Royal College of Paediatrics and Child Health (RCPCH) – Written evidence (PSC0019)

House of Lords Public Services Committee: Vulnerable children and public services

Written evidence submitted by the Royal College of Paediatrics and Child Health

Background

The Royal College of Paediatrics and Child Health (RCPCH) is responsible for training and examining paediatricians, setting professional standards and informing research and policy. RCPCH has over 19,000 members in the UK and internationally. We work to transform child health through knowledge, research and expertise, to improve the health and wellbeing of infants, children and young people across the world.

1. Paediatrician’s role with regard to child protection and safeguarding 

1.1 Child protection is everyone’s business

As child health professionals, child protection plays a role in everything we do. It is about protecting individual children identified as suffering, or likely to suffer, significant harm as a result of abuse or neglect.[1] We believe child protection is everyone’s business. Safeguarding is a broader issue regarding how we ensure children grow up in a safe environment. The RCPCH has a Child Protection Standing Committee.

1.2 Competencies and roles

To protect children and young people from harm, and help improve their wellbeing, all healthcare staff must have the competencies to recognise child maltreatment, opportunities to improve childhood wellbeing and to take effective action as appropriate to their role.

All staff who come into contact with children and young people have a responsibility to safeguard and promote their welfare and should know what to do if they have concerns about safeguarding and child protection issues. All NHS Trusts must have a named doctor and nurse for safeguarding, who will provide advice and expertise for fellow professionals and promote good practice within their organisation.[2]

An essential component of the RCPCH mission is to make safeguarding the health and wellbeing of infants, children and young people at the core of all we do. To support our members to do this, we have developed a safeguarding competencies framework specifically for paediatricians.

This is complementary to the full intercollegiate competency framework that is for all healthcare staff, ranging from non-clinical staff to experts.

Additionally, we have a Child Protection Portal, accessible to all our members, and others, that hosts a wide variety of resources about child protection, covering best practice and the latest evidence.

1.3 Systematic reviews

On the Child Protection Portal, there are a number of systematic reviews of evidence across a range of indicators associated with abuse or neglect. This helps inform clinical practice, child protection procedures and professional and expert opinion in the legal system.[3]

2. Defining vulnerable children

2.1. Children in the child protection system

This group includes those in Local Authority care, care leavers, on Child Protection/Child in Need Plans, and those who have Education, Health and Care Plans, and Statements of Special Educational Needs. They are already living in families identified as requiring additional support and are known to Local Authority services.

2.2 Children not known to services

Some children are vulnerable to abuse or neglect but not known to services. Risk factors for this include living in a household experiencing poverty, parental mental illness, parental substance misuse or living in a household where domestic abuse is happening.[4]

2.3 Children not known to services growing due to COVID-19

The on-going pandemic means that the group of children not known to services has likely increased. This is in part because of increased stress on families who have lacked their normal support mechanisms and because children and young people have had less opportunity to talk to or be noticed by trusted professionals because of the majority of children being out of school for a number of months and having less contact with their extended family and others. Schools play a big role in identifying child protection issues and where appropriate, making referrals to children’s social care. This will be further considered in section 5.

3. Health needs of vulnerable children

3.1 Children living in poverty

We know that vulnerable children have worse outcomes than their non-vulnerable peers. Whilst not all children living in poverty are vulnerable and not all vulnerable children are living in poverty, there is significant overlap. Children living in poverty are more likely to have the low birth weight, poor physical health like obesity and some chronic conditions and mental health problems.[5]

3.2 Looked After Children (LAC)

A Local Authority looks after a child if he or she is provided with accommodation, for a continuous period of more than 24 hours, or is subject to a care order or placement order. Unaccompanied asylum-seeking minors (under the age of 18 years) are also included in the looked after category. LAC are also commonly referred to as children in care. In England, fewer Looked After Children received their statutory health checks and vaccinations than their non-Looked After counterparts.[6]

3.3 Children in the child protection system

A child subject to a Child Protection Plan (CPP) or on the Child Protection Register (CPR) has been identified as being at risk of harm or experiencing harm. Between 2017 and 2018, the rate of children subject to a Child Protection Plan or Child Protection register increased from 24 per 10,000 to 45 per 10,000.[7] Children in the child protection system are more likely to experience a poorer physical and mental health.[8]

Neglect and abuse, (including physical, emotional or sexual abuse, and fabricated or induced illness), can have serious long-term effects on a child’s social, emotional and physical health and development, and educational outcomes. Children and young people who experience one form of abuse often experience other forms, and neglect is a key and recurring theme in serious case reviews.[9]

There is increasing evidence showing that Adverse Childhood Experiences (ACEs) have a negative impact on long-term health and wellbeing outcomes.[10]

3.5 Young carers

Young carers are children and young people under 18 years old who provide unpaid care to a family member who is disabled, physically or mentally ill, or misuses substances. They may care for siblings or other dependents, in the place of other members of their family who are unable to. Being an unpaid carer is associated with worse self-reported health, being up to seven times more likely to report not being in good health compared to those who don’t have unpaid caring responsibilities.[11]

3.6 Migrant children

There is evidence that the current NHS charging regime for migrants is leading to direct and indirect negative impacts on children and pregnant women.[12] Because of fears about charging, families may delay seeking medical attention when they need it, leading to exacerbation of health problems and a longer-term impact.[13] One example of this is lower immunisation uptake amongst migrant children compared to their non-migrant peers.[14]

3.7 Children in secure settings

There are about 1000 children and young people held in secure settings at any one time. They are vulnerable and often suffer poor physical and mental health.[15] In 2019, RCPCH published updated healthcare standards for children and young people in secure settings.

4. Service provision for vulnerable children

Vulnerable children use a wide range of services, including but not limited to children’s social care, CAMHS, youth centres, children’s centres such as Sure Start and elements of the Criminal Justice System.

4.1 Service provision in the last decade

There has been dramatically increased demand for children’s services in the last few years.[16] It’s estimated that the funding gap facing councils’ children’s services will reach £3 billion by 2025[17] – and this was calculated before COVID-19. This £3 billion includes £1.7 billion from the Early Intervention Grant, which used to fund services including Sure Start centres.[18]

Demand has also risen for CAMHS services – between 2013/14 and 2014/15 alone referral rates increased five times faster than the workforce.[19] Whilst the £1.7 billion of funding announced by the Government in summer 2020 for mental health support for children and young people is welcome, it comes on the back of number of consecutive years of cuts to the public health grant (which funds school nurses and some mental health services) that represents a cumulative reduction of £3 billion.[20]

The funding of youth services has also declined dramatically since 2010; a 70% cut in real terms.[21] Additionally, over 1000 services have been closed since 2009.[22]

4.2 Need to build strong, cross-sector services that respond to local need

Services for vulnerable children have overwhelmingly seen their funding reduce over the previous decade. Simultaneously, demand has been increasing. It is thought that the impact of COVID-19 will see demand further increase in the coming months and years. The UK Government should ensure Local Authorities have adequate resource to provide services to meet the local needs of the population they serve.

5. Impact of COVID-19

5.1 Impact of school closures to most students

For children and young people without a medical or known social vulnerability, not being at school could trigger a vulnerability because the loss of opportunities for school staff to identify concerns, and access initiatives to boost their wellbeing and the sources of support that have previously been available to them have been removed. This is exacerbated by the financial repercussions of the pandemic. One possibility is that increased numbers of children and young people with emotional health and wellbeing issues refuse to go back to school when they reopen, because of time away from a more social environment. This could become a child protection issue if parents are unable or unwilling to convince them to attend after a number of days or weeks.

5.2 Impact on children in the child protection system

Schools remained open to those identified as vulnerable, however we know that most of these children did not take up their places in either the first[23] or second period[24] of school closure.

5.3 Impact on LAC

The majority of initial and review health assessments for looked after children (LAC) are currently being performed remotely. This can be a less effective way of undertaking such checks because paediatricians may miss physical symptoms if they’re more difficult to identify, and young people may feel less comfortable sharing what can be sensitive information remotely. Looked After children are additionally most likely to have the increased health needs already identified for all children and young people. Similar processes are in place for adoption medical assessments and SEN health assessments. There has been increased risk of foster care placement breakdowns, and delays in moving young people in and out of semi-independent placements and changing foster placements. Care leavers and those in semi-independent placements have had to manage without as much support from social services.

5.3 Impact on Young Carers

A survey undertaken by the Carers Trust in July showed 40% of young carers say their mental health is worse since COVID-19.[25] 66% are feeling more stressed and 69% are feeling less connected to others. Many young carers have had to shield because the person they are caring for is Clinically Extremely Vulnerable (CEV).

6 Workforce redeployment during COVID-19

6.1 Redeployment of community paediatricians

During the first wave of the pandemic, a proportion of paediatricians working in the community were redeployed to support adult services. As of the first of May 2020, 21.1% of acute paediatric medical staff had been redeployed to acute adult services, and 13.2% of community career grade staff (plus 31% of community trainees) had been deployed to other areas of paediatric care.[26]

The redeployment of community paediatricians during the pandemic has particular relevance to this inquiry because these doctors' expertise is in working with vulnerable groups of children and their carers.  This group includes those with developmental disorders and disabilities, complex behavioural presentations, and those who are at risk of abuse or are being abused.[27] 

6.1 Redeployment of health visitors

Similarly, Health Visitors have a unique role in identifying child protection issues because they go in to family homes. During the first phase of the pandemic in 2020, 41% of health visitors said that members of their team had been redeployed.[28] RCPCH welcomed the letter from the Chief Nursing Officer Ruth May, the Chief Nurse at PHE Viv Bennett and Cllr Ian Hudspeth, the Chair of the Local Government Association’s Health and Wellbeing Board, published in October, which said Health Visitors should not be redeployed in the then-anticipated second wave of COVID-19.[29]

7. Capacity for catch-up post-pandemic

Due to redeployment last year, community paediatric teams were advised to prioritise a strategy to catch up on routine health appointments and the increased demand for mental health services.[30] 

In the context of the financial pressures facing Local Authorities – exacerbated by further demands on them in light of the impacts of the COVID-19 pandemic – it will be difficult to respond to the level of demand for services provided by Local Authorities.

As cited above, there are some children for whom the pandemic will have meant moving in to the vulnerable category, or the risk towards them has escalated as a result of the pandemic. Child related-incidents reported by councils have risen by more than a quarter since COVID-19 took hold. The number of serious incident notifications in England during the first half of the reporting year 2020/21 increased by 27% compared to the same period in the previous reporting year.[31]

8. Levelling up

8.1 Where do vulnerable children fit in to the levelling up agenda?

The Government’s flagship policy drive has to date, focused on infrastructure projects such as the Levelling Up Fund, rail electrification and ‘Treasury North.’ We believe that it’s impossible for the Government to achieve levelling up of the country if they look through only this lens. The delivery of public services is key to addressing inequalities in our society. We believe that if the Government focused on improving child health outcomes in the coming years, public service delivery would be improved, poverty will reduce, children’s life chances will improve and so too will the economic prosperity of the country.

8.2 Cross-government policymaking

RCPCH has been calling for a children and young people’s health and wellbeing strategy for a number of years. This would drive levelling up because it would ensure a ‘child health in all policies’ approach was taken across the departments of Whitehall, reducing the unintended consequences of policies that have negative impacts on child health. Recovery from the pandemic provides an opportunity for the Government, and wider society, to reconceive the basis on how policy is made in the future.

8.3 Calls to Government:

RCPCH believes there are five steps the Government should take that would reduce the number of vulnerable children in the UK, drive better child health outcomes and achieve levelling up.

• Use of NHS number as unique identifier – research demonstrates there’s a link between children’s health, education and social outcomes. Currently, the data collected on children is not routinely shared between different agencies. Having a unique, consistent identifier for children will allow professionals interacting with children to share information easily and better provide for their needs. Children repeatedly tell us that they don’t want to have to ‘tell their story twice’. For vulnerable children, these stories may well be upsetting to recount and they are more likely to be interacting with a number of agencies.[32]
• Scrap migrant health surcharge – as discussed in section 3.6, the migrant health surcharge deters families from seeking medical assistance when they need it. The Government should scrap it and conduct an impact assessment of the policy for the years it’s been in place.
• Independent commission into impact of COVID-19 on children and young people – whilst children and young people have been widely protected from the worst clinical impacts of COVID-19, its broader effects have disproportionately negatively impacted them. The Government should set up an independent commission into the impact of the current pandemic on children and young people to identify cross government and inter-agency approaches to delivering better services that help to address the myriad of needs across the full range of settings that care for children and young people.
• Provide sufficient funding for Local Authorities – Government must urgently increase funding to Local Authorities, commensurate to local population need. This must include restoring the £1 billion of real-terms cuts to the public health grant since 2015.[33]  Future investment in public health provision should increase at the same rate as NHS funding and be allocated based on population health needs.
• Children and young people’s health and wellbeing strategy – as discussed in section 8.2, the Government should introduce a children and young people’s health and wellbeing strategy to ensure a ‘child health in all policies’ approach to policymaking is embedded in its ways of working.
• Provide renewed investment, resourcing and ring-fenced funding of CAMHS services in England- funding provided should be reflective of local service demand, facilitate cross-agency working and be regularly reviewed. Funding for children and young people’s mental health services should grow faster than both overall NHS funding and total mental health spending.

March 2021