Chief Medical Officer for Wales Evidence Paper to the Children and Young People Committee
Children’s Health and Wellbeing
We must create conditions for the 962,000 children and young people of Wales to be happy, safe and well. There is clear evidence from Professor Marmot’s and other research to demonstrate the importance of early years’ intervention in tackling health inequalities and giving children the best start in life.
We must focus on supporting children living in all circumstances to enjoy healthy lives as well as getting the right support to children with long term conditions. The transition from child to adult services must also be a smooth one focussing on the individual. The approach must be based on policy integration throughout the life course, to give substance to the right of each individual child to the best health possible.
It is well understood the foundations for health and wellbeing start in the first few years of life as described in the Marmot[1], Field[2], and Allen[3] reports. Many of the government’s flagship policies focus on early intervention for example Flying Start, Families First and the Foundation Phase. The Child Poverty Strategy similarly identifies the early years as fundamental to children’s development. There is consensus that we can tackle inequality and improve children’s health and wellbeing by focussing on early years interventions. I will take an active role in building on the strong policy and core aims already in place.
Providing healthy environments and encouraging children to be active are vital to ensuring the best health outcomes for children. The 2011 Children and Young People’s Wellbeing Monitor for Wales gives a snapshot of the overall health of our children. Smoking, alcohol use and obesity are indicators of a nation’s future health and also health inequality markers. The 2011 Monitor indicated smoking among 15-year-olds remains more prevalent among girls but has continued to decline since its peak in the late 1990s among both sexes. Strong anti-smoking campaigns are already running and we are participating in the plain packaging consultation. We must also protect children from the dangers of second hand smoke and I will be monitoring the Fresh Start Wales campaign closely.
Data from the Heath Behaviour in School-Age Children[4] survey shows around 14 % of 13-year-olds (approximately one in seven girls and boys), and 32 % (one in three overall) of 15-yearold girls and boys reported drinking any alcoholic drink weekly. Whilst these figures represent a decline Wales remains in a group of countries internationally with the highest rates of teenage alcohol use. The Substance Misuse Strategy for Wales: Working Together to Reduce Harm 2008-18 sets out the action that Welsh Government and its partners is taking in relation to alcohol prevention, for example the Strengthening Families Programme 10-14 which is a substance misuse prevention intervention for children and their parents or carers. The forthcoming second stage delivery plan is currently being developed and it will contain a fresh focus on children and young people.
The Welsh Health Survey (2011) shows that around one third of children and over half of Welsh adults are overweight, that less than a third of adults and only 52% of children reported taking the recommended amount of daily exercise. We already have a number of initiatives in place, the Children’s Obesity Referral Programme, Welsh Network of Healthy School Schemes, annual health campaigns and this summer alone 8,500 families signed up to the Games for Life campaign which used the Olympics and Paralympics to encourage families to set plans to achieve their weekly targets for physical activity that will improve their health. We must continue to take coordinated action to tackle the complex area of child obesity. I have provided more detail on this subject below.
The health needs of the must vulnerable children must remain high in our priorities. Services for those with disabilities, long term health conditions, and in special circumstances have improved over recent years, demonstrated in the improvement recorded against National Service Framework key actions. We must seek continuous improvement in this area, particularly when children move towards adulthood, to ensure successful transition as service boundaries change.
The Welsh Government has firm foundations in place across all of these areas with a wide range of policies and actions already established. Ensuring children are happy, safe and well involves much more than health services. It is vital we continue to take a strategic approach to ensure that all government policy is coherent, coordinated, realistic, and most importantly promotes the rights of the child through demonstrating better life outcomes for the children of Wales, and tackling the inequalities which exist.
You asked me to provide information on specific areas and I have set out information on these below.
Health Inequalities among Children
The Welsh Government’s commitment to addressing child poverty is clearly laid out in the Child Poverty Strategy. Reduction of health inequalities is a key component of Together for Health. Together for Health requires each Health Board to set out and deliver targets to reduce health inequalities. The Welsh Government early years programmes, in particular Flying Start, again demonstrates the desire to reduce inequalities by targeting the most disadvantaged families for support. Much can be achieved through targeting programmes effectively.
The Children in Need census data shows that Children in Need and Looked After Children have significantly worse health outcomes than other children.Children in need are defined as those who receive social services from their local authorities, including children looked after by local authorities, and who had a case open for at least 3 months at the census date. For example the census shows that on average, 76% of all 4 year old Children in Need in 2010-2011 were fully immunised, compared with 81% of children not ‘in need’. We need to ensure our programs are targeted and include these children.
Child obesity is a marker of overall levels of child health and of inequality. There is clear evidence of a need to target resources to tackle child obesity. Approximately one in five 11, 13 and 15 year-olds in Wales is reported as being overweight or obese, the proportions being higher for boys than girls. Wales is in a cluster of countries towards the top of the international Health Behaviour in School aged Children study rankings, higher than Scotland and England. This is a position consistent to that found in 2001/02 and 2005/06 and therefore demonstrates a need for action. We are taking action to improve our information in monitoring of child obesity, the recently introduced Child Measurement Programme will be a key source of data in the future, using measured heights and weights in children in reception year (aged 4/5).
I am aware that a broad range of policies and initiatives are already in place. MEND – Mind, Exercise, Nutrition... Do It! – are currently contracted to deliver a children’s obesity referral programme across Wales. Over the next two years a minimum of 140 programmes will be delivered by MEND for a minimum of 1500 overweight or obese children and their families.
Change4Life provides a strong marketing campaign to help the people of Wales achieve and maintain a healthy body weight; to eat well, move more and live longer. The national Breastfeeding Programme, which includes UNICEF Baby Friendly Initiative, Breastfeeding Peer Support Groups and a Breastfeeding Welcome Scheme are in place as there is some evidence that babies who are not breastfed are more likely to become obese in later childhood. Healthy Start is a statutory UK wide scheme that provides a nutritional safety net to over 23,000 households in Wales. It is a means tested benefit scheme that provides eligible pregnant women and children (between one and four) with vouchers to spend on milk, infant formula and fresh or frozen fruit and vegetables. Further to this the Welsh Network of Healthy School Schemes are health and education partnerships which employ practitioners who work directly with schools to help implement a whole school approach to a range of health topics which include food and fitness. In addition The Minister for Housing, Regeneration and Heritage and the Minister for Education and Skills have co-opted Baroness Tanni Grey-Thompson to lead a small focussed Task and Finish Group to produce practical recommendations on what schools can do to increase levels of physical activity in children and young people.
The emotional wellbeing of children is as important as physical health. Young people who report low levels of satisfaction with life are less ‘healthy’ and more likely to be excluded from social activities and education. Wales now has in place a network of school-based counselling services throughout the country to promote mental wellbeing in schools. Together for Mental Health, launched this month, seeks to reduce the impact of mental health problems and illness on the Welsh economy and society. The new document and related Delivery Plan focuses on outcomes and sets out specific actions to improve resilience of children and young people.
Clearly a broad range of action is in place we need to ensure it is coordinated, measured and provides improved outcomes for children in all backgrounds.
Continuing Health Care and Transition to Adult Health Care
The Welsh Government will be issuing the Children and Young People’s Continuing Care Guidance in the next month. This will help Local Health Boards (LHBs), Local Authorities and their partners assess and implement bespoke packages of care for children and young people whose needs cannot be met by existing universal or specialist services alone. We will be ensuring the guidance is implemented effectively with a training program to support multiagency professionals.
The transition through adolescence is different for each young person and can be a difficult one. It can be especially distressing for a child to have the parameters of their world changed just because of a birthday particularly for those with continuing health needs who are often the most vulnerable and most reliant on combined health, social and educational services. I want to see better coordination of all services for children supported through transition. The guidance will support improvement, but we must ensure a coherent service with shared aims to support young people and young adults.
Implementation of the Children’s National Service Framework (NSF)
The NSF has 21 cross cutting standards and 203 specific and measurable key actions setting out the quality of services that children, young people and their families have a right to expect and receive. Good progress has been made in delivering the NSF over the 5 years to 2011, in particular in the areas of Maternity Services, Services for Disabled Children and Child and Adolescent Mental Health Services.147 of the 203 key actions (72%) have improved between 2006 and 2011, with 89 (44%) achieving the maximum score of 6, compared with 46 (23%) in 2006. 51 key actions remain unchanged, and 5 are worse, indicating the need for focus on service improvement in these areas.
After 7 years of the NSF, there have been significant shifts in the nature and emphasis of Welsh Government policy on children’s services for example there is now a separate delivery plan for Mental Health Services which includes Child and Adolescent Mental Health Services, the Families First and Flying Start Programs are being expanded and the development of a new approach to Additional Learning Needs is being established, and there is a separate Maternity Services Strategy. All this means the NSF no longer represents a single collective picture of current Welsh Government policy on services for children and young people. There is a need to review the NSF and develop a more outcome focused programme to ensure coordinated delivery of action on Children’s Health.
Timely Treatment for Children
The importance of children receiving a timely diagnosis and treatment is paramount.
We recognise there is more work to do here particularly with diagnosis of autism spectrum disorder (ASD). However we must recognise diagnosing ASD is complex, involving multi-agency, speciality assessments and this can take time.
Access to support should though not always be dependent on the completion of a formal diagnosis or assessment and we would expect professionals to ensure children and their families receive appropriate support at the right time.
The Welsh Government has continued to drive improvements in services and support at both the pre and post diagnosis stages. In partnership with the Wales Autism Research Centre the Welsh Government have secured grant funding from the Economic and Social Research Council to take forward work on children’s diagnosis. Nearly £200,000 including match funding to establish a network of expertise and mentoring and to facilitate changes to organisational systems supporting children’s diagnosis has been secured.
We have also supported Betsi Cadwaladr University Health Board to undertake a pilot project in North Wales aimed at developing a standardised approach to recording ASD diagnostic information. The Welsh Government is presently considering the findings of this pilot study.
In summary, progress is being made and outcomes are improving. We already have many policies and programs in place to improve the health and wellbeing of children in Wales. As social circumstances change we must respond to the evolving needs of children and their families, focusing on continuous improvement to achieve the best outcomes for children.
[1] ‘Fair Society Health Lives’ Professor Sir Michael Marmot 2008
[2] The Foundation Years: preventing poor children becoming poor adults Frank Field 2010
[3] Early Intervention: The Next Steps Graham Allen 2011
[4] Health Behaviour in School-aged Children (HBSC) study: international report from
the 2009/2010 survey. 2012. Copenhagen, World Health Organization Regional
Office for Europe.