Background

• A child is looked after by a local authority if he or she is provided with accommodation, for a continuous period of more than 24 hours, or is subject to a care order or placement order.¹ Unaccompanied asylum-seeking minors (under the age of 18 years) are also included in the looked after category. LAC are also commonly referred to as children in care.
• Children and young people are looked after due to a combination of reasons, many of which are related to social disadvantage. The most common reasons for being looked after include abuse and neglect, family dysfunction and families in acute stress.² Almost all of these events would fall under the umbrella of Adverse Childhood Experience (ACE).
• LAC are a vulnerable group and face a range of social and health inequalities. They have poorer educational outcomes; higher rates of special educational needs; higher rates of emotional and mental health problems; and when they leave care they experience higher rates of homelessness and unemployment when compared to their peers who are not looked after.³
• Poorer outcomes are associated with frequent changes of placement, or out-of-local-authority placements (where child or young people may be placed very far from their home), including increased anxiety,⁴ and increased risk of sexual exploitation and recruitment into “county lines” gang activity.⁵
• There are statutory duties to promote the health of all looked after children, including ensuring: up to date immunisations, regular dental reviews and a regular schedule of health assessments. These data are published annually.
• Data from Scotland are not directly comparable to the rest of the UK, as, unlike England, Wales or Northern Ireland, Scottish statistics also include children looked-after at home, with regular supervision from social care.

Key findings

• The rate of LAC remained generally stable from 2013 to 2016, but from 2017 rates have risen (except in Scotland, where rates have fallen year on year since 2012).
  • England: slight rise in rate of LAC from 60 per 10,000 people aged <18 years in 2014, to 65 in 2019.
  • Northern Ireland: Rise in rate of LAC from 66 per 10,000 people aged <18 years in 2014, to 71 in 2018.
  • Scotland: Falling rate of LAC from 151 per 10,000 people aged <18 years in 2014, to 144 in 2017.
  • Wales: Rise in rate of LAC from 91 per 10,000 people aged <18 years in 2014, to 102 in 2018.
• The number of asylum-seeking minors (under age of 18 years) in England peaked in 2016 and has since decreased.⁶
• In England, fewer LAC received their statutory health checks and vaccinations in 2018 than in 2016, but have begun to increase in 2019.
  • Immunisations: The percentage of LAC up to date with immunisations decreased from 87% in 2017 to 85% in 2018, increasing to 87% in 2019.
  • Dental review: The percentage of LAC up to date with regular dental review has remained stable at 84% from 2016 to 2018, but increased to 86% in 2019.
  • Annual health assessment: The percentage of LAC who have had their annual health assessments fell from 90% in 2016 to 88% in 2018, returning to 90% in 2019.

What does good look like?

Reverse the current deteriorating trend in statutory health care for LAC. The percentage of looked after children who are receiving the necessary statutory health assessments and immunisations is falling, which may reflect lack of capacity to meet rising the demand. This should be urgently addressed – statutory services, by their nature, must aspire to a 100% uptake.

Well-coordinated, targeted health services for LAC. Increases in provision should not be restricted to statutory services, but should address the variety of other health problems for which LAC are at higher risk. It is vital that there is a targeted, proactive and preventive approach to health provision for LAC which encompasses more than the statutory minimum e.g. in mental health and sexual health services. Joint working to provide well-coordinated services is particularly key for LAC who have been placed out of their local authority.

Transition into adulthood, and out of care. Care leavers are particularly vulnerable during the time when they leave care. Statutory health services stop at age 18, although social care support is provided up to the age of 21. Beyond that, there is significant variation between the countries regarding the support available to care leavers up to the age of 25 years. The gap between health and social care must be bridged with additional transition support and resources

Addressing the root causes. Addressing the social determinants of health which predispose children and young people to become looked after will help to prevent rising numbers of LAC in the future.

Better data. Official statistics on LAC are drawn almost exclusively from social care, and the quality of health data is variable. There are also very little routine data on health outcomes for those in care, much less for care leavers, other than the limited data on statutory processes. It is crucial that we have access to better healthcare data in order to better understand the impact on those in care, and to help monitor quality improvement efforts.

Policy recommendations

What can health professionals do about this?

• Child exploitation and contextual safeguarding. Keep in mind that LAC are vulnerable to exploitation, both by dint of the context and experiences which led to them being placed in care in the first instance, and some aspects of being in the care process itself.⁷ Health professionals may be a trusted confidante for those young people who may wish to disclose any information, and should remain vigilant in order to spot early signs.
• Right to a child advocate. Every looked after child has a right to an independent advocate. If you are working with a young person who is struggling to get their needs met or who feels they are not being listened to, help them access this independent support.⁸
• Signpost care leavers to ongoing support Care leavers now have access to a range of additional support up to 25, although the type of support and eligibility criteria vary across the UK. Make sure that LAC approaching their 18^th birthday know about this entitlement.
• Resources:
  • RCPCH has published an intercollegiate framework outlining expectations and guidance for the care of LAC.⁹
  • NICE public health guidance and quality standards for the care of LAC are also available.^{10, 11}

Contributing authors

• Dr Ronny Cheung, RCPCH State of Child Health Clinical Lead
• Rachael McKeown, RCPCH State of Child Health Project Manager
• Dr Rakhee Shah, RCPCH State of Child Health Clinical Advisor