Looked After Children JSNA | Boltons Health Matters
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Looked After Children JSNA


This is the JSNA chapter on looked after children. Theme chapters summarises implications for commissioning, who is at risk and why, the level of need in the population, service provision and use, unmet needs, what works in terms of evidence, community views and priorities, any related equality impact assessments, unmet service needs/gaps and recommendations for further needs assessment work. 


This chapter of the JSNA considers the needs of children who have become looked after as a result of a legal order or who have been accommodated on a voluntary basis in agreement with their parents/carers.  The needs of children who are looked after by the Council solely in the sense that they make use of short breaks provision are considered as part of the disabled children’s chapter.
Looked After Children (LAC) are one of the most vulnerable groups in society.  The majority of children who remain in care are there because they have suffered abuse or neglect. It is recognised that children in care have significantly higher levels of health needs than children and young people from comparable socio-economic backgrounds who have not been looked after.  Their life opportunities and outcomes are also often much poorer and poor health is a factor in this.  Past experiences, poor start in life, care processes, placement moves and many transitions mean that these children are often at risk of having inequitable access to health services, both universal and specialist.
The ‘National Healthy Care Standards’ tell us that all children and young people who are looked after should have access to:
• An environment that promotes children and young people’s health and wellbeing with trained and supported carers and within the wider community;
• Effective health assessments and treatment, excellent health services, and care;
• Opportunities to develop the personal social and life skills to care for their health and wellbeing, now and in the future.
The local authority’s duty to meet the social care needs of looked after children is set out in the 1989 Children Act and subsequent amendments.  The local authority has specific duties:
• To receive a child who is the subject of a care order into care and to continue to look after them while the care order is in force;
• To safeguard and promote the welfare of looked after children - finding out the wishes and feelings of child/parents before making any decision, and giving due consideration to those wishes and feelings and to the child's background;
• To promote the educational attainment of children in its care;
• To regularly review the needs and circumstances of a child in care and to appoint independent reviewing officers to do this;
• To provide appropriate advocates for children in its care;
• To continue to support young people after they have left the authority’s care.
The duty to meet the health needs of Looked After Children for both the NHS and local authorities are clearly laid out in ‘Statutory Guidance on Promoting the Health and Wellbeing of Looked After Children’.
The NHS is required to make arrangements to secure appropriate health services for the child, in accordance with the health assessment and the child’s health plan and need to understand the current flows of looked after children both in and out of the CCG area and ensure that services are commissioned to meet the needs of all Looked After Children.
All children in care are subject to a health plan.  Health assessments must be undertaken twice a year for children under 5 years, and annually for children and young people aged 5 years and over.

Implications for Commissioning

• Ensure that Care leavers receive a  full health history on leaving care including details of immunisations received and integrated learning from strengths and difficulties questionnaires.  This is a CQC recommendation.
• Bolton Council in conjunction with Bolton NHS Foundation Trust should take action to consider the emotional, mental health and long-term conditions of the current Looked After Children population to inform joint commissioning priorities and evaluation of progress in tackling health inequalities.  This is an Ofsted recommendation.
• The further development of a Joint Commissioning Strategy for LAC.
• A piece of work is to look at the timing of Health Assessments and the reasons why deadlines may not be achieved.
• Continue to monitor reported substance misuse amongst children in care and care leavers, and ensure that they are supported appropriately.
• Ongoing consultation with Voice 4U, Bolton’s Children in Care Council.
• Ongoing audit of the quality of assessments by all agencies involved in providing services for Looked After Children.
• Increased designated time for Designated Doctor role.

Who's at Risk and Why

There are currently over 67,000 children being looked after in England. 
Looked After Children are significantly more likely than their peers to leave school with few or no qualifications.  These young people are at higher risk of becoming involved in offending, becoming a teenage parent and of not being in education, employment or training once they have left school.   Early adverse experiences have been associated with increased risk of socio-emotional problems and psychiatric disorders such as depression in later life. 
Care Leavers are more likely to become NEET (not in education, employment or training) than their peers and the likelihood of this increases the earlier they leave care.  In Bolton in 2012, 67% of young people who ceased to be looked after aged 18 or over were in education, employment or training compared to 27% of those who left care aged 16.
Simkiss found evidence  that Looked After Children will tend to have poorer health outcomes than their peers who have not been looked after.   Among the areas of concern he noted are:
• Lower rates of immunization;
• Failure to receive all necessary immunisations;
• Higher than expected rates of myopia and astigmatism;
• Higher than expected rates of conductive hearing loss;
• The emotional consequences of neglect and abuse.
The effects of not having full immunisation can be devastating – for example, not being immunised increases the risk that a child will catch diseases such as measles and polio.
Dental care is also a major factor in the health of children in care.  In general Looked After Children visit the dentist less regularly than those not in authority care.  Additionally, when these children do go to the dentist they are more likely to need treatment.
Other health factors which are more likely to affect young children in care than their peers are :
• Changes in general practitioner;
• Suffer from anxieties and difficulties in interpersonal relationships;
• Higher levels of enuresis (“bed-wetting”);
• Looked after children’s health and development is regularly monitored and therefore they generally are in good health.
Disabilities and special educational need are more prevalent in children who are volunteered in to care and can, in part, be associated with their surrender in to care.  Children can have other specialist health needs more prevalent than the general population’s needs.

The Level of Need in the Population

The proportion of children in Bolton who become looked after is higher than in England as a whole.  At 31st March 2012 the rate was 80 per 10,000 children compared to 59 nationally.  It was, however, slightly lower than the 84 per 10,000 children in authorities with similar levels of deprivation.

Actual numbers of Looked After Children in Bolton has grown year on year from 348 in March 2004 to 521 in March 2011.  By March 2012 this had stabilised at 517 but 2013 saw yet another increase and the number of Looked After Children in Bolton at 31st March 2013 was 541.

During the year ended March 2012, the total number of children admitted to the authority’s care was lower than the total number of children discharged from the authority’s care for the first time since 2003.

In 2012, Bolton’s cohort of Looked After Children had a younger age profile than the national average with 34% being under the age of 5 compared to 25% nationally.  Conversely, only 11% of Bolton’s LAC were aged over 16 in 2012 compared to 20% nationally.

The proportion of Bolton’s LAC who are placed in foster care is in line with the national average (76% in 2012) but a higher proportion than national average are placed with prospective adopters and placed with parents.  The effect of this is that Bolton has a smaller proportion of Looked After Children in residential care than the national average, (7% in Bolton compared to 12% in England in 2012.

To meet their individual needs a small number of Looked After Children need to be placed outside of Bolton but this only applies to about 3% of the total LAC cohort.

Current Services in Relation to Need

The joint policy document ‘Promoting the Health of Looked After Children in Bolton’ was last updated in October 2010 and sets out in detail the roles and responsibilities of all agencies to maintain and promote the health and wellbeing of Looked After Children and Young People.  This includes the roles and responsibilities of:

The NHS: Dental Services, lead health professionals (Senior Nurse LAC, Specialist Practitioner Safeguarding, and Advanced Practitioner), primary care teams, designated professionals (designated doctor and nurse), the School Nursing Service and School Nursing lead professional, Health Visiting Service and lead professional, Community Nursing Service, CAMHS and Emotional Health Service for LAC and The Parallel Young People’s Health Centre.

Specialist substance misuse services: ‘360’ integrated multi-agency team of substance misuse workers.

Children and Families Social Care: including social work services (social workers, residential social workers, supervising social workers – Fostering and Adoption Team), foster carers, reviewing officers.

Community-based children’s social care services are provided by three Referral and Assessment teams, three Safeguarding Teams and three Looked After Children’s teams, supported by three teams for family support (which manage the borough’s children’s centres between them) and borough wide teams for children with a disability, youth offending, adoption, fostering, sexual exploitation, young people’s substance misuse, and young people leaving care.

Between 200 and 250 households foster for Bolton at any given time.  Council social care services manage a total of six Children’s Homes, including two Short-term Breaks facilities for Children with Disabilities and an Adolescent Support Unit.

There is an emergency out of hours service providing social care cover across the borough.

Services in Bolton have a solid track record in protecting and promoting the health of looked after children.  High numbers of children receive the required dental and optical checks.  Similarly, a high number of Looked After Children in Bolton receive the required immunisations.

School drop-ins and the work of the Parallel Health Centre play a crucial role in ensuring that looked after children get the right health care.  Bolton mental health practitioners have developed a pathway for Looked After Children’s mental health and this works closely with the LAC pathway within CAMHS Bolton.  There is now a Looked After Children pathway for CAMHS.  All referrals accepted to CAMHS are initially seen via a ‘Choice’ appointment and the Choice clinician may then decide to refer to the LAC Pathway for consultation, assessment and intervention.  The aim of this approach is to achieve adherence to the recent recommendations in the NICE/SCIE document ‘The physical and emotional health and wellbeing of looked after children and young people’.

To support the educational attainment of Looked After Children a Virtual School has been established.  This together with personalised education plans for each child and designated teachers in schools has reduced school absence and greatly improved the educational achievements of Bolton’s Looked After Children over the past three years.

Projected Service Use and Outcomes

ONS projections based on the 2011 Census suggest that the number of children and young people aged 18 and under in Bolton will increase by just over 10 % over the next decade from 68,201 in 2011 to 75,124 in 2021.  In 2013 this population group numbers 69,338.

The aim of reducing the proportion of children in Bolton who are received into care is simple but is not easy.  There is a very difficult balance to strike between ensuring that children are safeguarded, with their needs being met by their families and the need to intervene effectively when children are in need of protection.

The environment nationally in terms of safeguarding has, since 2008, become one in which there is an understandable aversion to risk.  This is evidenced nationally in the increase in numbers of children subject to a child protection plan and a corresponding increase in numbers of children who are looked after.  There is a strong governmental drive to increase levels of adoption which is viewed as a preferred way of achieving permanency.

In order for the looked after population to decrease, the number of children entering the looked after population has to be less than the number of children leaving the looked after population. Consequently effective control over their number of children entering the looked after system has to be operated alongside a planning framework for individual children which is focused on legal permanence and a safe and efficient exit from the looked after system.

Our focus therefore must continue to be on keeping children safely supported at home with their parents wherever possible but also on effectively assessing the quality of care children are experiencing and, where parenting is not good enough, assessing parental capacity and motivation to change.

Decision making for very young children needs to be done in a timely and effective  manner to avoid drift and to prevent them entering the care system at an older age. 

Therefore, alongside bringing the right children into care at the right time, we need to operate in a way that keeps older children out of care.  Research shows that older entrants to the care system do not have their life chances enhanced by coming into care.  The Adolescent Support Unit is the mainstay of our focus on reducing older entrants to the care system.  It provides an out-reach, in-reach and weekend respite residential care service. The service is available to families with children aged 10 to 16 years.  The Adolescent Support Unit aims to prevent young people becoming accommodated and also to prevent placements from breaking down.

Improving the quality of support provided to care leavers as they make the transition to adulthood is also a Government priority.

Evidence of What Works

Gilligan  identified that children in the care system are likely to be more resilient to adverse circumstances if they have the following:
• Supportive relationships with at least one adult;
• Supportive relationships with siblings and grandparents;
• A committed adult other than a parent who takes a strong interest in the young person and serves as a long-term mentor and role model;
• A capacity to develop and reflect on a coherent story about what has happened and is happening to them;
• Talents and interests;
• Positive experiences in school;
• Positive friendships;
• A capacity to think ahead and plan in their lives.
Ultimately, partner agencies in Bolton work hard in their corporate parenting role to ensure that the outcomes and life chances of young people admitted to care are better than they would otherwise have been.  National  and local analysis of data relating to care leavers demonstrates that the experiences of these young people whilst in care impact on later outcomes:
• More than half the children in children’s homes nationally and almost two thirds in Bolton leave care before they turn 18 years of age, compared with around a third of children in foster care;
• Young people on care orders are more likely to leave care at aged 18 than those who are voluntarily accommodated;
• Destinations of care leavers aged 16 and over vary according to their age; 16 year olds are more likely to return home to their parents whereas those aged 18 and over are more likely to move into independent living or adult social service care;
• There has been a steady rise in the number of former care leavers aged 19 in the last decade. Local authorities are also in touch with a higher number and proportion of care leavers than in 2002;
• The older young people leave care the more likely they are to remain in education;
• There is a link between stable placements whilst in care and being in education training or employment after leaving care. Young people who were in foster placements immediately before leaving care are more likely to be in education, employment or training than those who were in residential accommodation or living independently;
• Care leavers who are (NEET) for reasons other than illness or disability are more likely to be living in unsuitable accommodation.
Further key sources for information on effective interventions and evidence-based policy are highlighted on Bolton’s Health Matters by clicking here.

Community Views and Priorities

The Children in Care Council, Voice 4U, continues to play a strong and vocal role in influencing both policy and the way that services for looked after children are delivered.   This has included expanding the range of settings where health assessments can be undertaken.

Some care leavers have had the opportunity to contribute to decisions about the future shape of central health services.  This has significantly improved accessibility and supported a notable reduction in the local rate of teenage pregnancies.

Equality Impact Assessments

Equality Impact Assessment of the LAC strategy for Bolton noted that the Looked After Cohort is regularly monitored on ethnicity and age to ensure that we can feel confident that all sectors of the population are able to access this provision should it be needed.  Information about the age, and ethnicity profile of looked after children in Bolton is regularly considered by the Department’s SSMT and, where inequality of access is identified, strategies will be developed to address this.

Recommendations for Further Needs Assessment Work

• The impact of previous neglect, emotional harm and abuse on the health and wellbeing of Looked After Children – this is a CQC recommendation.
• Substance Misuse among LAC and Care Leavers – this is a CQC recommendation.
• Explore the feasibility of giving Voice4U a direct role in future Needs Assessments.

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