SCIE/NICE recommendations on looked after children: Promoting the quality of life of looked-after children and young people

Appendix C

The evidence

This appendix lists the evidence statements from five evidence reviews and four commissioned reports provided by external contractors and the public health collaborating centre (see appendix A). It links them to the relevant recommendations. (See appendix B for the key to quality assessments.) The evidence statements are presented here without references – these can be found in the full reviews (see appendix E for details). It also lists 22 expert papers and their links to the recommendations (see additional evidence). This appendix also sets out a brief summary of the cost-effectiveness evidence.

The five evidence reviews are:

The four commissioned reports are:

Evidence statement E1.5 indicates that the linked statement is numbered 5 in review 1.Evidence statement E2.7 indicates that the linked statement is numbered 7 in review 2.Evidence statement C3.6 indicates that the linked statement is numbered 6 in commissioned report 3. C1 indicates that the whole of commissioned report 1 is linked to the recommendation.EP1 indicates that the whole of expert paper 1 is linked to the recommendation.

The reviews, commissioned reports, expert papers and economic analysis are available at www.nice.org.uk/guidance/PH28

Where the PDG has considered other evidence, it is linked to the appropriate recommendation below. It is also listed in the additional evidence section of this appendix.

Strategic leadership, planning and commissioning

Recommendation 1 Prioritise the needs of looked-after children and young people: evidence statementsE4.3, C3.1, C3.2, C3.18; C1, C2, C4, EP6, EP10, EP11, EP13, EP16

Recommendation 2 Commission services for looked-after children and young people: evidence statementsE4.3, C3.1, C3.7, C3.12, C3.18; C2, EP4, EP6, EP11, EP13

Audit and inspection

Recommendation 3 Regulate services: evidence statements E4.3, C3.1, C3.2, C3.12, C3.18; C2, EP1, EP2, EP6, EP8

Recommendation 4 Inspect services for care leavers: evidence statementsC3.7, C3.12, C3.18; C4, EP6

Care planning, placements and case review

Recommendation 5 Implement care planning, placement and case review regulations and guidance: evidence statementsE4.2.7, E4.2.11, E4.3, C3.4, C3.7, C3.12, C3.18; C1, C2, C4, EP12

Professional collaboration

Recommendation 6 Support professional collaboration on complex casework: evidence statement C3.18; C1, C2, C3, EP11

Recommendation 7 Ensure everyone involved understands their role: evidence statement C3.1; C1, C2, EP6, EP12, EP13, EP15

Dedicated services to promote the mental health and emotional wellbeing of children and young people in care

Recommendation 8 Commission mental health services: evidence statements E5.3, E5.4, E5.16, C3.3, C3.7, C3.10, C3.11; C1, C2, EP6, EP9, EP11, EP22

Recommendation 9 Ensure access to mental health services for black and minority ethnic children and young people: evidence statementsE4.2.1, E5.16, C3.7, C3.18

Recommendation 10 Ensure access to mental health services for unaccompanied asylum-seeking children and young people who are looked after: evidence statementsE5.16, C3.7, C3.16, C3.18

Recommendation 11 Ensure access to specialist assessment services for young people entering secure accommodation or custody: evidence statementC3.7; EP3

Placements for children and young people – residential care, foster care and care by family and friends

Recommendation 12 Plan and commission placements: evidence statements E4.2.6, C3.5, C3.12, C3.19; C4, EP2, EP6, EP14, EP16, EP19

Recommendation 13 Use current information to make decisions about placements changes: evidence statements E4.2.6, E5.2, E5.9, C3.5, C3.7, C3.19; EP2, EP6, EP14, EP16, EP19

Recommendation 14 Ensure looked-after children and young people in secure and custodial settings have their care plan or pathway plan reviewed: EP3, EP14

Sibling placements and contact

Recommendation 15 Support sibling placements: evidence statements E3.12, E4.2.5, E5.14, E5.15, C3.18; C4, EP2, EP11, EP16, EP18, EP19

Supporting babies and young children

Recommendation 16 Assess the needs of babies and young children and ensure access to services: evidence statement C3.12; C1, EP11, EP21, EP22

Recommendation 17 Ensure there are specialist services for babies and young children: C1, EP11, EP21, EP22

Recommendation 18 Ensure carers and frontline practitioners working with babies and young children receive specialist training: C1, EP11, EP21, EP22

Recommendation 19 Reduce moves and achieve permanence for babies and young children: evidence statements C3.12; C1, EP11, EP21, EP22

Health assessments, records and information

Recommendation 20 Assess the health needs of looked-after children and young people: evidence statements E3.1, E3.2, E3.3, E4.2.13, C3.2, C3.7, C3.8, C3.12, C3.14, C3.15; C1, C2, EP8, EP12, EP18, EP21

Recommendation 21 Share health information and ensure consent is obtained: evidence statements C3.2, C3.12; C1, EP6, EP19

Recommendation 22 Update the personal health record (red book) and ensure this follows the child or young person: evidence statementsE3.3, E5.12, C3.2; C1, C2, EP8, EP18

Recommendation 23 Share information from assessments for court processes: evidence statement C3.2; C1, EP6, EP19

Personal quality of life

Recommendation 24 Meet the individual needs and preferences of looked-after children and young people: evidence statements E5.5, E5.18, C3.7, C3.12, C3.18; C4, EP15, EP16

Recommendation 25 Explore personal identity and support ongoing life-story activities: evidence statementsE5.2, C3.7, C3.13, C3.18; C4, EP11

Diversity

Recommendation 26 Ensure everyone understands diversity issues: evidence statements E5.2, C3.7, C3.16; C1, C4, EP11, EP18

Recommendation 27 Sharing learning about diversity: evidence statements E5.2, C3.4, C3.7; C4, EP10, EP18

Recommendation 28 Appoint a diversity champion: EP14, EP18, EP23

Recommendation 29 Produce and use a diversity profile: evidence statements C3.7, C3.12, C3.16; EP18

Recommendation 30 Ensure there is a diverse range of placements: evidence statements E5.2, C3.5, C3.7, C3.12; C4, EP18

Recommendation 31 Carry out core assessments: evidence statements E5.2, C3.7, C3.12; C4, EP18

Recommendation 32 Embed diversity in local plans: EP14, EP18, EP23

Recommendation 33 Provide expertise relating to unaccompanied asylum-seeking children and young people who are looked after: evidence statements E5.12, C3.16, C3.17; C1, C4, EP8, EP23

Recommendation 34 Provide expertise relating to black and ethnic minority children and young people: evidence statements C3.17, C3.20; C4, EP18, EP23

Supporting foster and residential care

Recommendation 35 Assure the quality of foster and residential care: evidence statement E5.12, C3.12, C3.17, C3.20; C1; EP2, EP9, EP13

Recommendation 36 Train foster and residential carers: evidence statements E2.1, E4.2.8, E4.2.12, E4.3, E5.1, E5.2, E5.3, E5.14, E5.15, C3.7, C3.12, C3.17, C3.20; C2, EP6, EP9, EP11, EP13, EP18, EP23

Recommendation 37 Support foster carers and their families: evidence statements E2.1, E4.2.12, E4.3, E5.8, E5.11, E5.14, E5.15, C3.8, C3.12, C3.20; C1, C2, EP6, EP9, EP11, EP18, EP21, EP23

Recommendation 38 Train for supervisors: evidence statements E5.10, E5.13; EP1, EP3, EP6, EP9, EP11, E5.14, E5.15, EP21

Care provided by family and friends

Recommendation 39 Consider developing a national strategy to implement statutory guidance for care provided by family and friends: evidence statements E4.2.6, E4.3, E5.17; EP18, EP19

Recommendation 40 Promote care provided by family and friends: evidence statement E4.2.6; C4, EP18, EP19

Improving education for looked-after children and young people

Recommendation 41 Develop teacher training: evidence statements E5.1, E5.3, E5.6, C3.7, C3.12; C1, C4

Recommendation 42 Involve designated teachers for looked-after children and young people: evidence statements E5.7, E5.8; C1

Recommendation 43 Monitor the quality of education for looked-after children and young people: evidence statement E5.7; C1

Recommendation 44 Support access to further and higher education: evidence statements E1.1, E5.9, C3.6; C1, C4, EP20

Recommendation 45 Support looked-after young people in further and higher education: evidence statements E1.1, E5.9, C3.6; C1, EP20

Preparing for independence

Recommendation 46 Support preparation for the transition to adulthood and moving to independence: evidence statements E1.1, E1.2, E1.3, E1.4, E1.5, E1.6, E1.7, E1.8, E1.9, E4.2.10, C3.7; C1, C4, EP6, EP14, EP20

Recommendation 47 Providing leaving-care services: evidence statements E1.1, E1.2, E1.3, E1.4, E1.5, E1.6, E1.7, E1.8, E1.9, E5.9, C3.7; C1, C2, C4, EP6, EP14, EP20

Recommendation 48 Conduct a comprehensive health consultation when young people move on to independent living: evidence statement C3.6; C1, C4, EP20

Recommendation 49 Support transfer to adult mental health services: evidence statements C3.7, C3.11

Training for professionals

Recommendation 50 Developing a curriculum for core training: evidence statements E2.1, E4.2.4, E4.2.12, E5.7, E5.8, E5.14, E5.15, C3.1, C3.2, C3.7,C3.8, C3.12, C3.18, C3.20; EP1, EP3, EP6, EP9, EP11, EP21

Recommendation 51 Train social workers to support looked-after children in an educational setting: evidence statementsE5.3, E5.7, C3.18; EP1, EP3, EP6, EP9, EP11, EP21

Recommendation 52 Train independent reviewing officers to support looked after children in an educational setting: evidence statements E5.3, E5.7, C3.7, C3.9, C3.12, C3.18; EP1, EP3, EP6, EP9, EP11, EP21

Evidence statements

Please note that the wording of some evidence statements has been altered slightly from those in the review team’s report to make them more consistent with each other and NICE's standard house style. This does not alter the meaning.

Evidence statement E1.1

There is moderate evidence of mixed quality from four retrospective US cohort studies (one [++],one [+], two [-]) to suggest that looked-after children and young people who received transition support services (TSSs) were more likely to complete compulsory education with formal qualifications than those who had not received these TSSs; whereas one prospective US cohort study (+) reported a non-significant finding in favour of the comparison group.

Evidence statement E1.2

There is moderate evidence of a positive effect of TSSs on current employment from one prospective (+) and two retrospective US cohort studies (one [+], one [-]) although one retrospective US cohort study reported no difference between those who had and had not received TSSs on current employment (++).

Evidence statement E1.3

There is moderate evidence of a mixed effect with regard to the effect of TSSs on employment history. Two retrospective US cohort studies (one [++],one [-]) reported that those who had received TSSs were more likely to have a better employment history than those who had not received TSSs, whereas one prospective UK cohort study (-) reported that those who had received TSSs were less likely to have taken an employment/academic career path than those who had not.

Evidence statement E1.4

There is moderate evidence of a mixed effect with regard to the effect of TSSs on employment at case closing. Two US cohort studies, one prospective (+) and one retrospective (-) reported that those who had received TSSs were more likely to be employed at case closing than those who had not received TSSs, whereas one retrospective US cohort study (-) reported that those who had received TSSs were less likely to be employed at case closing than those who had not.

Evidence statement E1.5

There is moderate evidence of a mixed effect with regard to the effect of TSSs on crime/offending behaviour. One retrospective US cohort study (-) reported that those who had received TSSs were less likely to have a problem with the law and one retrospective cohort study (++) reported that those who had received TSSs were more likely to have a problem with the law than those who had not received TSSs. One retrospective US cohort study (+) found no difference between those who had and had not received TSSs on never being arrested. Those who had received TSSs were less likely to have been arrested for serious crimes but more likely to be arrested for moderate crimes than those who had not received TSSs. However those who had received TSSs were less likely to receive short jail sentences and more likely to receive long jail sentences than those who had not received TSSs.

Evidence statement E1.6

There is moderate evidence for a positive effect of TSSs on parenthood from one prospective (+) and two retrospective US cohort studies (one [++] and one [+]), in that those who had received TSSs were less likely to be parents than those who had not.

Evidence statement E1.7

There is moderate evidence for a positive effect of TSSs on housing and independent living from six studies: one prospective UK cohort study and five retrospective US cohort studies. Those who had received TSSs were more likely to have a place to live (one [-] and one [++]) and were more likely to be living independently (two [+] and 2[-]) than those who had not received TSSs.

Evidence statement E1.8

There is moderate evidence of a mixed effect with regard to the effect of TSSs on homelessness. Two retrospective US cohort studies reported that those who had received TSSs were less likely to have had a homeless episode at discharge (one [++]) or to have ever been without a place to sleep (one [-]) than those who had not received TSSs. However two retrospective US cohort studies (one [+] and one [-]) reported no difference between those who had and had not received TSSs on homelessness.

Evidence statement E1.9

There is evidence of mixed quality to suggest no evidence of effect of TSSs on mental health outcomes. Three retrospective US cohort studies (one [++], one [-] and one [+]) reported no difference on general satisfaction, life satisfaction and depression. However one retrospective US cohort study (-) reported that those who had received TSSs were more likely to be hopeful about the future than those who had not.

Review 1: applicability of non-UK studies to UK care system and populations

The majority of studies included in this review were conducted in the US, with only one UK study and this will have implications for the applicability of the review findings to the UK context. The UK study reported very little quantitative data with no statistical comparisons. The findings from this review are based on studies that are small and furthermore some of the studies have been outdated by current legislation (for example, the studies from the 1990s will not have considered the recommendations of the Children’s [Leaving Care] Act 2001) so the study conclusions may not reflect current policy and practice. The small number of studies reviewed and their poor methodological quality and rigour are also of concern when considering the applicability of the findings of this review.

Evidence statement E2.1

There is evidence of mixed quality to suggest a mixed effect of training and support for foster carers on child problem behaviours. Three US RCTs reported that children looked after by carers who had received a training and support intervention had lower rates of problem behaviour at follow-up than children of carers who had not received an intervention, among the whole sample (one [+] and one [-]) and in older infants (one +). However, one UK RCT (-) and one UK prospective cohort study (-) reported no differences on child problem behaviours between children of carers who had and had not received a training and support intervention. One US RCT (+) reported that the younger infants looked after by carers who had received a training and support intervention had higher rates of problem behaviours than children of carers who had not received an intervention. The findings of this review are moderately applicable to the UK care system, given that half of the studies reviewed were conducted in the UK and all were conducted in recent years.

Review 2: applicability to the UK

Half of studies included in this review were conducted in the UK with the other half conducted in the US, which may have implications for the applicability of the review findings to the UK context. Many of the studies had small sample sizes, which is a concern; as is the poor methodological quality of some of the studies, despite the use of RCT methodology. However, all studies included were conducted in recent years, with many conducted in the last 4 years, which increases the applicability of the findings of this review.

Evidence statement E3.1

There is mixed evidence of reasonable quality from one US prospective cohort study (+) on the effectiveness of a comprehensive multidisciplinary assessment compared with usual assessment on access to services in general. This study also reported that looked-after children and young people who received a comprehensive multidisciplinary assessment and were referred to a service were more likely to have received a service at 6-month follow-up than those who received usual assessments and were referred to a service; however this difference was not apparent at 12-month follow-up. These findings may have limited applicability to the UK care system as this was a US study and was conducted 9 years ago.

Evidence statement E3.2

There is mixed evidence of reasonable quality from one US prospective cohort study (+) on the effectiveness of a comprehensive multidisciplinary assessment compared with usual assessment on access to services in general. This study reported that looked-after children and young people who received a comprehensive multidisciplinary assessment were more likely to be referred to a service than those who received usual assessments. Regarding referral to specific services, there is evidence from the same study to suggest no significant difference in referral rates to mental health services between looked-after children and young people who received a comprehensive multidisciplinary assessment with an identified need for the specific service and those who received usual assessments with an identified need for the specific service. These findings may have little applicability to the UK care system as this was a US study and was conducted 9 years ago.

There is evidence of reasonable quality from one US study (+) to suggest a mixed effect of a comprehensive medical case management programme. One US study reported that looked-after children and young people who received a comprehensive medical case management programme were more likely to receive psychiatric clinic services than those looked-after children and young people receiving usual service but slightly less likely to receive mental health services. This finding may be of medium relevance to the UK care system as this was a US study published 5 years ago.

Evidence statement E3.3

There is mixed evidence of reasonable quality from one US prospective cohort study (+) on the effectiveness of a comprehensive multidisciplinary assessment compared with usual assessment on access to services in general. This study reported that looked-after children and young people who received a comprehensive multidisciplinary assessment were more likely to be referred to a service than those who received usual assessments. Regarding referral to specific services, there is evidence from the same study to suggest no significant difference in referral rates to medical services between looked-after children and young people who received a comprehensive multidisciplinary assessment with an identified need for the specific service and those who received usual assessments with an identified need for the specific service. These findings may have little applicability to the UK care system as this was a US study and was conducted 9 years ago.

There is evidence of reasonable quality from one US study (+) to suggest that looked-after children and young people who received a comprehensive medical case management programme were more likely to receive physician services, hearing examinations and eye examinations services than those looked-after children and young people receiving usual service. This finding may be of medium relevance to the UK care system as this was a US study published 5 years ago.

There is evidence of reasonable quality from one US study (+) to suggest that providing all reasonably available medical records to the professional undertaking initial health assessment at entry into care increases uptake within 14-day, 30-day and 1-year periods. This finding may be of medium relevance to the UK care system as this was a US study published 2 years ago. There is evidence of poor quality from one UK non-comparative study (-) to suggest no significant difference in immunisation uptake rates among looked-after children and young people before and 12 months after providing social services with information on immunisation status. This finding may be moderately applicable to the UK care system as this was a UK study and was published 6 years ago.

Review 3: applicability to the UK

One non-comparative study included in this review was conducted in the UK with four prospective cohort studies conducted in the US, which may have implications for the applicability of the review findings to the UK context, although there is likely to be much similarity in medical assessments for looked-after children and young people in the UK and US. Many of the studies had small sample sizes, which is a concern, as is the poor methodological quality of some of the studies. However, all studies included were conducted within the last 9 years.

Evidence statement E4.2.1

There is evidence of mixed quality (five cohort studies and two reviews [all -], four cohort studies [all +]) for an association between older age at first placement and [increases in] placement breakdown or behavioural problems. [General direction is positive.]

Evidence statement E4.2.4

There is evidence of mixed quality (one review [-] and two cohort studies [both +]) for an association between professional foster care and [increased] placement stability. [General direction is positive.]

Evidence statement E4.2.5

There is evidence of mixed quality (two reviews and one cohort study [all -] and one cohort study [+]) for an association between sibling co-placement and placement stability and emotional and behavioural problems (). There is evidence of good quality (two cohort studies [both +] and one [++]) for an association between sibling co-placement and emotional and behavioural problems [General direction of association is positive.]

Evidence statement E4.2.6

There is evidence of mixed quality (two cohort studies and one review [all -] and four cohort studies [all +]) for an association between kinship care [now termed ‘family and friends care’] and placement stability. (There is evidence of mostly good quality [one cross-sectional study {-} and three cohort studies {all +}] for an association between kinship care and emotional and behavioural problems). [General direction is positive.]

Evidence statement E4.2.7

There is evidence of weak quality (two cohort studies [both -]) for a [positive] association between concurrent planning and placement stability).

Evidence statement E4.2.8

There is very good quality evidence (one RCT [++]) for a positive association between a shared parenting programme and externalising problems. [Externalising problems decrease.]

Evidence statement E4.2.10

Mixed results of associations between outcomes and transitional planning were reported. One review did not identify any evidence for an association between transitional planning (for example, independent living programmes) and placement stability or emotional and behavioural problems. There is evidence of good quality (one cohort study [+]) for an association between transitional planning and drug and alcohol misuse as an adult. There is evidence of mixed quality (two cohort studies [both -] and one review [+]) for an association between transitional planning and education and employment as an adult (general direction of associations where reported is positive).

Evidence statement E4.2.11

This review identified mixed results for associations with adult mentorship. No evidence was identified of an association between adult mentorship and placement stability or emotional and behavioural problems, but there is evidence of good quality (one cohort study [+]) for a [positive] association between adult mentorship and self-esteem, level of good health and participation in higher education, and a negative association between adult mentorship and suicide ideation.

Evidence statement E4.2.12

There is evidence of mixed quality (two cohort studies and one RCT [all -], two RCTs [both +] and one systematic review [++]) for an association between training for foster carers and emotional and behavioural problems. There is evidence of good quality (two RCTs [both +]) for an association between training for foster carers and permanent placement). [General direction of associations is positive.]

Evidence statement E4.2.13

This review reported mixed results for associations with physical and mental health assessments. No evidence was identified for an association between a full physical and mental health assessment and emotional and behavioural problems. There is evidence of weak quality (one cohort study [-]) for an association between a full physical and mental health assessment and mental health service use.

Evidence statement E4.3

There is evidence of varying quality from 17 studies (eight cohort studies and one RCT [all +], six cohort studies and two cross-sectional studies [all -]) to suggest that the number of placements is a risk factor associated with a reduced likelihood of a positive outcome, and that placement stability is a protective factor that is associated with fewer placement moves and fewer emotional and behavioural problems. However, it should be noted that this is not an exhaustive review and not all evidence on these factors and outcomes has been identified and assessed.

Evidence statement E5.1

There was evidence in seven studies (one [++] and six [+]) that looked-after children and young people had the view that:

Evidence statement E5.2

Statements from looked-after children and young people in 13 studies (one [++] and 12 [+]) provide strong evidence that looked-after children and young people feel that:

Evidence statement E5.3

Evidence that being supported is important to looked-after children and young people was reported in 10 studies (all +):

Evidence statement E5.4

Evidence on the importance for looked-after children and young people of having someone to talk to in confidence was found in eight studies (all +). Looked-after children and young people reported that:

Evidence statement E5.5

The significance for looked-after children and young people of contact with their birth families was revealed in 11 studies (one [++]; ten [+]). Studies reported that:

Evidence statement E5.6

Looked-after children and young people identified stigma and prejudice as a significant problem in their lives in seven studies (one [++] and six [+]). They reported that:

Evidence statement E5.7

Evidence about important issues for looked-after children and young people in relation to education was reported in 11 studies (one [++] and ten [+]). This evidence revealed that:

Evidence statement E5.8

There was evidence from seven studies (all [+]) about looked-after children and young people’s relationship with professionals. They raised similar concerns to carers. These include:

Evidence statement E5.9

Seven studies (one [++] and six [+]) provide evidence that preparation and support for leaving care is an important issue for looked-after children and young people. In order to improve the process of leaving care, looked-after children and young people said they needed:

Evidence statement E5.10

There was evidence in five studies (one [++] and four [+]) about carers’ relationship with social workers. Carers said they wanted:

Evidence statement E5.11

There was evidence from four studies (one [+] and three [-]) on carers’ views about whether they are ‘being a parent’ or ‘doing a job’. Carers’ views across the four studies indicate that they:

Evidence statement E5.12

There was evidence from four studies (two [+] and two [-]) on carers’ relationships with looked-after children and young people. Carers stated that they were:

Evidence statement E5.13

There was evidence from five studies (one [++], one [+] and three [-]) about carers’ use of a wider support network. The views of carers indicated that:

Evidence statement E5.14

There was evidence from four studies (two [+] and two [-]) about carers’ views on training. Carers say they want:

Evidence statement E5.15

There was evidence from three studies (one [+] and two [-]) on carers’ views about birth parents. Carers held strong views and felt that:

Evidence statement E5.16

There was evidence from four studies (three [+] and one [-]) about the accessibility and acceptability of services. Studies asked carers about services they wanted or would like to have access to. Three of the four studies included carers’ views on the acceptability of services they had received or had been in contact with. By comparing the participants’ direct quotes and author analysis across the four studies it was possible to identify three barriers to accessing services:

In terms of acceptability of services, all three studies included both positive and negative experiences of the services they received with no strong implications for the improvement of services being made by carers.

Evidence statement E5.17

There was evidence from two (++) studies on being a kinship carer. Participants described what it was like being a kinship carer which provided insight into the uniqueness of their experiences. The following emerged from their views:

Evidence statement E5.18

There was evidence in two (+) studies on parents’ views about maintaining contact with their children. Parents specifically stated that:

Evidence statement C3.1

Communication between professionals and services is undoubtedly aided by co-location, integrated front-line working and effective communication structures including regular consultation meetings, joint strategic planning and pooled resources.

Evidence statement C3.2

Effective practice in improving the health and wellbeing of looked-after children and young people relies on effective information sharing, communication across organisational boundaries and a shared commitment to improving their health and wellbeing. In describing effective information sharing and communication activity, the sites talked about the importance of having a range of structured and forward planned, information sharing meetings that had clear agendas and purpose, some of which were topic led and related to specific or emerging issues. Other examples were given as regular email correspondence between professionals and regular telephone conversations to discuss individuals or issues.

Evidence statement C3.3

In sites where Children and Mental Health Services (CAMHS) workers are co-located for part of the week, or where they are fully integrated into looked-after children and young people teams, the result is better and speedier access to CAMHS for looked-after children and young people.

Evidence statement C3.4

Effective strategy and planning is crucial in promoting productive partnership working at all levels. Joined-up, corporate and strategic planning impacts upon all other planning activity within the services, and ultimately improves the direct services to looked-after children and young people and their families.

Evidence statement C3.5

The evidence gathered in all sites and across the professional groups strongly suggests that the most important factors in influencing looked-after children and young people’s health and wellbeing outcomes are stability and consistency. The child or young person’s placement is of paramount importance and the characteristics of a quality placement are good matching of carer and child at the point of placement. Good matching is characterised by the matcher having robust and detailed information about the child, their characteristics and preferences so that they can match these against the lifestyle and characteristics of the foster carers at the point of matching. The matching process is also aided by timely planning, with the child and carers experiencing introductory meetings and agreeing to the time frame for the planned move. Additional characteristics of a quality placement are thought to be the consistent approach that the carer brings to the relationship, having commitment, staying power and demonstrating unconditional positive regard for the child. In summary, the quality of the relationship between the carer and child is crucial. Alongside this, stability of school placement and consistency in key workers are also thought to be highly influential in promoting health and wellbeing in looked-after children and young people.

Evidence statement C3.6

Good transition management is characterised by timely planning to ensure that young people are fully supported through the transition process. Young people voiced concern at the stark contrast between the lifestyle and support they had experienced in foster or residential care and the situation they face when leaving care. The significant reduction in their financial means, coupled with the added responsibilities of independent living affect their diet, opportunities for exercise and adds to their stress.

Evidence statement C3.7

Looked-after children and young people do not want to be identified as different from other children and young people and therefore it is important to offer them the same interventions and support services as their counterparts in universal settings, wherever possible. Evidence suggests that this is even more important for disabled looked-after children and young people who generally have a strong wish to access services alongside their able-bodied peers.

Evidence statement C3.8

Early interventions that focus on preventing adverse behaviours such as offending behaviour, substance misuse, smoking, obesity, and bullying are key to improving children and young people’s health and wellbeing in the future. Evidence suggests that activities and interventions that positively promote health and wellbeing – such as diet, exercise, emotional health and forming friendships, are the most engaging and successful. Such interventions are delivered to varying degrees in schools and universal settings with all children, but often, looked-after children and young people miss out on sessions or do not benefit from the consistent approach to these issues from a school, due to their frequent moves during care or the periods of school absence they experienced prior to coming into the care system.

Evidence statement C3.9

Specialist services do play an important role in improving health and wellbeing outcomes for some young people. Respondents felt strongly that the needs of every looked-after child or young person are different and that a range of universal and specialist services are needed to meet their bespoke needs.

Evidence statement C3.10

CAMHS support to the carers of looked-after children and young people with complex needs is highly valued by the recipients. In sites where carers are accessing this type of support, respondents spoke positively about the benefits. However, the evidence suggests that support to carers should be an additional service to the therapeutic intervention that should also be on offer to looked-after children and young people and not an alternative to this.

Evidence statement C3.11

Respondents in three sites named [reported] that there should be consistency in the ages that all [agencies] work to [for example, there are different cut-off points for points of access services] in responding to the needs of looked-after children and young people. In particular they felt CAMHS interventions should continue [after] when young people reach 18 years and should mirror the longer-term responsibilities of education and social care staff.

Evidence statement C3.12

Looked-after children and young people’s access to dental care is a concern to respondents. Sometimes they need to travel considerable distances to access a dentist that has the capacity to take them. A looked-after child or young person may not attend a planned dental check for reasons relating to unplanned placement moves, fear, phobias or confidence issues. Missed appointments result in some dental practices de-registering them. Some dentists are reluctant to embark on a treatment programme if a child is in a short-term placement. There are particular needs around meeting the specialist dental needs of disabled children and young people.

Evidence statement C3.13

Life-story work takes place inconsistently with looked-after children and young people. Evidence suggests that they would benefit from having access to consistent information about their history and the reasons for their being looked after. This needs to be an ongoing process with information updated as the child or young person moves through developmental stages. There appears to be little consistency in approach to life-story work and there is a tendency for it to be resource-driven rather than needs-led.

Evidence statement C3.14

Respondents at some sites reported ‘models of good practice’ in helping children and young people placed out-of-area access services. However, this was not the case across all sites which means that some children and young people are not receiving the same level services. Evidence suggests that this inconsistency in service delivery impacts on their future health and wellbeing.

Evidence statement C3.15

Sites would welcome national guidance to support the delivery of care to children placed out-of-area, and to children placed in area when they are looked after by another local authority.

Evidence statement C3.16

Evidence suggests that there has been a significant change in the demographics of the looked-after children and young people population in the last 5 years. Sites have accommodated increasing numbers of asylum seeking children and young people, a good proportion of which are unaccompanied (UASCYP). There appears to be a lack of appropriate mental health services for UASCYP and furthermore, services are unable to meet the complex needs of this vulnerable group. Young people express concern at the poor quality of accommodation in which some UASCYP are placed and considered that their eligibility and access to support did not match that provided to other care leavers.

Evidence statement C3.17

The high levels of support and in-depth training provided to foster carers on specialist schemes was seen as a benchmark that mainstream foster carers would welcome. In particular, out-of-hours support from a mental health (CAMHS) worker was seen as an effective way to manage a crisis and help prevent breakdown.

Evidence statement C3.18

In the main, looked-after children and young people interviewed did not speak positively about their relationships with social workers. Social workers are considered to have control and to make decisions, however they are not trusted by young people to carry through agreed actions. Evidence suggests a high degree of turnover in social workers working with looked-after children and young people. Children and young people say that they do not feel listened to by their social workers and that they are hard to reach. More typically, children and young people named foster carers, staff at school, independent reviewing officers and independent visitors as a source of trusted support.

Evidence statement C3.19

Evidence suggests that in circumstances where respectful relationships are built between carers and birth parents, this will assist in enabling a looked-after child or young person to thrive in their placement. Ongoing work with birth parents appears to be a neglected area although the likelihood is that looked-after children and young people are likely to return back to their care at some stage in their lives.

Evidence statement C3.20

Although most looked-after children and young people express high levels of satisfaction with their current placement, some were critical of the motivation of their previous foster carers and of the care that they had received. Young people advocate that there should be more regulation, inspection and spot checks of foster care placements.

Expert testimony

Cost-effectiveness evidence

The cost-effectiveness modelling for review 1 (see appendix B) estimated that interventions that support the transition of looked-after children and young people to adulthood are likely to be cost effective. Helping young people to find employment or continue with higher education improves health and social outcomes and is estimated to make long-term cost savings.

In line with the approach outlined in appendix B, the recommendations that were agreed by the PDG to result in more good than harm compared with current practice, which were of relatively small additional cost and which would probably yield cost savings in the long run, were considered to be cost effective. Indeed, the recommendations would in many cases be less expensive and more effective than current practice.

The PDG examined one draft recommendation – ensuring that all looked-after children and young people had a complete assessment of their physical, mental and emotional health at the time of entry to the care system – in some detail. The PDG concluded that the recommendation was likely to do more good than harm compared with current practice and, since resources should already be in place, the level of resources need not change, or need not change by very much.

As a result of data limitations, there is uncertainty regarding the cost effectiveness of the remaining recommendations, in particular those that relate to system-level changes, training, auditing/monitoring, multi-agency working and information sharing. For these, the PDG judged that they would do more good than harm compared with current practice, based on evidence it was presented with. In addition, the PDG judged that many of the recommendations were likely to have low or no additional cost, and so were very likely to be cost effective.

However, the PDG expected that some of the recommendations were likely to be costly. For these recommendations, the PDG did not have enough evidence on the magnitude of the costs and/or the effects to reach an informed conclusion about their cost effectiveness. This does not mean that these recommendations are not cost effective, just that the extent, if any, of their cost effectiveness is not known.

Fieldwork findings

Fieldwork aimed to test the relevance, usefulness and feasibility of putting the recommendations into practice. The PDG considered the findings when developing the final recommendations. For details, go to the fieldwork section in appendix B and www.nice.org.uk/guidance/PH28

Fieldwork participants who work with looked-after children and young people were positive about the recommendations and their potential to help promote the physical and emotional health and wellbeing of these children and young people. Many participants stated that they exemplify best practice.

For clarity, they felt it would be best if the recommendations were grouped together according to who should be taking action. Generally, greater clarity was needed on who should take action – wherever possible, specific job roles should be included.

Participants also wanted more explicit links to existing guidance and policy. In addition, they expressed a need:

The recommendations were seen to reinforce aspects of the Department of Children, Schools and Families ‘Statutory guidance on promoting health and wellbeing of looked after children’.

Practitioners and commissioners said the recommendations did not offer a new approach, but agreed that the measures had not been implemented universally. They believed wider and more systematic implementation would be achieved if there were:

Consultation with looked-after young people and care leavers

The guidance was well received by looked-after young people. In particular, there was strong support for the recommendations on life-story work, access to personal information and health assessments.

In addition, there was strong support for recommendations that aim to make ‘the voice of the child heard’, with participants stressing the need for clarity about their role in decision-making. They also stressed the need for greater involvement and control in terms of decisions made about and for them.

They were pleased to see the issue of stigma and prejudice addressed – violence and bullying was a particular concern. Participants suggested expanding this group of recommendations to include, for example, assertiveness training for looked-after children.

The question about whether or not it would be possible to implement the recommendations was also raised, with some recognising that limited resources and heavy caseloads get in the way of best practice.