“Children and young people who grow up in care are up to four times more likely to suffer poor health 30 years later than those who grew up with their parents” (1)
In 2020/21 there were 80,850 children who were looked after, and 28,440 entered care in that same year (2). Children enter the care of the local authority for several reasons, but a constant is that a child experiences trauma due to being separated from their birth family and/or negative experiences. Children in care are not a homogenous group, with many experiencing additional difficulties due to their background or characteristics. Each year children leave care and a significant number experience longer term social and health exclusion. A young person raised in their parental family experience a gradual transition into adulthood, but for a young person leaving care there is often nowhere to return for support or guidance. They are excluded from the ongoing care of a family and abruptly become an adult (3).
Whilst not all children in care will have experienced maltreatment, the impact of being in care has lasting effects which can lead to ongoing trauma. Meltzer et al (4) propose that 45% of children in care have at least one psychiatric diagnosis, and this increases to 72% in residential care – compared to 10% in the general young person population. This has significant implications for the National Health Service (NHS) both in terms of worse health outcomes (1) but also how the NHS responds and understands these health needs. However, does the NHS recognise its role?
Implications for NHS services
The shocking reference at the start is from a 30-year longitudinal study published in 2020 which analysed the self-reported health status of care leavers between 1971 and 2011. The research identified that adults who had lived in residential care settings in childhood reported 3 to 4.1 times worse health than those in parental homes after 30 years (1).
There are currently over 80,000 children in care and each year children leave care which results in the number of adults who are care experienced increasing year on year. These adults are at greater need of health services but might not access or are denied due to waiting lists. The longer-term impact of care experienced affects health provision but also for the NHS as an employer. There are amazing examples where organisations are actively supporting recruitment for care leavers, but are we doing enough throughout a person’s career?
Care Leavers as a Health Inequality
The NHS Long Term Plan recognised the impact that “the most vulnerable children, who need extra help from the state to safeguard their wellbeing, do not reliably get the support or access to the services that their needs demand. This results in poorer health outcomes, particularly for care leavers.” (5)
COVID-19 has focussed attention on health inequalities and a key aim post pandemic is the reduction of these disparities. The national Healthcare Inequalities Improvement Programme (HiQiP) was established in 2021 to support the ambitions from the NHS Long Term Plan (5) and identified five priority actions which were included in the 2021/22 NHS operational plan (6) including the need to “accelerate preventative programmes that proactively engage those at greatest risk of poor health outcomes”.
Health inequalities is not a new problem, as outlined in the Marmot Review 2010 (7). The HiQiP outlines a targeted population approach, which is referred to as Core20PLUS5 (8). The Core20 includes the 20% most deprived based on the Index of Multiple Deprivation (IMD). Second, the PLUS which covers Integrated Care System (ICS) identified population groups whose health is disproportionally disadvantaged. Lastly, the 5 clinically determined risk groups – maternity, severe mental illness, chronic respiratory, early cancer, and hypertension case finding.
The 2022/23 NHS operational plan (9) reinforces the role the NHS must play in population health and prevention, and that the “ICSs will take a lead role in tackling health inequalities by building on the CORE20PLUS5 approach introduced in 2021/22”.
The Marmot Review in 2010 (7) identified six policy objectives to reduce heath inequalities, which included that a child deserves “the best start in life” and enabled to “maximise their capabilities and have control over their lives”. A child in care often does not receive this best start or realise their opportunities. Whilst the NHS Plan (5) includes reference to care leavers, in subsequent policy direction and operational planning guidance there is no mention of this vulnerable group. The importance of child and young people’s health as a foundation for later life is fundamental.
Transition
Currently children in care services do not routinely extend to care leavers, and this period of transition is a time of uncertainty and vulnerability. Health assessments cease at the age of 18 and there is no further specific follow up by health. This is a potential area for further review about what a care leaver at the age of 18 wants or needs to support this period of transition and to ensure that they are not lost between services.
Trust is key to support continuity of care, and the children in care team could ensure access to services continues and that specific health needs are met.
“We need support with the anxiety of leaving care and facing the world on our own” (10)
A young person from a parental home will continue to receive support and guidance about health, and for a care leaver the state was their corporate parent. The NHS should therefore play a stronger role in support to prevent ill health later.
Mental Health
The Care Leavers Association (CLA) was commissioned by the Department of Health in 2013 to undertake research into the health needs of care leavers and the report Caring for Better Health was published in 2017. The key findings from this report outline that a high number of care leavers experience low self-esteem, anxiety, depression, and isolation (10).
The transition from CAMHS to adult mental health services can result in delays to access services, due to a lack of a clear pathway. Young people often feel abandoned without the support from a parent to advocate and guide (11).
Improving Access to Psychological Therapies (IAPT) schemes provide talking therapies to help individuals overcome anxiety and depression and to find or stay in work. Feedback from care leavers is that they cannot access IAPT because of waiting lists or access criteria but they are also not receiving any support from adult mental health services (10).
There is increasing awareness of the need for trauma informed care in the NHS, which aims to understand the impact of previous trauma on the person and their health. It is important that this includes recognition of the trauma care leavers have experienced (3). It is through implementing this approach and including recognition of care leavers that professionals will be able to understand the difficulties individuals may present with and how to support them.
A care leaver may exhibit heightened responses to situations due to past trauma, and through a life course this impact can be more pronounced. This includes the transition to adulthood, but also at other significant events.
Enabling to thrive
So, why have I written this blog? Well, I am care experienced, and there is a growing body of NHS staff who are care experienced and are passionate about raising awareness as this topic isn’t discussed to the level it should be and have formed the NHS Care Experienced Peer Group.
An individual who is care experienced and supported can move from surviving to thriving. I have thrived due to a loving foster family from the age of 14, an amazing husband and incredible support from the NHS as an employer.
Care leavers have superpowers due to our experience which includes immense resilience, tenacity, loyalty, and passion to make a difference.
NHS England has recently signed up to the Care Leavers Covenant, to ensure improved access to a career. It is so much more as it will also increase awareness of the health needs of care leavers, and begin to reduce the significant health inequalities.
The NHS Care Experienced Peer Group was established in 2021 and welcomes care experienced colleagues and allies from across the NHS. It is a place to highlight and celebrate the successes of care leavers to inspire them to achieve their full potential. If you are interested, please look here.
Howard Pescott works in a full-time role as an Associate Director of Quality and Safety in Sussex Community NHS Foundation Trust. Twitter @HowardPescott
Howard is also supporting the development of the NHS Care Experienced Peer Group.
References
- Murray, E et al. Non-parental care in childhood and health up to 30 years later: ONS Longitudinal Study 1971-2011. European Journal of Public Health. 2020: 30: 6: 1121-1127.
- Children in Care. Public Health Profile. accessed 01.08.2022
- Sulimani-Aidan, Y et al. Psychological distress among care leavers during the transition to adulthood: Risk and protective factors throughout their life. Child and Family Social Work. 2022: 27: 324-339.
- J et al. The mental health of children and adolescents in Great Britain. ONS: 2000.
- The Long Term accessed 01.08.2022
- 2021/22 priorities and operational planning guidance: Implementation guidance. NHS 2021.
- Marmot, M. Fair Society, health lives: the Marmot Review: strategic review of health inequalities in England Post-2010. 2010.
- Core20PLUS5: An Approach to Reducing Health Inequalities. NHS 2021.
- 2022/23 priorities and operational planning guidance. NHS 2022.
- Caring for a better health: An investigation into the health needs of care leavers. The Care Leavers Association. 2017.
- Butterworth, S et al. Transitioning care-leavers with mental health needs: ‘they set you up to fail’! Child and Adolescent mental health. 2017: 22:3: 138-147.