part of the solution”

This session looked at the new group-work approach used withing Gloucestershire to improve family relationships. Interactive Theatre is used as a positive learning tool. The session aimed to demonstrate clear, practical ideas and strategies that can be used with parents and carers wisheing to improve family life. The session covered Gloucestershire’s “Talking to the Fist”programme to parents who are experiencing conflict and violebce from their adolescent. Evaluations of Parenting Puzzle show that after completion of the group-work programme, parents’ communication and family relationships improved. This had a positive impact on children’s wellbeing.

Will Davis and Wendy Hyett, FSS3 Parent Educators, Gloucestershire Social Services

Preventing Sexual Exploitation: a multiagency approach

The workshop described the setting up of a multi agency response to working with young people who are being sexually exploited who are both looked after and living in families. The focus was on intelligence gathering, diversion and managing the interview process and links with the mainstream child care service, and moving on to look at the therapeutic needs of the young people. The team has social workers, education social workers and police officers working together to support wellbeing by diverting the activity of perpetrators and working with young people on the periphery of activity to prevent involvement. Preventative work in school settings was also discussed.

Amanda Hatton, Assessment and Commissioning Service Manager, Blackpool Borough Council Education and Children’s Services.

Embedding Health Teams in Social Services: opportunities and challenges

The workshop gave a short description of the development and structure of CAMHS and paediatric teams in Westminster. The teams have developed opportubities and encountered challenges that will be of great use to share with others who are considering similar initiatives. There was a case study for participants to work on using the model Westminster has developed.

Patrick Bentley, Family Therapist CAMHS Intervention Team, Christine Nicholls, Designated Nurse LAC, Selina Perocevic, Child Psychotherapist, Katie Robinson, Health Development Manager. Westminster Social and Community Services

Key Messages from the workshops

1. Involve children and young people actively in shaping services. For example Portsmouth’s health information leaflet was designed by young people.
2. Involve young people creatively. For example Newham’s DVD has captured young people’s views and ideas of how to promote health and wellbeing across the borough’s looked after population of over 700 children.
3. Create or use multi-agency partnerships and pool budgets to tackle issues adversely affecting health and wellbeing. For example Blackpool’s sexual exploitation project and Westminster’s multi-agency health team based in social services.
4. Support families and parents by providing services that are accessible and speak in the language that families and parents can relate to. For example Gloucestershire’s evaluated and very energetic parenting programme

Useful References

National Children’s Bureau (2005a) Healthy Care Programme Handbook

National Children’s Bureau (2005b) Carers Can! Play and be creative with children and young people.

Broad, B (2005) Improving the health and well-being of young people leaving care. Dorset, Russell House Publishing

Brodie, I and others (1999) The health of children looked after by local authorities. British Journal of Nursing, 6,7,386-91

Skuse, T and Ward, H (1999). Current research findings about the health of looked after children. Paper for Quality Protects seminar: Improving health outcomes for looked after children. Dartington Social Research Unit and Loughborough University

Meltzer, L and others (2003) The mental health of young people looked after by Local Authorities in England. Office of National Statistics. The Stationery Office.