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

Background: the context, considerations and scope of the recommendations

Context

• Experiences of looked-after children and young people in England Open

  About 60,900 (28) children and young people were looked after by local authorities in England in 2009 (year end 31 March) (Department for Children, Schools and Families 2009a). This was 2% more than in 2008 but the number had changed little since 2005.

  • The number of boys who were looked after increased during 2005 to 2009, while the number of girls decreased.
  • The number of white children and young people who became looked after decreased during 2005 to 2009, while the number of Asian children and children from other black and minority ethnic groups increased.
  • About 40% of the total in 2009 were children younger than 10, but in recent years there has been a decrease in the numbers aged 5–9 and a significant increase in the number of over-16s who are looked after.
  • Most looked-after children (about 73% in 2009) were in foster care, about 13% were in residential settings and 10% were placed with parents or were living independently (no separate figures are available for care by family and friends).

  Early experiences may have long-term consequences for the health and social development of children and young people. A number have positive experiences in the care system and achieve good emotional and physical health, do well in their education and have good jobs and careers. However, entering care is strongly associated with poverty and deprivation (for example, low income, parental unemployment, relationship breakdown).

  About 60% of those looked after in England have been reported to have emotional and mental health problems and a high proportion experience poor health, educational and social outcomes after leaving care (Department for Children, Schools and Families 2009a). However, a small number of research studies and surveys in 2000–2008 have reported improvements in providing settled accommodation and entering employment, further and higher education or training (Stein 2009).

  One third of all children and young people in contact with the criminal justice system have been looked after (Department for Children, Schools and Families and DH 2009). However, a substantial majority of young people in care who commit offences had already started to offend before becoming looked after (Darker et al. 2008).

  Looked-after children and young people should have clear expectations for their care and wellbeing (Children’s Rights Director for England 2007). The report stated that they should expect to take part in decisions that affect their lives, be kept healthy and safe, be treated with respect, and be treated equally to other children and young people. However, local variations in service access and support can mean that these expectations are not always met.

• National policy and guidance Open

  There is a wide range of policies and guidance relevant to looked-after children and young people (see the list in section 9).

  Statutory guidance on promoting the health and well-being of looked after children

  In November 2009 the then Department for Children, Schools and Families (DCSF) published ‘Statutory guidance on promoting the health and well-being of looked after children’. This replaced the guidance, ‘Promoting the health of looked after children’, published by the Department of Health in 2002. The new guidance aimed to remove inconsistencies and promote better-coordinated care. Local authorities, primary care trusts (PCTs) and strategic health authorities in England should implement it in accordance with sections 10 and 11 of the Children Act 2004. Local authorities must also comply under section 7 of the Local Authority Social Services Act 1970 with duties to promote the health of looked-after children and young people(29).

  The revised document also includes practice guidance on access to services, care planning and placement quality, physical health and health promotion.

  Care planning, placement and case review regulations and statutory guidance for local authorities

  In March 2010, the DCSF published ‘The Children Act 1989 Guidance and Regulations volume 2: care planning, placement and case review’ (2010). This document was issued as part of a set of statutory guidance which, together with the 2010 regulations, defined the core duties primarily of local authorities for ensuring more purposeful care planning, placement and review for looked-after children and young people. Associated documents include the ‘IRO handbook’ (DCSF 2010a) and the ‘Sufficiency guidance’ (DCSF 2010b) on securing sufficient accommodation for looked-after children.

  The regulations and guidance propose to strengthen the role of the social worker as 'frontline corporate parent' and the role of the independent reviewing officer (IRO) for monitoring the performance of the local authority in properly managing and implementing the care plan. The main aim is to put the child at the heart of the care planning process. The guidance also sets out how to meet the accommodation needs of the child and ensure an effective and timely review of the child’s case.

  Inspection guidance and standards for looked-after children outcomes and services

  Ofsted’s ‘Framework for inspection and guidance for local authorities and partners’ (2009) sets out the process and scope of integrated inspections (with the Care Quality Commission) and identifies inspection topics, including quality of care planning and review, corporate parenting approaches and education outcomes. A limited revision to the framework is expected to be published in Autumn 2010 to reflect feedback from the first year of inspections.

  At the time of writing this NICE/SCIE guidance in September 2010, the Department for Education’s national minimum standards for adoption, children’s homes and fostering were being revised after a consultation (DCSF, 2009b). The standards are for use by Ofsted and may be used by providers for self-assessment of their services. They aim to achieve positive welfare, health and education outcomes for children and young people, and reduce risks to their welfare and safety.

  28.

  Figures released by the Department for Education (PDF) in September 2010 put this figure at 64,000 for the year ending 31 March 2010. Of these, 52% are children and young people taken into care because of abuse or neglect, and this figure has increased since 2009.

  29.

  It includes statutory guidance on: joint working and responsibilities; performance management and inspection; commissioning responsibilities; out of authority placements; notifications of placements; frameworks for healthy care; service management and delivery; health plans; care planning; assessment; child and adolescent mental health services (CAMHS); leaving care; involving children and young people; the roles of the social worker, health and other professionals (including the independent reviewing officer, lead health professional, designated doctor and nurse); and access to positive activities.

Considerations

This section describes the factors and issues that the Programme Development Group (PDG) took into account when developing the recommendations. The recommendations are set out in section 1.

• Needs of looked-after children and young people Open

  3.1 A great majority of children who become looked after do so because of abuse, neglect or family dysfunction that causes acute stress among family members. Entry into care is usually a traumatic experience and brings with it a significant sense of loss that can be insufficiently recognised in care planning. Older children in care may also experience significant problems at school. For those children and young people who remain in long-term care creating a sense of belonging and emotional security is vital to their health and wellbeing.

• Quality of care and placement stability Open

  3.2 Ensuring that children and young people feel attached to carers and experience a sense of ‘permanence’ has been a key issue for the PDG. Much of the evidence that the PDG received identified quality of care and stability of both the placement and education as critical to achieving permanence. Frequent placement changes can severely lessen the sense of identity and self-esteem of a child or young person, and can also adversely affect their experience of, and access to, education and health services. A system that allows multiple moves may be seen as harmful. Repeated separations or moves may therefore be regarded as indicators of emotional harm.

  3.3 The PDG agreed, however, that the length of time in a placement should not be the sole indicator of its success, and noted that the current national indicators for placement stability indicate little about the quality of the placement. As such, they can divert attention from the actual experiences of children and young people. A placement may be long lasting but an unhappy experience and it is then more important to move than to stay.

  3.4 Although placement moves disrupt all areas of a child’s or young person’s life, the impact of changing a placement may be less harmful if continuity is maintained in other areas of their life. This may include staying at the same school, maintaining contact with their siblings, family or past residential or foster carers, and keeping social and community networks including friends and the same social worker or support team. In addition, positive transitions to new placements can be achieved and children and young people can feel less unsettled if information about their needs and preferences is passed on and used to inform future placements.

• Audit and inspection Open

  3.5 Local authorities have responsibility for the care and welfare of looked-after children and young people. The responsibility for commissioning an individual’s healthcare is clearly identified in the guidance ‘Who pays? Establishing the responsible commissioner’ (DH 2007) and the recent ‘Statutory guidance on promoting the health and well-being of looked after children’ (Department for Children, Schools and Families and Department of Health 2009).

  3.6 The data on emotional health and wellbeing collected by the Department for Education using the ‘Strengths and difficulties questionnaire’ (SDQ), if used appropriately, could help to identify children and young people who may need additional specialist support at home or at school (Department for Children, Schools and Families and Department of Health 2009). But it is only one measure and needs to be supported by other assessments and knowledge of the child or young person.

• Residential and foster care, and care provided by family and friends Open

  3.7 The PDG recognised that stability of placement, quality of care, stability of education experience and planning for permanence are as applicable to children and young people in residential care as they are to those in foster care. Failure to address these issues risks compounding existing health and social inequalities and increases their vulnerability to social exclusion as young adults.

  3.8 The PDG noted that children and young people placed in residential care are some of the most vulnerable and traumatised individuals in the looked-after population. They also recognised that fostering is a complex task that requires a rehabilitative and therapeutic approach and an understanding of the challenges and rewards of caring for children and young people, some of whom may have experienced abuse and neglect.

  3.9 The PDG heard evidence that foster carers who deliver high-quality care have a consistent parenting style that combines clear guidance and boundary setting with emotional warmth, nurturing and good physical care, and so develop a strong sense of belonging. Evidence also suggests that social workers and other practitioners in frontline roles are good at identifying successful, high-quality foster homes.

  3.10 Although there is less robust evidence on defining good residential care than foster care, the characteristics of good residential care are similar and include descriptions of the same type of parenting style. The PDG believed this type of approach to parenting in both settings is most likely to contribute to the ability of children and young people to develop healthy attachments and become more resilient.

  3.11 Foster and residential carers also have an important role in helping looked-after young people make the transition to adulthood, in the same way that many do for their own children. High-quality foster and residential care will prepare young people properly for leaving care. However, the PDG noted that young people with complex needs face particular problems in the transition from care to independence and considered that all residential homes should have a culture, organisation and regulations that help staff to equip young people with the skills to support their move into adulthood.

  3.12 The PDG heard evidence that placements with family and friends last longer and score higher on a measure of wellbeing than some other types of placements despite the children and young people having the same level of difficulties as those in other care settings. The same evidence reported a number of benefits to being placed with family or friends, including high levels of commitment shown to children and young people despite increasingly challenging behaviour, and good placement stability when care is provided by grandparents. However, the PDG heard that despite the benefits of care by family and friends there is evidence that these carers face greater strain as they receive less support from children’s services than foster carers.

• Siblings Open

  3.13 The PDG heard that a large number (up to 80%) of looked-after children and young people who have a brother or sister also in care are living separately from them. Thorough assessment is required if siblings are to be separated. The PDG took the view that placements that enable siblings to live together or close by or which allow them to attend the same school are likely to be beneficial. However, it was noted that this is not always the case and there may be situations where it is preferable to separate siblings.

• Diversity Open

  3.14 The PDG recognised that achieving and maintaining a sense of security may be more difficult for children and young people from black, minority ethnic and multiple heritage backgrounds, and for unaccompanied asylum seekers. These groups may face racism and isolation which can additionally challenge their ability to develop resilience and high self-esteem. The PDG noted that all looked-after children and young people need to develop resilience and high self esteem, and that the care plan needs to reflect the individual needs for each child or young person.

  3.15 Data from Department for Children, Schools and Families (2009a) show that 27% of the care population are children and young people from black and minority ethnic backgrounds. The proportion of different ethnic groups has remained similar since 2005, and at 31 March 2009 there were 3700 unaccompanied children seeking asylum in care – an increase of 200 from 2008. There is wide diversity of ethnicity and cultural experience within and among these groups of children and young people, and the PDG considered that it is poor practice and unhelpful to use broad categories such as white, black, mixed race, Asian and African.

  3.16 Looked-after children and young people who are also unaccompanied asylum seekers have additional and different complex needs following their dislocation from family, community and home. They may also have experienced or witnessed extreme violence, abuse and rape. Their physical and emotional health needs will require specialist interventions. Professionals need to be alert to these circumstances and ensure support is provided that is sensitive to their needs.

• Health assessments, records and information Open

  3.17 The PDG recognised the importance of collecting and recording comprehensive, factual and non-judgemental information about looked-after children and young people. Professionals who rely on incomplete records can make decisions that adversely affect the child or young person.

  3.18 Equally important is ensuring that health information held on looked-after babies, children and young people is accurate, kept up-to-date and transferred at the right time. The PDG recognised that health history may not be incorporated into the initial healthcare assessment, plans may not be updated and recommendations may not be followed through. In addition, records may be misplaced when the child or young person is placed outside their local area, or when children are admitted to care, discharged and re-admitted again some time later.

  3.19 The loss of personal health information has significant implications for the immediate and future health and wellbeing of looked-after children and young people. The birth family’s health history may take on an additional importance when young adults begin to plan their own families. Recommendations in this guidance reflect these concerns.

• Dedicated services to promote mental health and wellbeing Open

  3.20 The PDG considered the role of mental health services, including child and adolescent mental health services (CAMHS) (CAMHS 2008). It was agreed that more flexible and accessible services are needed to improve mental health and emotional wellbeing, prevent the escalation of challenging behaviours and reduce the risk of placement breakdown. The recommendations in this guidance set out how a more flexible service should be configured.

  3.21 Children and young people placed out of the local authority area are less likely to receive services from CAMHS in their new location. Looked-after children and young people should be regarded as a priority group for specialist mental health services, especially when moving from one area to another.

  3.22 The PDG looked at the links between CAMHS and adult mental health services – in particular, whether the remit for CAMHS could be extended to young people over 18 who were in care. The committee noted that many young people who receive psychological support from CAMHS would not meet the criteria for accessing an adult mental health service, despite having significant complex needs requiring specialist intervention.

• Supporting babies and young children Open

  3.23 Decisive action is of key importance to the wellbeing of very young children who come into the care of local authorities. The majority are from families where parents are struggling with issues such as domestic violence, substance abuse, alcohol abuse and mental health problems, often in combinations. While some parents succeed in overcoming their difficulties during the child’s formative years, not all are able to do so.

  3.24 The absence of a permanent carer at such a young age can jeopardise children’s chances of developing meaningful attachments and have adverse consequences for their long-term wellbeing. It may be difficult for children to settle in nurseries and other early years settings if they have not experienced secure relationships with care givers.

  3.25 Very young children can become closely attached to foster care families and can experience great distress if moved to a new placement. However, for some children the need to establish stability and permanence may override this consideration.

• Improving educational outcomes Open

  3.26 Evidence shows that educational attainment influences the health, social and employment prospects of a child or young person. Schools have a duty to provide full-time education for looked-after children and young people. This includes students with complex needs who may exhibit the most challenging behaviours and who are also the most vulnerable. An awareness and understanding of the complex issues these children face in an educational setting is essential.

  3.27 Although schools should give priority to admitting looked-after children and young people under government regulation (The Education [Admission of Looked After Children] [England] Regulations 2006), the PDG was concerned that some schools may still be reluctant to admit them or, when they do, may be quick to exclude them when there is a problem. The PDG also acknowledged that the education system does not pay sufficient attention to facilities for looked-after children and young people who are particularly gifted.

  3.28 The PDG recognised the important role of the designated teacher and designated governor in each school. They need to be more assertive in helping schools to manage tensions that might arise concerning the attainment and behaviour of looked-after children and young people.

• Reaching adulthood and preparing for independence Open

  3.29 Moving to independent living and starting the journey into adulthood are landmark steps for most young people. Young people who have been looked after are more disadvantaged and face more difficulties than their peers in achieving independence. They become independent at a younger age and have to cope with major changes in their lives in a much shorter time and with less support than their peers. Physical and mental health problems can increase after they leave care. Outcomes can be more serious and enduring for some looked-after young people who have very damaging pre-care experiences or multiple placements, or who leave care early.

  3.30 The PDG noted that health and wellbeing are closely connected to other aspects of young people’s lives such as access to housing, employment and education, as well as personal and social support.

  3.31 The PDG considered that access to accommodation and employment opportunities are crucial for the successful transition into adulthood of young people leaving care. The PDG also noted that good mental health, in particular, is strongly associated with employment (see ‘Long-term sickness absence and incapacity for work’, NICE public health guidance 1930).

  3.32 The PDG recognised that without adequate support many young care leavers feel marginalised within the wider community and still experience the stigma of having been in care. Without an adequate knowledge of their rights and entitlements they are ill-equipped to cope with their move into the outside world.

  3.33 In the current economic climate it is essential that agencies are mindful of the additional pressures that young people leaving care are likely to experience. Agencies will need to sustain support to reduce the impact of these extra pressures, which are likely to be felt by many young people leaving care for some time to come.

• Safeguarding Open

  3.34 Looked-after children and young people are not inevitably more vulnerable to harm than other children, as vulnerability depends on the quality of care given. However, the PDG heard evidence that there are still concerns for the safety and welfare of looked-after children and young people in some placement settings. It is estimated that 8–10% of social care provision for children in care is inadequate in helping them stay safe (Ofsted 2008). Concerns exist about some fostering services and residential care homes, and most young offenders institutions. However, since the mid-1990s agencies have strengthened their safeguarding arrangements considerably.

  3.35 Safeguarding is a broad concept and can incorporate harm from other children and young people, harm from carers and staff, self-damaging behaviour, ineffective care planning and lack of participation by children and young people in their statutory reviews. All staff associated with children and young people in care have safeguarding responsibilities and should comply with the statutory guidance and national minimum standards on safeguarding. There are a number of recommendations in this guidance that also relate directly to safeguarding concerns, such as listening to the child or young person and putting the child or young person at the centre of care planning.

• Evidence Open

  3.36 Sources of evidence presented to the committee included a number of systematic reviews, an extensive qualitative review of the views of children and young people who were or had been in care, and their families, a detailed sample analysis of Joint Area Reviews, two practice surveys, and fieldwork with commissioners, independent service providers and frontline practitioners. In addition, 23 evidence papers were presented to the PDG by expert witnesses that detailed the most recent evidence and information. Presenters included academics, experts and voluntary agencies with specialist knowledge and experience. Individuals with particular practice experience were co-opted to the committee to inform debate at particular points in the guidance development (see appendix A in this document).

  3.37 In addition, children (where appropriate) and young people were asked for their views on the guidance. These views were reported to the PDG, some of which resulted in changes to the recommendations, such as the inclusion of assertiveness training to help tackle bullying without using physical or verbal aggression. Some children and young people also asked that professionals be honest about what is possible when children and young people are asked about their wishes or views on services.

  3.38 The PDG acknowledged that robust evaluation of the impact of strategies, policies or specific interventions to promote health and wellbeing for looked-after children and young people is impeded by the heterogeneity of the group and the settings, and the multidisciplinary nature of the teams and services caring and working for them. As such, the current effectiveness evidence is limited or not applicable to the UK.

  3.39 Variables not systematically addressed by study designs are the multi-faceted nature of health and wellbeing and the complex interaction between these concepts. Confounding factors include the short duration of programmes, lack of access to participants and the difficulty of sharing of information. Further barriers are the lack of appropriately designed measures for this vulnerable, complex population (including quality of life for both effectiveness and cost-effectiveness evaluations) and poor implementation and understanding of the type of multi-agency, evaluation frameworks needed to provide robust data.

  3.40 The systematic reviews for evidence of effectiveness therefore identified only a small number of relevant studies. Most were of poor quality, with small samples or focussed on a relatively narrow range of interventions that were easier to identify and evaluate. Few pieces of work included any information that would address subsidiary questions about the effective components of an intervention and the particular barriers and facilitators to service access or implementation. Where reviewers identified studies that provided evidence of the effectiveness of an intervention, methodology and limitations were inadequately reported or absent. In the majority of cases it was evident that other factors might have influenced the results (for example, existing health conditions or experience before entry into care).

  3.41 There was a lack of effectiveness evidence on policies, strategies and interventions that could improve the physical and emotional health and wellbeing of looked-after children and young people in general and those who are most vulnerable and disadvantaged in particular. Groups under-represented in the evidence include babies and very young children, children and young people with restricted physical abilities or learning disabilities, black and minority ethnic groups, unaccompanied asylum seekers, and young people who are lesbian, gay, bisexual or transgender.

  3.42 The recommendations in this guidance represent the PDG’s careful consideration and debate on the best available evidence that was presented, including limitations. The PDG concluded that these recommendations set out the best available approach for multi-agency working to sustain or improve the quality of life of looked-after children and young people.

  3.43 The numbering of the recommendations is not a hierarchy of importance. However, it is particularly important to implement the recommendations that include asking children and young people about their opinions and experiences of the care they receive, and being clear about what can be achieved. This should be at the heart of high-quality decision making and service commissioning.

  3.44 If an intervention is not mentioned or recommended in this guidance it may be that there is currently a lack of evidence that it is effective or cost effective. In future, such evidence may be demonstrated.

  3.45 The PDG has made recommendations to develop methodology and quality-assure research in this area. A number of key questions have been identified that need to be answered to improve services and interventions for looked-after children and young people. These are listed in section 5.

  3.46 The PDG was aware of two initiatives currently being piloted by the DH in a number of areas in England. Although the outcomes from this work were not available at the time of completing this guidance, the PDG noted that they may inform future policy development for looked-after children and young people. The initiatives are:

  • research on introducing the values of social pedagogy into residential care homes; social pedagogy focuses on holistic care and building relationships as foundations of healthy emotional development, and the PDG heard evidence from the UK and Denmark on this approach
  • the ‘Staying put’ pilots, which aim to improve support for care leavers by helping young people remain in care after the age of 18.

  The PDG recognised that some of the components described in these initiatives are likely to be already present in high-quality residential homes and foster care where good practice is standard. The committee further noted that much of the evidence and discussion about the values that underpin quality of care in the UK are similar to those of social pedagogy.

• Cost-effectiveness evidence Open

  3.47 A cost-effectiveness modelling exercise was conducted for the effectiveness review of support services for looked-after young people who were making the transition to independent living at the age of 18 (review 1 – see appendix B). For the other effectiveness reviews undertaken (‘Training and support’ and ‘Access to health and mental health services’, see appendix B), a lack of data meant that no meaningful modelling could be undertaken.

  3.48 The PDG considered the appropriateness of a cost-consequences framework, which is recognised in the scope for this guidance as an appropriate method of analysis where there is a lack of meaningful data for cost-effectiveness analysis. This required the PDG to consider the best available evidence on the costs and effectiveness of services of relevance to the recommendations under consideration and to draw on their expertise to make an appropriate recommendation, where gaps in the evidence existed. This approach benefits from greater flexibility to draw on the multiple sources of evidence available to the PDG (including expert testimony, evidence from qualitative and quantitative reviews and the findings of a practice survey). For further details, see appendices B and C.

  Despite limitations in the cost-effectiveness evidence presented, the PDG judged that each of the recommendations, if implemented properly, would do more good than harm compared with current practice. 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 would be costly. For these recommendations, the PDG did not have enough evidence on the magnitude of either 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 their cost effectiveness is not known.