CEC 36
Senedd Cymru | Welsh Parliament
Y Pwyllgor Plant, Pobl Ifanc ac Addysg | Children, Young People and Education Committee
Gwasanaethau i blant sydd wedi bod mewn gofal: archwilio diwygio radical | Services for care experienced children: exploring radical reform
Ymateb gan Iechyd Cyhoeddus Cymru | Evidence from Public Health Wales
1. Before care: Safely reducing the number of children in the care system
Please outline a maximum of three top priorities for radical reform of services for safely reducing the number of children in the care system:
Priority 1:
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Adopt a public health approach to reducing the number of children in the care system Introduction: Safely reducing the number of children in the care system is aligned with reducing health inequalities. The experience of living in poverty and deprivation has a negative impact on physical and mental health. For families living in poverty or experiencing economic shocks which are insufficiently mitigated against via welfare support, the risk of children being neglected, harmed or abused is increased.
The cost of living crisis, as well as the ‘triple challenge’ of COVID-19, Brexit and climate change, have significant implications for the health and well-being of people in Wales. In a health needs assessment carried out by the Wales Violence Prevention Unit, the detrimental impact that COVID-19 and its associated restrictions has had on children and young people’s experience of violence and adverse childhood experiences (ACEs) was highlighted. Many CYP have faced an increased exposure to violence, including domestic abuse and family violence, physical abuse, self-harm, sexual abuse and exploitation, and bullying and harassment online, particularly during lockdown restrictions. Furthermore, a worsening of mental health among CYP resulting in an increase in low self-esteem, loss of social skills and other mental health concerns. Such impacts on health and well-being extend throughout people’s lives and can transfer across generations. This creates a long-term challenge for systems and services in Wales.
(A Health Needs Assessment: The impact of COVID-19 on children and young people’s experiences of violence and adverse childhood experiences. Full-Report_The-impact-of-COVID-19-on-children-and-young-peoples-experiences-of-violence-and-adverse-childhood-experiences_2021-06-03-101247.pdf (violencepreventionwales.co.uk)) Like the pandemic, the cost-of-living crisis comes on the back of entrenched poverty in Wales and associated poor and unequal health outcomes and is a public health emergency. In 2020 nearly one in three children were living in poverty (31 per cent). The Children’s Commissioner for Wales has called for Welsh Government to set new targets to address child poverty highlighting the needs of ethnic minority and disabled children, who are particularly impacted.Low-income families are most at risk from the cost-of-living crisis which increases worry and stress. This leads to psychosocial problems in children and parents including an increased risk of domestic violence, deterioration in mental well-being and mental health and an increase in health harming behaviours such as alcohol and substance abuse and negative impacts on physical health.
Increasing the financial resilience of families and young people is the first priority in the face of child poverty. Welsh Governments’ Income Maximisation Action Plan 2020-21 had some success in addressing child poverty across four areas of action. These included promoting benefit take up, school costs including extending the provision of free school meals, transport costs for young people and extending financial advice services and temporary flexibilities to emergency support funds, in the wake of the pandemic. Welsh Government has increased financial support through the Pupil Development Grant, which aims to provide support for children in low-income households and looked after children with school related costs, as part of the cost-of-living support package in the budget in 2021/22 and 2022/23. Currently the Basic Income Pilot for Care Leavers is exploring whether a direct monthly payment, on top of other supports already in place for care leavers and any money earned through work, can help one of the groups most disadvantaged by poverty to improve their lives and longer-term prospects.
A public health approach to reducing the number of children in the care system requires a broad, evidence informed, system-wide response:
Reducing the number of children in the care system means acting simultaneously to address current outcomes for children, and long-term inequalities for children and families including: 1. Providing sufficient, targeted, accessible, non-stigmatising, system wide support to mitigate against the impact of child and family poverty and health inequalities.
2. Taking action on, and account of, the social, economic and environmental factors that influence healthy child development, physical and mental health and well-being (the wider determinants of health) and how they can interact with each other, and other factors such as discrimination, stigma and poor physical health, to have a cumulative, negative impact (intersectional inequalities). Universal services, including health and education, provide the first opportunity to identify children and families in challenging circumstances, or where there are issues of concern, and work with them, and others where necessary, to formulate the most appropriate mitigating action and support. Children’s relationships, circumstances and experiences shape their development as they grow towards adulthood, so equitable access to ongoing support is required. However, the period during pregnancy and the first two years, a period known as the First 10001 Days, is a particularly important stage of development. During this period, but also during the early years up to 7 years, adopting a public health approach to support the child and family can help establish good foundations for a child’s physical and mental health both in the short and long term Action to support parents in their parenting role is essential to give all children the best start in life. Ensuring effective support for parents requires an understanding of both the elements of parenting that positively impact on a child’s development and the mechanisms through which parents can most effectively be supported to thrive in their parenting role. Adopting a public health approach to supporting parents provides a route to understand the factors driving immediate outcomes as well as inequalities across the life course and also helps explain how these factors impact on children directly and indirectly through their impact on parents and parenting. Crucially it recognises and requires action on the wider structural and psychosocial factors that enable parents to thrive in their parenting role and illustrates how the unequal distribution of these factors drives inequalities in outcomes. A public health approach to supporting parenting helps to address an important mechanism by which disadvantage can be passed from one generation to the next and a route through which intergenerational cycles of disadvantage can be broken. (Public Health Wales 2022. Developing a Public Health Approach to Supporting Parents https://phw.nhs.wales/publications/publications1/developing-a-public-health-approach-to-supporting-parents-technical-report/) The time during pregnancy and up to a child’s second birthday, often referred to as the First 1000 Days, represents a critical period when attachments are formed with caregivers and children begin to explore and communicate with the world around them. It is during this time that we see the most rapid phase of brain growth and development and where the foundations for future health, wellbeing and prosperity are built. During the first 1000 days a child’s experiences and interactions with the environment are predominantly provided and mediated by their parents or caregiver. As a result, parents/caregivers are the primary influence on their child’s early exposures, experiences, and development. Confident, resilient, and positive parenting is associated with improved outcomes for children now and into their future. Health visiting and midwifery services, as the universal support services in the first 1000 days, are uniquely placed to systematically assess families’ needs and facilitate early access to a broad range of support. They provide all parents with holistic support informed by the systematic identification of need in the first 1000 days to enable effective early intervention through prompt access to additional support that is proportionate to family’s needs. Midwifery, health visiting and those working with families should be supported to understand and act on the psychosocial and structural factors that influence parent’s opportunity to thrive during pregnancy and in their parenting role. Parents report that they may not discuss concerns or disclose problems for fear of being judged and families have told us that a trusting relationship between parents and professionals is important. This takes time and continuity to develop, services need to be designed in ways that facilitate trusted relationships to develop. (Public Health Wales. (2017). The First 1000 Days Parental Insights report. Cardiff: Public Health Wales.)
Children and young people’s mental health and well-being. The mental health of the UK’s children and young people was deteriorating before the pandemic. In Wales the School Health Research Network Student Health and Wellbeing survey showed a decline in the mental health and well-being of 11–16-year-olds in Wales in 2021 compared to 2019 echoing other data evidencing the negative impact of the pandemic and associated restrictions on the mental wellbeing of children and young people. Children and young people from more socio-economically disadvantaged backgrounds are more at risk of deteriorating mental well-being than their peers. Recent data shows that 17.3% of children in Wales receiving care and support are reported with a mental ill health status. This includes those diagnosed by a medical professional, receiving or on a waiting list for CAMHS support, and those reporting symptoms yet to be diagnosed. Parental mental ill health was recorded as a parenting capacity factor present for 42% of children receiving care and support. A Mental Wellbeing Impact Assessment on impact of the COVID -19 pandemic on the mental health and well-being of children and young people aged 11-16 concluded with a list of actions encapsulating a public health approach to children and young people’s mental health: · Listen to young people and ensure that they have the opportunity to inform policy and recovery measures · Improve access to mental health and wellbeing support · Address long term impacts and inequalities in mental health and wellbeing · Enhance the protective factors for mental wellbeing · Strengthen action on mental health and wellbeing in education · Support parents and family relationships · Carefully consider the language used in communications and information provision · Use and access to digital tools and internet connectivity – aim for digital inclusion and availability of reliable information on the benefits and risks of internet use. · Communities, housing, and the built and natural environment – improving access to good housing, safe outdoor space, green space and play space. Increasing opportunities for community participation, resilience, and cohesion. (Public Health Wales. (2022). Protecting the mental wellbeing of our future generations: learning from COVID-19 for the long term A Mental Wellbeing Impact Assessment Approach. https://phw.nhs.wales/publications/publications1/protecting-the-mental-wellbeing-of-our-future-generations-learning-from-covid-19-for-the-long-term-executive-summary/) Equitable access to information and support for children, young people, and their families to address mental health and well-being and their underlying drivers including financial, housing, employment and access to health services is fundamental. Appling the principle of proportionate universalism (resourcing and delivering of universal services at a scale and intensity proportionate to the degree of need) to service support aims to build resilience, and address problems at the earliest opportunity to minimise inequalities in children and young people’s mental health and well-being. The Whole School Approach to Emotional and Mental Well-being (Education Wales, 2021) takes a proactive and preventative approach and aims to provide direction to address the emotional and mental well-being needs of all children and young people as part of school communities. It involves learners, parents and carers, staff and governors working together to improve wellbeing. Similarly, the Welsh Network of Healthy Schools Schemes embeds broader whole school approaches to health and wellbeing, including facilitating education and health partnerships and embedding core components of whole school approaches such as school leadership and pupil and community engagement which enhances school connectedness. As schools embed their whole school approach it is important that they understand the community that they serve. Schools are encouraged to identify the needs of specific groups of learners who may be at greater risk of experiencing poor mental health and well-being (which will include those in the care system, those living with parents/carers with a mental illness, those in households experiencing domestic violence, etc) and to use this information to inform appropriate early intervention. Schools also need to demonstrate how they proactively recognise signs of mental ill health and well-being problems and how they work with others to facilitate access to timely help and support. Delays in identifying and meeting emotional health and mental well-being needs can have far-reaching effects on all aspects of children and young people’s lives, including their chances of reaching their potential and leading happy and healthy lives as adults. Education settings can offer universal, targeted, and selected support. School relationships with multi-agency external professionals and support services are important to develop appropriate action plans and referrals as necessary. The CAMHS In-Reach programme provides school staff with access to specialist mental health staff who can advise/consult on individual learners and provide training, so they are better able to support learners who turn to them for help The NYTH/NEST Framework is a system-wide, community-based initiative developed to promote a ‘No Wrong Door’ approach to addressing the mental well-being of children and families in Wales. The NYTH/NEST Framework is a planning tool for Regional Partnership Boards that aims to ensure a 'whole system' approach for developing mental health, well-being and support services for babies, children, young people, parents, carers and their wider families across Wales. The central aim is for trusted adults closest to the child, in their family or school for example, to have easy access to as much information, advice and specialist support as they need to provide the first line of support for the child or young person. Thereafter a ‘No Wrong Door’ approach to accessing additional services or support to help improve the child’s wellbeing and mental health is available. The NEST Framework - NHS Wales Health Collaborative
The Wales Violence Prevention Unit has adopted a public health approach in piloting a place-based, whole system approach to violence prevention in South Wales. The approach is informed by research, evidence-based programmes and evaluation and incorporates work to address the following three key areas: · Youth violence is violence affecting children and young people up to age 25 and includes bullying, intimate partner violence, sexual violence and abuse, online abuse and violence, gang violence, knife and gun crime, exploitation, and modern slavery.
· Adverse childhood experiences are stressful experiences during childhood that directly harm the child, such as sexual and physical abuse, or affect the environment in which they live, such as domestic violence, the impact of which can continue to affect people as adults.
· Violence against women, domestic abuse and sexual violence are acts of violence or abuse disproportionately expressed towards women, though anyone can be a victim of these types of violence. The Public Health Institute, who provided an evaluation, report that; ‘Mobilising change across the whole system is an effective way of tacking complex public health issues, resulting in coordinated and collaborative approaches to bring about sustainable change.’ This includes the features described in the following table:
Of the above the features the ones that are viewed as key to a successful application of the approach are: · Developing relationships · Engaging stakeholders · Ensuring supportive leadership · Having a robust and sustainable approach The Public Health Institute evaluation concluded that ‘The VPU is influencing sustainable change by embedding a public health approach to violence prevention’. However, the work is currently focussed on South Wales, though elements of the approach have been taken up in other parts of Wales and does not benefit from long term funding. Sustainably funding the model to be delivered across Wales would facilitate the reach of the approach into all Welsh communities, children, and families. Wales Violence Prevention Unit (Public Health Wales. (2021). Wales Violence Prevention Unit: Whole Systems Evaluation Report - June 2021. Wales-Violence-Prevention-Unit_Whole-Systems-Evaluation-Report-2020-21.pdf (phwwhocc.co.uk)
Examples of levers and approaches to address the wider determinants of health and intersectional inequalities that underpin drivers of children coming into care. · Complying with the socioeconomic duty The socioeconomic duty is a duty under the Equality Act 2010 placed on a range of public bodies in Wales; ‘The Duty places a legal responsibility on bodies when they are taking strategic decisions to have due regard to the need to reduce the inequalities of outcome resulting from socio-economic disadvantage.’ Welsh Government. (2021). A More Equal Wales: The Socio-economic Duty Equality Act 2012. Statutory Guidance. WG42004 A More Equal Wales The Socio-economic Duty Equality Act 2010 (gov.wales) · Appling Health Impact Assessments under the Public Health (Wales) Act 2017 Health Impact Assessments (HIA) are ‘a systematic means of taking health into account as part of decision making and planning processes. They are a tool which can be used in any area of public, private or voluntary sector activity, and at both national and local levels’). HIAs can be carried out to inform and develop ‘policies, plans and programmes which have outcomes of national or major significance, or which have a significant effect at the local level on public health.’ Senedd Wales. (2017). Research briefing Public Health (Wales) Act 2017. 17-025-web-english.pdf (senedd.wales) |
Priority 2:
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Supporting actions to deliver the goal of a ‘Trauma – informed Wales’ and ensure its long-term sustainability. Since 2017 the ACE HUB Wales has been leading the way in raising awareness of adverse childhood experiences and developing research, training and tools to facilitate the goal of making Wales an ACE Aware Nation. The ACE HUB has collaborated with Traumatic Stress Wales, with the support of Welsh Government, to produce a Trauma-Informed Wales Framework to help people, organisations and systems to prevent adversity and trauma and facilitate the development of a whole systems approach to bring consistency and coherence of support to those that have experienced adversity and trauma. This includes a clear definition of ‘trauma-informed approach’:
A trauma informed approach is underpinned by five practice principles which are universal and informed by research evidence. They can be used to identify current trauma informed approaches and inform the improvement and development of others:
The trauma practice framework includes four levels of practice which describe different helping roles, rather than being aligned with a particular profession or setting. As the approach is person-centred an individual may need support at a number of levels at the same time. The four levels aim to ‘promote compassionate, empathic and supportive relationships, services and specific personalised and co-produced interventions. They enable self-awareness and self-determination in the individual and community cohesion. They recognise that an effective trauma-informed intervention often does not require formal treatment’.
Ensuring the long-term sustainability of this work, to achieve the goal of a Trauma-informed Wales across all people services, will contribute to the aim of safely reducing the number of children entering the care system. |
Priority 3:
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Provide sufficient, high quality, integrated early childhood education and care for all communities in Wales with aligned ‘family-orientated’ policies in education and the workplace. Early childhood education and care (ECEC)
The availability of sufficient, accessible good quality early years child-care and pre-school placements in all local communities plays an important role in providing a healthy start for infants and young children as well as facilitating learning and employment for parents and carers. Good quality ECEC has been found to be of particular value to children form disadvantaged backgrounds when accessed early and for a sustained period.
A “two generation” or family-oriented approach is recommended - Links with parental leave and breastfeeding policies are crucial. With childcare predominantly a task for female family members ECEC is key within family-friendly policies with the potential for a “triple dividend” of children’s positive development, women’s empowerment and economic growth.
(Public Health Wales. (2022). International Horizon Scanning and Learning Report: Early childhood education and care. International Horizon Scanning and Learning Report: Early childhood education and care - World Health Organization Collaborating Centre On Investment for Health and Well-being (phwwhocc.co.uk) |
2. In care: Quality services and support for children in care
Please outline a maximum of three top priorities for radical reform of services for children in care:
Priority 1:
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All services accessed by and offered to children in care should be trauma-informed. (see priority 2 in section 1 – Before care) |
Priority 2:
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Those responsible for the care and education of children in care should be supported to develop a shared understanding about the importance of promoting and protecting mental wellbeing.
(Public Health Wales Conceptual Framework for Mental Wellbeing Promoting individual and community wellbeing - Public Health Wales (nhs.wales) ) |
Priority 3:
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Those caring for children in care should be supported to understand the importance of the First 1000 Days They should be supported to develop and implement approaches that ensure babies in the care system benefit from responsive interaction, appropriate nutrition and care, a nurturing carer-child relationship, routines and positive boundaries and have opportunities to interact with the world, as well as being kept safe from harm. (Public Health Wales 2022. Developing a Public Health Approach to Supporting Parents https://phw.nhs.wales/publications/publications1/developing-a-public-health-approach-to-supporting-parents-technical-report/) |
3. After care: On-going support when young people leave care
Please outline a maximum of three top priorities for radical reform of the on-going support provided when young people leave care:
Priority 1:
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A paradigm shift is needed to empower those leaving care to lead the future design of services. Co-production is an underpinning principle of the Social Services and Well-being (Wales) Act 2014 and is central to policy and service re-design. Recent research carried out by PHW on care experienced individuals experience of homelessness found that there was a desire amongst research participants to improve the system they had experienced for the benefit of those coming behind them. · Engaging and elevating the voices of young people with lived experience is essential at all levels, not only in their own care but in all aspects of service design such as strategy, policy and practice. · Young people leaving care often want more control and a say in decision making that affects them directly. To have a voice, young people need access to good information, advocacy and advice so they can make informed decisions. · Valuing the experience and insight of care leavers in the design of services and policies will help those services and policies to be better focused on the needs and wants of the young people that use the service. (Public Health Wales. (2022). Preventing Homelessness in Care Experienced Individuals. Preventing homelessness in care experienced individuals - World Health Organization Collaborating Centre On Investment for Health and Well-being (phwwhocc.co.uk)) |
Priority 2:
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Increase and upskill the children and young people’s social care workforce A sufficient, skilled and stable workforce is key to providing the high quality, informed and collaborative approaches required to support care experienced people into independence. · Continuity of care and support means young people having social workers and personal advisors that can be relied upon to be consistently alongside young people as they move into independent living. This is fundamentally important as these young people will not share with their peers a stable and supportive family base, which can be relied upon to be there when the inevitable problems and challenges of the transition to independence arise. · Continuity of care and support, having time to establish relationships and work closely with young people as they leave care is important to facilitate the identification of difficulties at an early stage. This enables more effective and timely preventative action to be put in place, whether this be to do with housing, health, education, welfare or employment. (Public Health Wales. (2022). Preventing Homelessness in Care Experienced Individuals. Preventing homelessness in care experienced individuals - World Health Organization Collaborating Centre On Investment for Health and Well-being (phwwhocc.co.uk)) |
Priority 3:
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Care leavers should receive additional support to strengthen their social relationships and community connections
Care leavers should receive additional support during pregnancy and when they become parents so that healthy relationships can be established with their children to benefit both parents and infants. Care leavers could benefit from services that offer targeted support during pregnancy, the transition to parenthood and early years of their child’s life to help them to thrive in their parenting role. Research carried out in Cardiff University on the poor outcomes of parents in and leaving care has led to the production of a charter for corporate parents to help better support parents in and leaving care.
(Public Health Wales Conceptual Framework for Mental Wellbeing Promoting individual and community wellbeing - Public Health Wales (nhs.wales) ) (Public Health Wales. (2022). Preventing Homelessness in Care Experienced Individuals. Preventing homelessness in care experienced individuals - World Health Organization Collaborating Centre On Investment for Health and Well-being (phwwhocc.co.uk)) |
4. Anything else
Do you have anything else you would like to tell us?
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