Looked-after children (LAC) are one of society's most vulnerable groups. But the NHS has so far failed to give them a high priority.
These children have often been abused or neglected and moved from pillar to post. Some live at home with their parents under supervision and some with other relatives or with friends, a foster carer or a potential adopter, or they may be in a home.
They are likely to have emotional difficulties and avoid school, and may never have seen a dentist or optician. Rates of drinking, drug-taking, smoking and sex are high. One Scottish survey estimates that as many as 45% have mental health problems.
Last month, Scotland attempted to improve the lot of these children by becoming the first UK country to publish standards that LAC nurses should strive to meet (NT News, 16 September, p5).
The 'capability framework' was developed by NHS Education for Scotland and the Scottish Government with the LAC Scottish Nurse Forum, social workers, carers and looked-after children themselves.
It is hoped that its 116 'capabilities' and 'practice learning outcomes' will clarify the levels of skills that LAC nurses need, improve training, help address inequalities in care, and, of course, raise the standard of healthcare for the children.
Kathy Pickles, an LAC nurse for the Forth Valley who helped shape the framework as a member of the LAC Scottish Nurse Forum, says it clears up confusion about what LAC nurses do and should help improve the care they provide.
'This is about young people - they do deserve to have a specialist framework. They deserve to have a better quality of care and more consistent care,' she says.
'The biggest issue is they have never built trust and security in infancy. They don't learn to trust and control their emotions. I'm working with a 15-year-old who's got the cognitive ability of a six-year-old, because he was neglected as a baby,' she adds.
'We have to reach out to them. You might go out and see them in their foster placement, at school or in McDonald's. You might communicate with them by text message because this builds trust.'
Across the UK there are nearly 81,000 LAC aged under 18. Only 17% of them are in Scotland - the majority, nearly 75%, are in England but none of the UK's other countries is as yet following Scotland's example.
'They deserve to have a specailist framework to ensure better and more consistent care'
The Department of Health admits that it does not know how many LAC nurses there are in England because their job titles and roles vary. Scotland has managed to collect this information, even though the role is covered by 10 job titles. It has
37 LAC nurses, six of whom are dedicated to mental health.
The RCN wants the rest of the UK to follow Scotland's example and develop frameworks clarifying the role, remit and working arrangements of LAC nurses. It also wants standard templates for health assessments so that LAC nurses know what paperwork to expect when a child is transferred into their care.
Liz Allan, acting chairperson of the RCN's LAC nurses' special interest group, says LAC nurses need to have a distinct identity.
'In some areas, child protection and LAC services fall under the same person and are budgeted under safeguarding. Child protection is about following procedures in care,' says Ms Allan, a LAC nurse in East Kent. 'LAC nursing is not a role that can be subsumed into another post, such as child protection.'
The RCN is also pushing for LAC nurses to be employed by trusts rather than local councils. It wants the DH to use a forthcoming update of its 2002 guidance document Promoting the Health of Looked After Children to give PCTs and LAC nurses a statutory role in promoting children's health. The document, promised in the white paper Care Matters: Time for Change in June 2007, is expected to be published early next year.
'Employment through PCTs is probably better because you have access to supervision. It also gives more independence to LAC nurses as advocates for the health of looked-after children,' says Ms Allan.
Local councils are duty bound to ensure that designated or named LAC nurses give yearly health assessments, health planning and health promotion to looked-after children. But the NHS does not have such a duty. This has left some LAC nursing posts in a precarious position.
The multidisciplinary Children's Centre in Cardiff is an example. Initial funding of the LAC service at St David's Hospital has run out and money is being sought from NHS core services.
Senior nurse at the centre Nuala Mahon says funding is problematic because of the NHS' long budgeting cycles. This is despite guidance and regulations published by the Welsh Assembly last year.
Towards a Stable Life and a Brighter Future placed a duty on local health boards to appoint clinical nurse specialists under the Children Act 2004 to coordinate LAC healthcare plans and address the children's specific needs. It requires nurses to demonstrate skills and competencies and recommends that the responsible local council, local health board and NHS trust develop joint protocols on the nurses' roles and responsibilities. Even though it has its own regulations, the Welsh government does not know how many LAC nurses Wales has.
Northern Ireland is furthest behind. It has only three LAC nurses for its five health and social care trusts, serving nearly 2,400 looked-after children. Trusts have been told they must find their own funding for LAC nurses, which is one reason for the shortage. The Northern Health and Social Care Trust had to cancel a LAC nurse post because of a moratorium on recruitment.
Amber McCloughlin, a child-protection nurse specialist at the trust, says: 'We don't have named nurses or designated doctors of looked-after children. It's just people doing their daytime job and this is just an add-on. People are working in isolation. In Northern Ireland, trusts are going cap-in-hand to get mainstream money when they've identified a need. Even the statutory health assessments are being done by GPs, maybe by paediatricians.'
LAC nurses are specifically trained to do these assessments and are probably more cost-effective.
This inconsistent approach across the UK does not make the LAC nurse's job easy.
Under the white paper Care Matters, all looked-after children aged 4-16 must be screened for mental health problems. In Brighton, teachers and carers help LAC nurses build up a full picture of each child's well-being.
Vanessa Wright, nurse consultant for LAC for the multiprofessional Brighton and Hove Children and Young People's Trust, appreciates she is fortunate to be employed by an integrated trust that ensures she gets the funding she needs.
'I was able to go to the director of social care and negotiate with her for some funding for my team to carry out that work,' says Ms Wright. 'If we were in a completely separate organisation it would have been very difficult.'
She says a competency framework would be of tremendous help in improving services.
'The growth of LAC nursing has been organic, without a particular unified identity or framework,' she says. 'It's not so clear for employers what they should be looking for in a LAC nurse. A single competency framework could prove useful for people commissioning services and for people devising job descriptions.'
The Scottish capability framework
The framework can be used for self-assessment, personal development and developing teams. It covers five domains:
Each domain contains: