Abstract
Introduction
In accordance with the Care Planning, Placement and Case Review Regulations 2010 for England, Initial Health Assessments (IHAs) have been largely carried out in recent years by community paediatric services. Rapidly increasing numbers of children in the care system (nationally, 24% increase for 16+ since 2007) have strained existing services. It is widely recognised that those aged 16 or more (16+YP) provide particular challenges in Kent due to the large area covered by the Trust and high rates of non-attendance for their IHA. It was felt that a new service was needed to better support and meet the needs of this group.
These notes discuss how this new service is being developed, outline key messages from research and give examples of how a dedicated service can improve engagement and positive experience for looked after 16+YP.
Local context
Some areas of Kent are among the most deprived in England according to national markers. The population of children in care has increased by 25% since 2010, with numbers above that of other comparative regions (Department of Health, 2014). There are high numbers of unaccompanied asylum seeking children (UASC) and young people arriving in Kent – 649 in March 2013, with numbers predicted to rise (Kent County Council Sufficiency Strategy, 2013).
Rationale for the new role
Entry into care can be a protective factor for young people, many of whom go on to make a successful transition to adulthood. However, an unpredictable number still experience poor outcomes in comparison to the general population (Schofield, et al., 2012). For example, 7.3% of children in care come into contact with the youth justice system compared to 3% of all children and young people. Offending rates vary according to length of time spent in care and type of placement. Those who have been looked after for 12 to 18 months are more likely to offend than those who spend longer in care (Blade, et al., 2011). Working with young people in an inclusive, friendly way to develop goals or define their own outcomes can help promote a sense of what their future might hold and how to accomplish it (Parker, et al., 1991).
Guidance increasingly recognises the need to assess children and young people in a more holistic way (NICE, 2010) and the needs of 16+YP are not necessarily well served in a paediatric setting. It was felt that an experienced looked after children’s nurse with the appropriate range of skills and experience for this age group would be best placed to offer the new service. Although regulations require the first assessment, including a physical examination, to be undertaken by a registered medical practitioner, it could be argued that this would relate more to the younger child. The majority of 16+YP have had their long-term health needs identified already by universal or specialist services and physical examination may not be necessary. It is recognised that this may not be the case for UASC and since many have additional needs, they could require a different service. It was agreed that any young people seen by the Specialist Nurse Practitioner (SNP), with health concerns identified at IHA, would be referred to the GP, specialist doctor or community paediatrician.
The health concerns for looked after 16+YP are usually complex, incorporating physical, mental and sexual health issues. Often poor diet and risk-taking behaviours such as smoking, drinking or drug use are present or established before they enter the care system. It is widely recognised that exploration of existing issues, health promotion and preparation for independence need to be embedded in any service for this group. It was also felt that the role of the SNP should incorporate appropriate time, after the IHA, to follow up Health Action Plans and ensure that recommendations have been carried out.
Many looked after 16+YP find it hard to trust and engage with regular health services and may not be aware of what is available. They need signposting and support to access ‘one-stop shops’ and fast-track provision. Young people need professionals who are comfortable with them, able to talk to them in a language that they understand and who show they are listening when young people respond (Scottish Executive, 2000: 6). Key messages from NICE (2013) were about involving young people in services, supporting them with issues around personal identity and relationships, promoting independence and encouraging them to fulfil their potential and develop skills for adulthood. A report by the National Society for the Prevention of Cruelty to Children (NSPCC) (Taylor, et al., 2012) found that relationships for young people in care are often frail and disjointed, and highlights the significance that they place on having someone they can talk to who will ‘listen’ and can understand them. Young people require breathing space to describe their concerns and to feel that they have some control over their own perceived powerlessness (Taylor, et al., 2012).
Service objectives
The objectives were to:
deliver timely, holistic, young person-focused IHAs, taking into account the young person’s choice of venue, date and time; develop and deliver a wide range of support for general health issues, sexual health, risk-taking behaviours, independence skills, emotional health and well-being and signpost as required; offer support to other professionals; develop and maintain robust partnerships and links among doctors responsible for children in care, the Virtual School Kent (VSK) team and other relevant professionals.
Referral criteria
It was agreed that the SNP would accept referrals for IHA of newly looked after 16+YP, but excluding UASC in independent living where IHAs are commissioned separately. UASC aged 16 and over placed in foster care would be seen by an SNP; those with complex medical needs would be referred to community paediatricians.
Results
Following a two-week induction period the SNP commenced the role in November 2014. In the first month, of 28 requests received, nine appointments were offered and of those, seven attended. Due to some initial confusion regarding referral criteria, 19 inappropriate referrals were returned to the allocations team, including 14 UASC in independent lodgings and two with complex needs, already under the care of community paediatricians. The SNP phoned the carers of three young people who had been in care for two to four months and were refusing or cancelling appointments that had been set. These assessments were booked and seen within the following week. All three responded very well in spite of the perceived problems with engagement.
In the second month, 16 appointments were offered with 13 attending. There were no inappropriate referrals. Of the three not seen, one young person refused but engaged eventually and two were delayed due to age disputes.
In the third month (to current), a request was received to see a hard-to-reach young woman who had been in a psychiatric unit for one year and was now in a foster placement but did not respond well to any professionals. In spite of warnings from her social worker that she would not speak, she engaged very well and the home visit was successful.
Joint working
The SNP was asked to cover a GP-led service for UASC for one month due to a temporary breakdown in the service for this group. This was carried out with support from the nurse practitioner at the local surgery and gave the SNP valuable insight into the health and emotional needs of this group. The SNP was able to work closely with the social worker, sexual health outreach and interpreting service regarding two young people who had been the victims of serious sexual assault.
Supervision
The SNP meets weekly with the allocated Designated Doctor for children in care to quality assure, discuss issues and sign off Health Action Plans.
Feedback
Some very positive feedback from social workers has already been received, for example: In both cases we have worked on together, the young people – both victims of rape – have disclosed to you more details that will allow us to best support them. X felt safe enough to tell you information that was crucial in our risk assessment and X’s care plan and that X had not felt able to tell anyone else. It was your skills and experience with young people that gave X the opportunity to open up and meant that this opportunity was really capitalised on. Thank you for taking the time to keep me updated so that we could discuss and make the plans for urgent action, keeping the young person’s needs at the centre and not losing the trust that you gained. Y is a difficult young person to engage with but she said you were very nice and not too intrusive. She felt that you listened to her and discussed her health in general and not just her mental health. Y felt comfortable in your presence, which she rarely does with anyone she hasn’t met before. Z said she felt comfortable having the assessment at the placement address as she was really worried about attending a hospital but felt at ease throughout the whole health assessment process. I wish to thank you again for making what could have been a really difficult assessment a nice experience.
Challenges
The main challenges were:
missing health information on entry to care; difficulty negotiating services – delays in the age assessment of UASC meant delayed registration with a dental practitioner, who required NHS numbers before seeing this group; an interpreter not always being available when needed, again delaying IHAs; it being a new role, the triage process is needed for allocations; travelling across Kent to cover a large geographical area.
Summary
The SNP has found that having the ability to offer young people a choice of venue and flexibility of times for their IHA has already improved attendance and timescales. This new service is still evolving but feedback and data indicate that it has been well received by carers, social workers, interpreters, health professionals, and most importantly, the young people themselves, many of whom will come into care with complex issues around emotional and health and well-being. Their first impressions of the health service for children in care will stay with them for life and may shape their views of health as a whole, so it is important to get it right first time.