MHW0043

Written evidence submitted by the NSPCC

Introduction

1.     The NSPCC is the leading children’s charity fighting to end child abuse in the UK and Channel Islands. We help children who have been abused to rebuild their lives, protect those at risk, and find the best ways of preventing abuse from ever happening. To achieve our vision we:

-          Create and deliver services for children which are innovative, distinctive, and demonstrate how to enhance child protection;

-          Provide advice and support to ensure that every child is listened to;

-          Campaign for changes to legislation, policy, and practice to ensure the best protection for children;

-          Inform and educate the public to change attitudes and behaviours.

2.     The Rees Centre, University of Oxford, undertakes research and evaluation to improve the outcomes and life chances of children and young people in foster care.[1] We review existing international research and conduct new projects that address the gaps in the existing literature. Foster carers, and young people who have experienced care, are valuable members of our research teams. The Rees Centre is the Evaluation Coordinator for the DfE’s £100m Children’s Social Care Innovation Programme.

3.     The NSPCC has extensive experience working with young people in care and developing innovative programmes to support them, including services such as Face to Face.[2] In July 2015, the NSPCC launched Achieving Emotional Wellbeing in Looked After Children: A Whole System Approach.[3] This report, which drew on new research from the Rees centre, offers a comprehensive evidence base for our recommendations; demonstrates the challenges involved in meeting looked-after children’s emotional and mental health needs; and illustrates that poor outcomes for looked-after children are not inevitable.

Executive Summary

4.     The NSPCC believes that every child can recover from the trauma of abuse or neglect. It is a priority for us to ensure that all children who have experienced abuse and neglect receive the support they need to rebuild their lives. ChildLine receives 100 contacts each week from children experiencing mental health issues following abuse, and last year we also saw a 124% increase in the number of counselling sessions where young people spoke about issues accessing support services.[4] Recent NSPCC research also highlighted that 1/5 of children referred to specialist NHS mental health services are rejected for treatment.[5]

5.     The Government’s focus on children’s mental health is hugely welcome, yet we remain deeply concerned about the lack of support available to abused children. Despite commitments from Government to improve Child and Adolescent Mental Health Services (CAMHS), it is vital that resources are prioritised for the most vulnerable.

6.     The NSPCC and Rees Centre are encouraged by the decision to hold this inquiry and we are submitting joint evidence, having worked together to develop our evidence base. We are keen to share our learning with the Committee to support its vital work on looked-after children’s mental health and would welcome the opportunity to provide expert oral evidence to expand on this submission. We are also keen to ensure that the voices of children in care are placed at the heart of this inquiry, and we are delighted that young people involved in NSPCC services have been invited to give oral evidence.

7.     45% of looked-after children have a diagnosable mental health problem; they are four times more likely to have a disorder than their non-looked-after peers; 4 to 5 times more likely to attempt suicide; less likely to attain good results at school; and more likely to end up homeless. 6 out of 10 children in England first enter care due to abuse or severe neglect.[6] They are likely to have lived with trauma and difficulties ‘over and above’ those experienced by their peers; they may also experience unstable care journeys, which can exacerbate existing emotional difficulties.

8.     Improving the mental health and emotional wellbeing of looked-after children has been a longstanding priority for the NSPCC and we have a shared concern with the Rees Centre that immediate improvements must be made. Our research illustrates the dearth of mental health services to support children throughout their time in care, and that the health assessments children receive on entering, and throughout their time in care, are completely insufficient in meeting their mental health needs. Foster carers are also left without the proper support to help manage the emotional and behavioural problems presented by the children they care for.

9.     We believe that the mental health outcomes for children in care are unacceptable and the Government is failing to live up to its role as the corporate parent by failing to care for some of the most vulnerable members of our society.

10. Looked-after children are often left without proper emotional support until they reach a crisis point. In order to support this generation of children in care, the government must follow through on its commitment to parity of mental and physical health.

Key recommendations

• All children who enter care are entitled to a specialist assessment of their emotional and mental health needs.

• Looked-after children’s mental health and emotional wellbeing is proactively monitored and supported throughout their time in care to prevent more severe and long-lasting problems.

• Carers are fully supported to meet the emotional needs of children in their care and maintain the stability of their placements.

• Care leavers should be entitled to receive mental health support until the age of 25.

• Social care, health, and education services in each authority work together to jointly commission integrated services that fully support looked-after children’s emotional and mental health needs.

• Clinical Commissioning Groups’ Local Transformation Plans address how looked-after children’s mental health needs will be prioritised.

Is the guidance by the Department of Health and Education, published in March 2015, sufficient to ensure the mental health and wellbeing of looked-after children and care leavers?

Key recommendation

• All children who enter care are entitled to a specialist assessment of their emotional and mental health needs.

11. The 2015 guidance marked a positive step towards a greater emphasis on the mental health of looked-after children; the NSPCC/Rees Centre were pleased to note the parity of esteem for mental and physical health. We concur that equal importance should be placed on mental and physical needs of looked-after children.

12. However, while we welcome this guidance, it falls short of addressing the mental health needs of looked-after children. While it outlines that looked-after children should have a Strengths and Difficulties Questionnaire (SDQ) screening completed as part of their health assessment, we are concerned that this will be inadequate to ensure that their emotional and mental health needs are correctly identified at an early stage.[7] Looked-after children’s initial health assessments rarely include the involvement of a mental health professional, reducing the chances of identifying their mental health needs. Furthermore, there should be direct contact with the child and their carer to fully explore the child’s emotional and mental health needs.[8]

13. To ensure that parity is embedded in the support children receive at a local level, the NSPCC/Rees Centre recommend that children should be given a specialist mental health assessment when entering care. Their mental health and emotional wellbeing should be proactively monitored. If this monitoring identifies potential difficulties at a later stage, opportunities for further assessment of the child’s mental health should be made available. Not only would this reflect the approach taken to children’s physical health, which is assessed at least on an annual basis, it would also act as a preventative measure that would identify early signs of mental distress in a clinically susceptible population.

14. We would be happy to share our proposed amendments to the guidance, which re-orientates it from an explicit focus on physical health by incorporating explicit references to emotional wellbeing in order to ensure this is fully embedded. In addition to ensure children entering care receive a specialist assessment and their needs are monitored throughout their time in care, the guidance should also ensure that:

-          Where relevant, mental health professionals are consulted to inform the child’s care planning.

-          Children’s care plans are expanded to reflect the importance of safeguarding their emotional wellbeing; for instance, through re-naming it a ‘Health and Wellbeing Plan’. 

-          Explicit emphasis is placed on providing training, support and clinical consultation to foster carers to support improved quality and stability of children’s placements. This support should be identified through the child’s mental health assessment and detailed in their ‘Health and Wellbeing plan’.

-          Joint Strategic Needs Assessments (JSNAs) should include effective measurement and tracking of the emotional wellbeing of children in care to inform and improve the commissioning of services.[9]

To what extent are the aims articulated in the guidance being implemented at a local level?

Key Recommendation

• Looked after children remain disadvantaged, despite new guidance; this would be mitigated by more forceful language and a statutory requirement for regular mental health assessments.

15. Although the guidance states that the mental and physical health of looked-after children should be treated equally, yet unequal access to mental health services remain. Parity between looked after children’s physical and mental health requires a more targeted system of support. Mental health assessments, and the proper treatment to facilitate early intervention, will stem the downward spiral that, all too often, occurs in children’s emotional wellbeing when they enter care.

16. Case studies in the NSPCC’s Achieving Emotional Wellbeing report illustrate that, although the guidance recommends equal mental health provision for all children (irrespective of their movement between local authorities or the length of time that a placement lasts), children in the care system are often disadvantaged for the following reasons:

-          A high turnover of children’s social workers means that referrals are not followed through.

-          Foster carers have a pivotal role in identifying children’s needs and pushing for treatment; without a mental health assessment, access to support will often depend on the level of awareness and willingness to advocate by an individual foster carer.

-          CAMHS refuse to work with children who are not in stable placements, affecting the most vulnerable children in care. 

-          Logistical considerations can result in children in out-of-authority placements struggling to access mental health services.

-          Despite clear statutory guidance that movement between authorities should not affect access to mental health support, in reality, payment negotiations between commissioners and service providers can result in long delays.[10]

17. To address the barriers to support faced by children placed outside their local area, we recommend that NHS England set a national tariff for looked-after children’s mental health assessments, following the example already set for initial health assessments.[11] They should also increase the accountability of local providers by requiring that they make a decision within four weeks about the therapeutic services they can offer a looked-after child. Recommendations regarding strategic planning for CAMHS should be implemented at a local level. Despite the existence of wellbeing measurement in public health benchmarks, many local authorities do not include it in their Joint Strategic Needs Assessments (JSNAs), leaving many unprepared to handle the deep reservoir of need for mental health support from the looked-after community. Therefore, the NSPCC/Rees Centre recommend that local authorities are required to include a measurement of the wellbeing of looked-after children within their JSNAs and that this requirement is regularly inspected.

How might the extent and quality of mental health and wellbeing services provided for looked-after children and care leavers improve, including the training and support for carers and social workers?

Key Recommendation

• Children who have experienced abuse or neglect, such as those in care, should be prioritised by CAMHS, and foster carers should be given greater support to manage the complex needs of the children in their care.

18. Improved mental health and wellbeing should be achievable for any child in care, but services need to respond to the greater prevalence of mental health problems in looked-after children. We strongly advise that NHS England should require CCGs’ Local Transformation Plans to address the mental health needs of looked-after children as a specific vulnerable group.[12]

19. Existing services fail to meet the needs of the 45% of looked-after children who have a clinically diagnosable mental health condition.[13] The NSPCC’s Achieving Emotional Wellbeing report demonstrated that an inappropriately high threshold for accessing CAMHS can result in children, and their foster carers, being left to cope until a crisis point is reached. For instance, one foster carer explained that:

“We tried from day one to get some support for him […] We went to CAMHS and they saw us but they didn’t do anything with him. […] Then when we called notice all the stops were suddenly pulled out.”[14]

20. Similarly, the report noted instances where support was delayed until more severe symptoms presented, sometimes resulting in harm to the self or other individuals. Waiting until more serious problems present can put children’s placements at risk and result in long-lasting mental health problems that, all too often, have lethal consequences.[15] 

21. If children do access services, they may have specific problems that CAHMS are unprepared to treat; often this arises when children have experienced sexual abuse, or children who display harmful sexual behaviour.[16]

22. Alongside mental health assessments, the NSPCC/Rees Centre recommend four steps to improve support for foster carers, which, in turn, would improve the wellbeing of looked-after children:

-          Recognising the crucial role that foster carers play, by improving the status of fostering through high quality training and recognising the complexities of caring for children who have experienced abuse or neglect.

-          Foster carers stress that training should be practical, enabling them to respond quickly, effectively, and compassionately to the children’s potentially challenging behaviours.

-          Foster carers should have regular access to clinical consultations.

-          Matching children with the right foster family can ensure a stable and successful placement.[17]

23. Measures should be implemented at every level to ensure that looked-after children’s needs are addressed in a comprehensive manner. A 2014 Rees Centre report noted that not all foster carer training programmes show positive results. Therefore, it is important “to ensure that effective ones are used and that carers are supported to make the most of them.”[18] Effective training would ensure that looked-after children are surrounded by a network of individuals who cushion some of the difficulties that they face in care.[19]

Is there sufficient coordination between relevant elements of the education system, the care system, and the health system to support mental health and wellbeing, and how might this be improved?  

Key Recommendation

• Social care, health, and education services in each authority work together to jointly commission integrated services that fully support looked-after children’s emotional and mental health needs.

24. A child’s journey through the care system should be at the foundation of all policy; children come into regular contact with an array of institutions, which offers an excellent opportunity to support this vulnerable group. However, effective support will only develop if institutions operate in a co-ordinated manner. 

25. One area where there is a paucity of co-ordination, is the period of transition – either because one has reached 18 or because one is returning home. Failed family reunification illustrates the problems that a lack of co-ordination can cause; 2/3 of children who return home experience further abuse, and end up returning to care because the existing problems were not addressed.[20] This results in children oscillating between living with family and foster carers, which, unsurprisingly, has a negative impact on children’s wellbeing. Therefore, the NSPCC/Rees Centre recommend that the decision to return children to the family home is only taken when there is confidence (amongst all parties) that the initial problems have been addressed and sufficient on-going support will be provided; allowing parents, and child, to thrive together. Improved communication between social work, health, and education are vital if all those responsible for the care of children are to be able to make an informed decision about the capacity of the parent and the support in place.

What contribution can schools make in supporting the mental health and wellbeing of looked-after children alongside services such as CAMHS?

Key Recommendation

• Schools must be better prepared to respond to the complex needs of looked-after children, with careful attention paid to their emotional wellbeing and mental health.

26. Schools are in a unique position to support looked-after children; with so many changes occurring in their life, schools can provide stable social networks. Children’s friends are often likely to attend the same school and their teachers are well placed to notice changes in their behaviour and to provide emotional support.

27. Looked-after children’s educational attainment is known to be poorer than their peers.[21] Research conducted by the Rees Centre and the University of Bristol examined factors that affected looked-after children’s educational attainment.[22] This research found that:

-          Children who have been in care for over a year perform better suggesting that care can be a supportive factor in children’s educational progress.[23]

-          Children who first enter care after age 11 are more likely to make poorer progress.

-          A higher score on the SDQ predicts poorer GCSE results.[24]

28. Some young people interviewed in this study described school as a ‘haven’ away from their chaotic home lives, and noted that individual teachers were key providers of support over many years. However, some respondents felt that school staff and social workers need to be better trained to ensure that the child’s needs are addressed. Teachers also reported being insufficiently prepared in attachment to work with young people who had experienced trauma or unmet attachment needs.[25] Moreover, transition between schools can cause looked-after children significant problems;[26] and even when expected, this change can be difficult to manage.[27] A survey of Virtual Schools has revealed examples of promising practice to address this, such as the use of transition mentors.[28] Therefore, the NSPCC/Rees Centre recommend:

-          Schools have access to robust information on supporting the emotional wellbeing of looked-after children on their virtual school rolls, and are empowered to spend the Pupil Premium Plus to address mental health needs.

-          Promoting understanding of how attachment and trauma impacts on the educational outcomes of looked-after children.

-          Extending effective partnership and multi-agency working.

-          Extending the Virtual School services which support children’s emotional wellbeing, through transition mentoring.

-          Increased opportunities for Virtual Schools to work with the child’s professional network (particularly foster carers).

How can young people, and their carers, be more involved in designing mental health and wellbeing services for looked-after children, including when making the transition to adult services?

Children are the experts on the care system and their experiences should drive innovation in mental health and wellbeing services at every stage.

29. Both the NSPCC’s and Rees Centre’s recent reports have highlighted the crucial importance of ensuring that looked-after children have a voice in decisions about their own care and about the services that are offered to support them.[29] Young people told the NSPCC that while they would like to receive a service which is informal and flexible, and which allows them to build a trusting relationship with therapeutic staff, what they are in fact offered is too often overly formal. This can be daunting for many looked-after children and reduces their willingness to engage with mental health services; instead, support should be delivered in a way that feels light-hearted:

“You need to mask counselling in a way. You need to make the environment fun […]. It should be informal; you can talk about football.”

“It’s about how you address the child’s problem. You need to find out their interests, what they like doing.”

30. An evaluation of the NSPCC’s Face to Face service found that young people valued the flexible, child-led focus of the service, which allowed them to choose the time and location of sessions, as well as placing their desired outcomes at the centre of the service.[30] Children and young people that have experienced the care system are experts on their own experiences. Therefore, we particularly welcome the Committee’s invitation to the young people we work with to speak at parliament about their own perspectives on the system.

October 2015