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1 Introduction
In their recent report on the evidence base for promoting the health and wellbeing of looked after children and young people in England and Wales, Chambers and colleagues wrote that:
The physical and mental health of children in care is often very poor in comparison to that of their peers with higher levels of substance misuse (Department of Health 1997a), significantly higher rates of teenage pregnancy than for the non-care population (Corlyon and McGuire 1997; Brodie, Berridge and Beckett 1997; Biehal and others 1992 and 1995) and a much greater prevalence of mental health problems (Bamford and Wolkind 1988; McCann and others 1996; Buchanan 1999; Avcelus, Belerby and Vostanis 1999, Dimigen and others 1999, Richardson and Joughlin 2000).
(Chambers et al. 2003, p8)
This report aims to bring together the evidence from research and official statistics to test whether this statement is true for children and young people who are looked after and accommodated in Scotland. Broadly, these are children and young people living in foster care or residential units, though an increasing number are being placed with relatives or friends. They are usually placed there as a result of a voluntary agreement between the family and a local authority, by a supervision requirement from a children's hearing or following an emergency protection order. The report considers what research tells us about the health of children and young people in general in Scotland, and the looked after and accommodated population in particular.
Research from across the UK has been considered as many children and young people looked after and accommodated in Scotland share similar characteristics and experiences with their counterparts elsewhere in the UK. Distinctions have been made when discussing research from England, Wales and Scotland. It should be remembered that, in England and Wales, the term looked after children, for the most part, corresponds with children described in Scotland as looked after and accommodated. There are some differences, however; for example, a young person counts as looked after in England and Wales even when placed at home under a Care Order, while a child on home supervision in Scotland is looked after but not looked after and accommodated. This report will also consider the messages for policy and practice and identify if there are significant gaps in our knowledge.
Goals for a Healthy Scottish Nation
Article 24 of the United Nations Convention on the Rights of the Child (1989) states that:
State parties recognise the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health.
(United Nations)
Much of the literature on health discusses a medical model or 'absence of illness', but there has been a move more recently to a more holistic definition. This is embodied in the World Health Organisation's well-known definition of health as ' a state of complete, physical, social and mental wellbeing and not merely the absence of disease or infirmity'; in other words, health is about focussing on the prevention of disease and the promotion of healthy lifestyles, as well as managing and 'curing' illness.
The agenda for improving the health of the nation and, in particular, of looked after and accommodated cildren and young people, is shared by politicians and policymakers across the UK. In 1998, the House of Commons Select Committee reported on the health of looked after children and concluded that:
… the failure of local authorities to secure good health outcomes for the children and young people they look after is a failure of corporate parenting.
(House of Commons Select Committee, para. 265)
This combined with the findings of the independent inquiry led by Sir Donald Acheson in 1998 into the inequalities in health, raised the profile of the health needs of children and young people. In England and Wales, efforts to address this were promoted through the introduction of Quality Protects (1999) and Children First (2000) respectively. These initiatives aimed to improve the life chances of children in care. In 2002, the Department of Health published Promoting the Health Care of looked after children, which charged chief executives of primary care trusts with improving the health care of the most disadvantaged children. More recently, the Green Paper Every Child Matters (2003), identified health as a key area to which services must respond in an integrated way.
A similar drive to improve the health of the Scottish nation has been taken forward by the Scottish Executive. For Scotland's Children sets out a vision for all children and young people in Scotland by emphasising that all should have access, from birth, to the services and environments necessary to ensure they fulfil their potential. It is a vision that depends on an ability to take account of and respond to the whole child, including their health. Health policy documents such as the White Paper Towards a Healthier Scotland and Our National Health: A plan for action, a plan for change aimed to improve the health of children and young people and tackle inequalities in health provision, often through interventions early in life.
The government has priority objectives to reduce smoking, alcohol and drug misuse, dental decay among five-year-olds, and pregnancies among 13 to 15 year olds (Scottish Executive 1999). Choose Life (Scottish Executive 2002a) also set out the key targets for reducing the number of incidents of deliberate self-harm and suicides.
Health inequalities in general
Sir Donald Acheson (1999) identified trends in socio-economic determinants for health. Unemployment, poorer quality of housing or homelessness and lack of access to private means of transport were all associated with poorer health outcomes. Adults who had bought housing with the aid of a mortgage and had access to private transport tended to be more economically active, and in the socio-economic groups which enjoyed higher average disposable income, better health outcomes were found. Low income, deprivation and social exclusion are related to poorer mental, physical and emotional health and diet, as well as a low incidence of breastfeeding (Hill and Tisdall 1997; Acheson 1999; van Beinum, Martin and Bonnett in Scott and Ward (eds)).
The Acheson report also reported differences in health trends between different ethnic groups. People from black (Caribbean, African and other) and Indian communities have higher rates of limiting long standing illness than white people, but those of Pakistani or Bangladeshi origin have the highest rates. Furthermore, it reported excess mortality among men born on the Indian sub-continent and among men and women born in Africa, and both Scotland and Ireland (Acheson 1999).
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