Terry Philpot is a
Writer on Social Care...
The often indifferent health care offered to looked-after children and young people is one of the less remarked upon scandals that beset them.
Not only does it tend to get a lower priority than educational achievement but even the young people themselves rank housing, relationships and employment as more important to their health than health-related matters such as eating habits, smoking or access to the NHS (Saunders and Broad, 1997).
Some young people's attitudes are perhaps summed up by the young person who said: 'Having to take your clothes off for a strange doctor, when you don't feel ill is yet one more abuse of (sic) the system' (Mather and Batty, 2000).
Consumer resistance or professional neglect, the fact is that these children and young people get a raw health deal. Studies such as as those outlined by Daniel et al (2002) have shown that only 10% were registered with a GP, that there is poor take-up of immunisation and child health surveillance, and that looked-after children fared far worse than children living with their families when it came to routine dental care and immunisation.
Children in care also suffer unrecognised or neglected chronic health problems (Williams et al, 2001).
Perceptions of health promotion
One key to this is how health promotion is perceived: is this through a 'medical' or by an assessment that looks at lifestyle, as well as immediate health matters? If the latter, what are the skills needed to offer such an assessment service?
Department of Health guidance (DH, 2002) saw a central place for health assessment rather than medical examination, moving away from what Hill and her colleagues (2002) call 'a clinical diagnostic model to a more flexible and holistic approach, where physical examination is discretionary' (see Policy box and box on page 27).
The designated nurse
Part of this new health assessment approach is the concept of the designated nurse, which is symptomatic of an enhanced role for health professionals other than doctors.
The Children Act regulations, which accompany the guidance, allow nurses, under the supervision of a doctor, to undertake review health assessments.
This reflects wider shifts in practice going hand in hand with new emphases on primary care nursing and health visiting, and universal screening for all children giving way to a focus on children who are vulnerable and disadvantaged.
Initiatives such as Sure Start and the dismantling of divisions between social services and health have jumbled up old hierarchies and made elastic once-settled boundaries.
One result is a new breed of specialist nurses working with children and young people in care, of whom there are thought to be 90 in England and Wales.
One project reported by Hill et al (2002) was in Southampton where initial assessments are carried out by doctors. There was an analysis of files to look at the range of children's health problems and the efficiency of the health care planning process in order that two independent nurses could make a judgement about which professional skills could most appropriately meet children's problems. It showed that health concerns were more likely to be presented at the follow-up review. There was agreement that in the majority of cases (30 out of 46 children's records), nurse-led reviews would have been most appropriate. While there was disagreement about three cases, nurse advice on lifestyle matters would have added quality to the assessments.
A project in Cardiff referred to by Hill et al (2002) offered nurse-led holistic health assessments to children in residential care and those with foster carers of very difficult children. It demonstrated positive improvements in all areas assessed after the project's inception.
BAAF Adoption and Fostering's medical group is revising its family placement health assessment forms to allow nurses and health visitors to do health checks rather than paediatricians.
But this is not an either-or situation. As Kathy Dunnett, designated nurse for looked-after children, Welwyn and Hertford Primary Care Trust, says: 'We are not saying that one is better than the other. Nurses do have a real role to play but I don't think that there is a right way or a wrong way. What is needed is a choice to meet these young people's health-care needs.'
Hill et al (2002) come to the same conclusion: 'It would be na[ip6]ve to assume that one professional could address (the variety of health needs and the range of skills required), not least because of the age spectrum of the children and young people involved.'
Problems with the new approach
But while the good news is that nurses' enhanced role is proving beneficial to children in care, working arrangements across the country are haphazard. Some authorities have not implemented the guidance, and some nurses have permanent posts, while others are dependent on money from initiatives such as Quality Protects, which may dry up.
The new guidance offered no strategic vision of how services should be provided and delivered so local policy may create national unevenness.
Catherine Hill, a consultant community paediatrician, designated doctor for looked-after children and senior lecturer in child health, University of Southampton, thinks that there is 'potential' for a more uniform system but that there was a 'lost opportunity' when the guidance was being developed. But, she suggests, there could be progress by strategic health authorities looking at coherence between primary health trusts and local authorities.
Guidance need not be rigid but could offer 'suggestions about structure, minimum standards as to who does what', without allowing for the laissez-faire approach which exists now.
Another way forward could be through the coming National Service Framework on children in special circumstances. However, this may well only state generalised principles rather than prescribe structures. It is also possible that the subject could be but a small part of the NSF and so could be lost or marginalised.
Growing acceptance of nurse role
Nurses are treated as professionals with their own skills - the time of being seen as handmaidens of the medical profession is long gone. Indeed, Vanessa Wright, nurse consultant for looked after children, South Downs Health Trust (see case study), says: 'My experience of medical colleagues is that they are happy that nurses have this role (in health assessment).
'The majority think that it is more appropriate that a nurse should have led on the assessment because of the skills which nurses bring to this; the time they have to do it; and because the diagnostic skills of a doctor are not needed here as this is very much about health promotion for these children.'
But the diverse environments in which specialist nurses with children in care work can make it difficult for them to make their full contribution. Many of the nurses were professionally isolated - a third not working within a multidisciplinary team (Hill et al, 2002). Teams varied in makeup - colleagues might be social workers or paediatricians, psychologists or other health workers. Nurses working alone in a local authority found it most difficult to shift entrenched practice.
Analysis also suggests that local authorities are less likely to commit to long-term funding than health.
As one graduate nurse with 25 years' experience said, when asked by the researchers about the continued funding of her post: 'I have to prove my worth to social services.'
- Terry Philpot is Editor, with Anthony Douglas, of the book Adoption: Changing families, changing times (Routledge, 2002)
Author's contact details
Promoting the health of looked after children
Key points in Department of Health policy
Promoting the Health of Looked After Children (DH, 2002) outlined a framework for the delivery of services from health agencies and social services to children and young people in the care system.
- A health assessment must be undertaken as soon as practicable after a child starts to be looked after, once available health information has been collated
- The assessment should include physical and mental health and health promotion
- The first assessment should be undertaken by a suitably qualified medical practitioner, and may include a physical examination
- A written report of the assessment and a health plan is to be prepared for each child
- The frequency of subsequent health reviews for children aged between two and five should be once every six months and once a year for those over five
- Health reviews should be undertaken by whoever is deemed most appropriate. This might be a registered nurse or midwife under the supervision of a registered medical practitioner
- Notifications are required to both the primary care trust from the areas the child is leaving and the area to which they are moving.
Source: DH, 2002.
Principles of good health care for looked-after children
- Health assessments and health plans should promote the current and future health of the child or young person and not focus solely on detecting ill-health. Issues covered should include developmental health and emotional well-being
- The individual child or young person should be at the centre of the process of health assessment, planning, intervention and review
- They should be given the opportunity at all stages to express their wishes and concerns and these should be listened to
- Health professionals should conduct health assessments in a way that enables and empowers children and young people to take appropriate responsibility for their own health
- Assessments and services should be sensitive to age, gender, disability, race, culture and language. They should be non-discriminatory and promote equality of access to services
- Where possible and appropriate, the child or young person's birth parents should be involved
- The child or young person's informed consent to all health care and treatment should be actively sought and recorded
- Assessments should be conducted within a standardised and systematic framework.
Source: DH, 2002
CASE STUDY: A CONSULTANT NURSE FOR LOOKED AFTER CHILDREN
Vanessa Wright, Consultant Nurse, describes her experiences
I took up the post of nurse consultant for looked after children in October 2000, at South Downs Health Trust in East Sussex. The need for a specialist health professional to work with looked-after children was identified by the lead consultant community paediatrician, who is also the medical adviser for fostering and adoption and clinical director for child health.
The preparation of a service development bid coincided with the introduction of nurse consultants to the national nursing structure (DH, 1999) and led to funding approval for the post by partners in the local health economy. Brighton and Hove has 469 looked-after children aged 0-17, higher than any other unitary authority and higher per capita than the average for England and Wales. (CSCI, 2004). About 60 are looked after primarily because of a disabling condition requiring regular respite care, the rest because of adverse family circumstances, including abusive or neglectful parenting. A few are unaccompanied asylum-seeking or refugee children.
My main role is to effect improvement in the health of this vulnerable population and I have a central role in co-ordinating health assessments and health care. An agreed notification system with social services ensures that I am told about every child entering the care system as soon as possible, often within 24 hours. I then begin gathering information about the health and social circumstances of each child and this supports the decision about which professional is best placed to carry out the initial health assessment. I see most children over the age of three years but refer to an appropriate paediatrician if a medical assessment is necessary. Many children have suffered neglect and/or abuse and they present with a wide range of physical and emotional/mental health needs, often accompanied by developmental or educational delay.
When arranging a health assessment I negotiate on behalf of each child to ensure the best venue, day and time, and about who should be there. Birth parents are usually invited unless there is a serious risk to the child, carers or professionals. I make referrals to various statutory and voluntary services, many of which now identify looked-after children as a priority, and I have strong links with child and adolescent mental health, dentistry and sexual health services, among others.
Various initiatives have been developed to cater for the health needs of different age groups, such as the appointment of a part-time nurse - funded by the local authority - with sexual health and counselling skills to work with the young people aged 16-21 years in the leaving care team. This group has high rates of teenage pregnancy and many have difficulties accessing health services.
Looked-after children require regular health reviews. In collaboration with service managers we have developed a new service, using school nurses and health visitors, who are skilled at delivering a child-centred and flexible model of care based on health promotion principles. We developed a notification protocol with the local authority, a training programme and new forms for the assessments and plans. Early indications are that this is resulting in a much improved service for the children and young people.
Working across professional and agency boundaries is a key part of this work. In Brighton and Hove, for example we have many babies born to substance-misusing parents, and some of these children become looked after very early in life. Carers often need extra guidance and support to understand medication regimens, symptom recognition and the complex medical and social issues.
In some areas, the health service has been slow to take up the challenges of this work. Therefore sharing practice is particularly important in the national arena. This is facilitated by membership of the health advisory group for the British Association for Adoption and Fostering and of the Community Practitioners' and Health Visitors' Association special interest group for looked-after children.
Working with looked-after children can be difficult and emotionally taxing, and good support and supervision are essential. As a nurse consultant, I am fortunate to have links with senior managers and practitioners in health and social care, and this enables me to exercise influence on strategic and practice-level developments, while maintaining my clinical role. Brighton and Hove has a tradition of close working partnerships between agencies, and is now a pilot children's trust with a children's commissioner in post.
Vanessa Wright, RGN, RHV, Consultant Nurse for Looked After Children, South Downs Health Trust, Brighton, East Sussex
Commission for Social Care Inspection. (2004)Inspection of Children's Services. London: CSCI.
Department of Health. (1999)Making A Difference. London: DH.
Daniel, S., Heelas, A., Hill, C., Smith, S. (2002)The health needs of young people leaving care. In: Wheal, A. (ed.). The RHP Companion to Leaving Care. Lyme Regis: Russell House Publishing.
Department of Health. (2002)Promoting Health for Looked After Children: A guide to healthcare planning, assessment and monitoring. London: DH.
Hill, C., Wright, V., Samphreys, C. et al. (2002)The emerging role of the specialist nurse: Promoting the health of looked-after children. Adoption and Fostering 26: 4,.
Mather, M., Batty, D. (2000)Doctors for Children in Public Care. London: BAAF Adoption and Fostering.
Saunders, L., Broad, B. (1997)The Health Needs of Young People Leaving Care. Leicester: De Montfort University.
Williams, J., Jackson, S., Maddocks, A. et al. (2001)Case control study of the health of those looked after by local authorities. Archives of Diseases in Childhood: 85: 280-285.