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06 BASIC HEALTH AND WELFARE

Articles: 6, 18, 23-26, 26, 27

A) HEALTH AND HEALTH SERVICES

Article 24

335 The Executive is committed to improving the health and well-being of children and this is demonstrated in the policy document, Delivering for Health, which sets out the actions required to improve health services in Scotland. It has three major work-streams on tertiary paediatrics, child health and maternal health.

336 First and foremost, the rights and responsibilities to provide for their children's health and welfare rest with parents. But a range of services provided by the NHS, local authorities and voluntary and independent organisations, in health centres, nurseries, pre-schools and schools, family centres and in the community have a vital role in helping parents to ensure their child's healthy development and maximise their potential.

Access to health services

337 All health and mental health services are free at the point of access for all children in Scotland regardless of their age, gender, ethnic origin, religion or sexual orientation. Individually assessed needs will always determine the services provided, the location of provision and the attention to prevention and recovery. Children in rural areas are given the same priority as others though in all cases rural or urban there may be differences in provision and access determined by the local organisation of services. NHS Boards and partners have local flexibility to implement health policies and structure health services in order to meet local needs and circumstances provided the main objectives of national policy and direction are recognised.

Action Framework for Children and Young People's Health in Scotland

338The Action Framework ( www.scotland.gov.uk/Publications/2007/02/14154246/12) was commissioned by Ministers in June 2004 and developed by the Children and Young People's Health Support Group. It is primarily designed to capture in one document the key areas of activity relating to children's health in Scotland for the next 3-10 years and to provide a basis for taking forward work on key child health issues. The Action Framework was published in February 2007. It provides guidance on delivering measurable improvements in health outcomes and health services for children in Scotland and makes clear that the national health care policy context for children in Scotland is firmly rooted in the UNCRC.

339 The Action Framework distils this activity into actions and progress measures designed to support and inform the planning and prioritisation undertaken by providers and commissioners of healthcare, for example Health Boards, Regional Planning Groups and local authorities. It will provide a mechanism by which progress can be monitored over time and act as a major source of information for clinicians, the public and other stakeholders interested in the progressive improvement and development of children's health and health services in Scotland.

Health for All Children (Hall 4)

340 In 2003, the Royal College of Paediatrics and Child Health published the report of its most recent UK-wide review of child health screening and surveillance activity - the fourth edition of Health for All Children, commonly referred to as Hall 4. The Hall 4 review examined existing child health surveillance and screening activity, including the purpose, content and timing of interventions. The report sets out an evidence-based framework for intervention to assess, monitor and support children's health and development throughout childhood and adolescence, based on staged intervention and underpinned by strong health promotion activities.

341Hall 4 marks a shift away from a solely medical model of checking young children for abnormalities, towards a holistic approach, with an emphasis on health promotion, prevention and intervention for children at risk, whether for medical or social reasons. It recommends a reduced programme of universal child surveillance and screening to enable professionals to concentrate their efforts on activities for which there is good evidence of health benefit and to achieve more effective targeting of support for those most in need. The universal core programme of contact with families will form the basis of a holistic assessment and there will be an agreed plan with each family, to identify the nature of any additional support required.

342 The framework set out in Hall 4 is firmly rooted in the need for an integrated approach to the delivery of services and support for children and families, co-ordinated in the early years through health. The proposals highlight the need to work across professional boundaries, drawing more effectively on the range of regular contacts that children and families have with other professionals in childcare and education, supported by clear routes for liaison, consultation and referral to health professionals when there are concerns. Implementation of Hall 4 links with a range of other Scottish Executive policy developments, most notably Getting it right for every child.

343 The full impact of Hall 4 will not be seen for some years. A robust evaluation of the impact of the policy change on the health of pre-school age children in Scotland, and specifically on the level of inequalities in key health outcomes, will be conducted between 2007 and 2011.

Waiting times

344 One of NHSScotland's priorities is to reduce waiting times for all patients, including children. There are no waiting time targets specifically for children - waiting times targets apply to all patients. Significant progress has been made. In 2003, the national maximum waiting time for hospital inpatient and day case treatment was 12 months. This was reduced to 9 months on 31 December 2003 and to 6 months in 2005. A further target was set to reduce the maximum waiting time to 18 weeks by the end of 2007. NHSScotland delivered this new target on 31 December 2006 and are working to sustain this. Consequently, no child should now wait more than 18 weeks for routine inpatient and day case treatment.

345 A national maximum waiting time target has also been set for a first outpatient appointment. This is that from 31 December 2005, no patient will wait more than 26 weeks. This target will be reduced to 18 weeks from the end of 2007.

346 The tables below show the progress made in reducing waiting times since 2003 for hospital inpatient and day case treatment and since 2005 for first outpatients.

TABLE 28 Number of patients including children on the Inpatient and Day Case Waiting List with a Guarantee ¹ by length of wait

Source: ISD Scotland: SMR3
1 Patients with an Availability Status Code ( ASCs) are excluded from the national maximum waiting time guarantee. ASCs are applied when patients for example ask for their admission to be deferred for personal or social reasons or are medically unfit.

TABLE 29 Number of patients including children on the Outpatient Waiting List ¹ without an Availability Status Code2 by length of waiting

Source ISD Scotland: Outpatient Waiting List
1 Information on the number of patients waiting for a first outpatient appointment following referral by a General Medical/Dental Practitioner has only been collected since 30 September 2004.
2 Patients with an Availability Status Code are excluded from the national maximum waiting time standard. ASCs are applied when patients for example ask for their appointment to be deferred for personal or social reasons and where a patient did not attend their appointment.

Immunisation programmes

347 The UK, Scotland included, has one of the most successful Childhood Immunisation Programmes in the world. Vital protection has been provided for children in Scotland from serious infectious diseases. The Executive continues to encourage parents to immunise their children. It is the safest and most effective way of protecting all children, and the wider community, against the risks of serious infectious diseases.

348 Important changes to the Childhood Immunisation Programme were introduced in 2006, recommended by the Joint Committee on Vaccination and Immunisation:

• the introduction of a new vaccine to protect against pneumococcal infection;
• a pneumococcal vaccination catch-up programme;
• amending the MenC vaccination schedule to give two doses of vaccine in the first year of life, and a booster dose in the second year; and
• the addition of a booster dose of Hib vaccine in the second year of life.

349 To support the new changes to the childhood immunisation schedule, NHS Health Scotland has produced a range of information resources. New leaflets, and factsheets for parents and healthcare professionals were sent to GP practices, community pharmacists, health promotion units and NHS 24 call centres. These resources are for all those involved in advising about immunisation, including health visitors and practice nurses. There has also been a television and radio publicity campaign.

350 The Executive is aware of parental concerns about the combined measles, mumps and rubella ( MMR) vaccine, and is committed to continue working with health professionals to give parents the factual information they need to make an informed decision in favour of MMR. Expert advice from around the world clearly shows that the MMR vaccine remains the safest and most effective way to protect children from these very serious, and potentially fatal, diseases. Expert scientific committees, the Committee on Safety of Medicines and the joint Committee on Vaccination and Immunisation, keep research developments under review, and advise the Executive. The evidence is that MMR vaccine does not cause autism. There are no plans to change current immunisation policy on MMR.

TABLE 30 Annual primary immunisation uptake rates at 24 months, Scotland - year ending March

Source:
1. SIRS/ GIRS from March 2002 to September 2002. From December 2002 the SIRS and GIRS systems amalgamated into a Scottish system.
2. Form ISD(S)13 from March 1995 to December 2001. This form was an aggregated return and collected information on the immunisation status of resident children reaching their first and second birthdays in a given quarter.
3. Immunisation uptake rates are only updated for the most recent evaluation period based on the latest data extracts available. Information presented for previous evaluation cohorts is based on the data extracts available at that particular point in time.

Health services for minority groups

Article 2

351 NHSScotland aims to ensure that whatever the individual circumstances of people's lives, they have the right type of care to suit their individual needs. To support NHS Scotland achieve this, Fair for All initiatives have been established to consider the health needs and service experiences of communities across the 6 equality strands - age, disability, gender, race and ethnicity, religion/belief and sexual orientation. Support for Health Boards has included facilitating learning networks, production of guidance, providing research and information and developing targeted approaches to addressing the specific health concerns of their constituent communities.

352NHS Scotland's National Resource Centre for Ethnic Minority Health developed the initial Fair for All framework for the delivery of culturally competent services, which has since been developed across the other equality strands. In addition, the Scottish Refugee Integration Forum established a Health Subgroup which met during 2006 to develop a set of actions for the Executive to carry out to help ensure refugees and asylum seekers, including children can fully access health services.

353 The Subgroup agreed that much work was already being done, by the NHS, voluntary organisations and community workers, to help refugees and asylum seekers ensure their health needs are met. Current developments such as Community Health Partnerships and other national initiatives designed to meet the requirements of the Race Relations Amendment Act 2000 were also evolving and the full benefits of such schemes are yet to be felt. The Subgroup recognised that any actions should fit within the frameworks of existing work and refugee and asylum seekers needs should be embedded in any monitoring and reporting structures. These principles are also relevant for other equality groups.

Breastfeeding and maternal support

354 Paragraph 42 of the 2002 Concluding Observations recommended the promotion of breastfeeding. The Executive recognises the substantial contribution that breastfeeding makes to infant nutrition, growth and development and has supported breastfeeding over the last decade. There are some encouraging signs that breastfeeding initiation rates are increasing. A key step has been the introduction of the Breastfeeding etc. (Scotland) Act in 2005. The Act makes it an offence to prevent or stop anyone feeding a child in a public place - any person should be able to feed a child when required and in the most appropriate place for them, without the fear of interruption or criticism. To help publicise and support the Act, the Executive has produced Advice for Employers. It makes clear that the Act applies to all employers and employees in premises where the public have general access.

355 Support and encouragement for breastfeeding can be provided at many levels. For example: health promotion adverts at a national level; policies in maternity hospitals at NHS board level and primary care teams working with individual women and groups within the community. While these can support and encourage mothers to initiate and continue breastfeeding, there are a wide range of other factors that influence mothers. Maternal age and deprivation are known to be strongly associated with the likelihood of breastfeeding.

356 Provisional data for 2006 show that 44.2% of mothers were recorded as breastfeeding their babies at the health visitor's first visit (around 10 days) and 36.3% of mothers were recorded as breastfeeding their babies at 6-8 weeks. This compares with 45.1% and 37.2% respectively in 2005. However, breastfeeding rates have risen overall since 2001, when this information was first published for all ten participating NHS Boards. Babies in Lothian and Borders NHS Board areas are most likely to be breastfed; breastfeeding rates are lowest in Lanarkshire NHS Board area. Young mothers who smoke and live in the most deprived areas are the least likely to breastfeed their babies.

TABLE 31 Number and percentage recorded as breastfed at the 6-8 week review

Source: The Child Health Surveillance Programme - Pre-school ( CHSP- PS)
Notes: the 10 NHS Boards that now participate in the programme account for approximately 84% of the pre-school population. The Boards now involved are: Argyll & Clyde, Ayrshire & Arran, Borders, Dumfries & Galloway, Fife, Forth Valley, Greater Glasgow, Lanarkshire, Lothian and Tayside
"Breastfed" means exclusively breast fed or fed mixed breast and bottle
Missing or unknown data has been excluded|
P - provisional

357 There are a number of personal, social and cultural issues including deprivation and maternal age which may influence a new mother's decision as to whether or not she breastfeeds. The charts on the following page demonstrate the effects of these factors. They show breastfeeding rates calculated by maternal age group and deprivation for children who had received a first visit and a 6-8 week review and demonstrate that both maternal age and deprivation have an independent effect on breastfeeding. Breastfeeding rates are higher in the less deprived areas and within each deprivation quintile breastfeeding rates improve as maternal age increases. Older mothers are more likely to breastfeed than younger mothers, however the differences in breastfeeding rates above the 30-34 age group is less apparent.

CHART 1 Breastfeeding recorded at the first visit by maternal age and SIMD deprivation quartile

Source: CHSP- PSISD Scotland February 2007
1. Exclusively breast fed or fed mixed breast and bottle.
2. Figures relate to children born between 2001 and 2006.
p Data for 2006 are provisional.

CHART 2 Breastfeeding recorded at the 6-8 week review by maternal age and SIMD deprivation quartile

Source: CHSP- PSISD Scotland February 2007
1. Exclusively breast fed or fed mixed breast and bottle.
2. Figures relate to children born between 2001 and 2006.
p Data for 2006 are provisional.

358 The Executive is committed to supporting those interventions which evidence has shown have a positive effect on increasing breastfeeding rates among low-income groups. These include peer support programmes, ante and post-natal support groups and the targeted education of health professionals.

Low birthweight and malnutrition

Articles 24 and 26

359 Low birthweight is a strong predictor of neonatal and infant mortality and of poor outcomes in child health and, in particular, the development of cognitive skills. It is also related to illness in adult life, such as diabetes, stroke and lung disease. Health care professionals in Scotland provide a range of supports to parents and children to help address concerns about low birthweight, for example: good antenatal care; clear infant feeding guidelines and good advice for parents on feeding methods; supervision of babies, assessed and maintained by the midwife and then the health visitor; and a patient-centred method of care.

360 The table below demonstrates that despite this activity the proportion of low birthweight babies has remained fairly static in recent years. Much of this is explained by the increased survival rates of lighter babies due to improved technical advances.

TABLE 32 Number and proportion of low singleton births under 2500g: 1999-2005

Source: ISD Scotland SMR02

Confidential counselling and advice

Article 16

361 As a matter of course, health professionals provide confidential support, advice and treatment to children. Issues of confidentiality are included as part of the undergraduate training and ongoing Continuing Professional Development around sexual health services. Demonstrating knowledge of confidentiality has been included in professional standards such as those for nursing staff working in specialist or generic sexual health services. This is also addressed in inter-agency training on child protection issues. As part of ongoing implementation of the Executive's strategy Respect & Responsibility - Strategy and Action Plan for Improving Sexual Health in Scotland, we have asked that Sexual Health Lead Clinicians ensure that confidentiality is addressed. The results of the work commissioned by the Executive on Confidentiality for Disclosure of Underage Sexual health activity will reinforce this.

Healthcare data

TABLE 33 Infant and child mortality rates - Scotland

Source: General Register Office Scotland

TABLE 34 Rates of maternal mortality, including its main cause

Source: General Register Office Scotland

TABLE 35 Proportion of births occurring in hospitals - Scotland

Source: NHS: Information Services Division

TABLE 36 HIV-1 infected children: cumulative to 31 March 2006 - Scotland

Source: Health Protection Scotland

B) MENTAL HEALTH AND WELL-BEING

Mental health services

362 The 2002 Concluding Observations recommended that the UK take all necessary measures to strengthen its mental health and counselling services for children. Improving population mental health and well-being is a key part of the Executive's health improvement strategy. The Mental Health of Children and Young People's Framework for Promotion, Prevention and Care (2005) ( www.scotland.gov.uk/Publications/2005/10/2191333/13337); Delivering for Mental Health (2006) (www.scotland.gov.uk/Publications/2006/11/30164829/0); and the Action Framework for Children and Young People's Health in Scotland provide a combined and current focus for improving child and adolescent mental health services ( CAMHS) in Scotland.

363 The Framework emphasises the need to provide more consistent support for children and to ensure high quality care and support for those children who are experiencing mental health problems. Delivering for Mental Health, sets the agenda to 2010 for further improvement to mental health services in Scotland overall, and specifically includes commitments for delivery by 2009, which support the aims and ambitions of the Framework.

364 The Executive is committed to implementing the Framework by 2015 and Delivering for Mental Health is intended to support the implementation process with milestones that track progress to 2010. The milestones relate to the planning and development process and the need to increase the CAMHS workforce as detailed in the 2007 Action Framework.

365Delivering for Mental Health identifies two key delivery milestones on named mental health link persons being available in every school; and training for those working with or caring for looked after and accommodated children - both by end 2008. A third commitment to reduce the number of admissions of children to adult beds by 50% by 2009 is also included.

366 The Mental Health (Care and Treatment) (Scotland) Act 2003, which came into force from October 2005 placed new duties on NHS Boards to provide services and accommodation appropriate to the needs of children who require psychiatric inpatient treatment. This followed detailed advice on the future of psychiatric inpatient services for children and young people in Scotland was published in Psychiatric Inpatient Services for Children and Young People: A Way Forward (2004).

367 Progress against all commitments and milestones will be monitored through existing performance management processes and the Delivering for Mental Health implementation and performance arrangements.

368 According to a pilot study commissioned by the Edinburgh Young Carers Project in 2004, Y oung Carers Health and Well Being, young carers are twice as likely as their peers to suffer emotional stress or mental health issues source. The Executive is undertaking a wide-range of work to provide appropriate help and support for young carers and their families.

369 Progress against all commitments and milestones will be monitored through existing performance management processes and the Delivering for Mental Health implementation and performance arrangements.

370 To help address workforce issues relating to children and young people's mental health, the Executive commissioned a report: Getting the Right Workforce, Getting the Workforce Right: A Strategic Review of the Child and Adolescent Mental Health Workforce, published in December 2005. It identified 3 key areas for workforce development activity: building the mental health capacity of the network of children's services; addressing the workforce requirements of community based CAMHS; and building the workforce associated with in-patient and intensive CAMHS. The report recommended that a plan for phased investment in the workforce should be developed in conjunction with plans for implementation of the CAMHS Framework, with the aim of doubling the size of the NHS based CAMHS workforce by 2010. It considered the workforce implications of the Framework and produced a range of proposals about how these might be met; with the aim of developing workforce activity and doubling the size of the NHS based CAMHS workforce within 10 years. Recognising the importance of reliable and informative data to inform workforce planning and service developments, the Characteristics of the Specialist CAMHS Workforce report was published in 2006. This provides specific data about the CAMHS workforce in Scotland across a range of portfolios.

Counselling services

371Delivering for Mental Health contains a commitment to increase by 2010 the availability of evidence-based psychological therapies for all age groups in a range of settings and through a range of providers. Work continues in partnership with NHS Education Scotland to take this forward.

Prevention of suicide and self harm

Article 6

372 The Executive regards preventing suicide and reducing the rate of suicide in Scotland as an urgent public health issue. There are around 800 deaths by suicide or undetermined intent in Scotland every year.

373The Choose Life Strategy was launched in 2002. Its target is to reduce suicides across the population by 20% by 2013. Funding for Choose Life totals £8.6m total across 2006-08. Among the priority groups for suicide prevention action are children (especially looked after children) and young people (especially young men). Every local authority area in Scotland now has an identified local Choose Life coordinator to lead locally tailored action on suicide prevention.

374 The Choose Life National Implementation Support team in partnership with many other statutory and voluntary organisations have worked to support and strengthen accessibility to mental health and counselling services for children who self harm. This has largely occurred in two settings - schools and communities.

375 In schools a variety of initiatives across Scotland aim to engage pupils and staff in understanding and responding to self harm. For example, the Highland stigma and self harm play encourages pupil participation in terms of debating and responding to scenes which review the impact of stigma and self harm. It shows how to seek help if a child is worried about themselves or a friend. Prior to it being delivered in the school setting, staff are given information on self harm and sources of support available nationally or in their local area. It is aimed at S4, 5 and 6 pupils (15-18 years).

376 In East Renfrewshire, following a survey by a school's educational psychology team a service to support pupils who self harm was established. This provides support and structured linkage to services outwith the school. East Renfrewshire have since introduced a policy on preventing suicide and self harm in schools which ensures all staff are aware of the procedures to support pupils who may be self harming or at risk of suicide.

377 In communities, Choose Life have worked with a variety of national and local partners to increase their ability to recognise, respond to and support children who self harm or at risk of suicide. For example, funding support has been provided on a national basis to ChildLine and Samaritans to: increase the number of trained telephone, text and e-mail volunteers; train volunteers in suicide intervention skills; and expand their delivery of schools programmes aimed at developing emotional resilience of children, this includes, mental health and well-being, anti-bullying and suicide prevention.

378 An independent evaluation of the first phase of implementation of Choose Life was published in September 2006. Amongst its recommendations the evaluation said that there should be a strategic integration of prevention of self-harm into the work of Choose Life in phase 2 and that the Choose Life implementation team should provide guidance about how to identify and reach the subgroup of people whose self-harming behaviour puts them at high risk of future suicide - including consideration of how people who are admitted to hospital following an episode of self-harm are managed. Many of those treated in hospital will not represent a high suicide risk - and a small, but significant, minority of those who do not attend hospital will be high risk (and will go on to commit suicide). The Executive is broadly considering the practicalities of taking these recommendations forward.

Research on the causes and backgrounds of suicides

379 In 2004, the Executive launched a three stage process to ensure that suicide prevention policy is supported by a reliable, relevant and up-to-date evidence base. The first phase of this was a scoping study to establish the territory and focus for a series of research reviews to collate and co-ordinate the existing evidence base in suicide and suicide-related behaviour. The second phase comprised two major reviews: one focusing on the effectiveness of interventions to prevent suicide (report to be published in autumn 2007) and the second exploring the risk and protective factors for suicide and suicidal behaviour which is due for publication in spring 2008. In the third phase, research will be commissioned to fill gaps identified in the two reviews.

380 The Executive commissioned secondary analysis of General Register Office for Scotland statistics about suicide among those aged 15 and over in Scotland between 1989 and 2004, in order to examine temporal trends and risk factors at national and local levels. Over the period, male suicide rates increased by 22% and female suicide rates by 6%. Male rates were 4 times higher than female rates in the 15-34 age group. Male rates tended to decline with age (having peaked in the 25-34 age group), while female rates were lowest in the youngest and oldest age groups. The higher the level of socio-economic deprivation, the higher was the standardised Suicide Mortality Ratio. The suicide rate was significantly higher in the lowest social class than in any other social classes in all local areas of Scotland, irrespective of the degree of socio-economic deprivation in the area where people lived. ( Platt, Setal (2007)) The Epidemiology of Suicide in Scotland 1989-2004: an Examination of Temporal Trends and Risk Factors at National and Local Levels, Scottish Executive.)

381 The population suicide figures for Scotland since 2000 suggest there may be an emerging downward trend. It is however too early to tell if there is a significant longer term trend. In the period 1998-2000, the suicide rate among 10-24 year olds in the most deprived quintile was 14.45 per 100,000 - in 2003-05 it had reduced to 8.42 per 100,000. In the most affluent quintile the figure was 4.18 per 100,000 in 1998-2000, but this figure rose to 4.49 per 100,000 in 2003-05. The figures are small however and they fluctuate, therefore any trends derived from this data should be treated with caution.

382 To support innovative research work able to contribute to advancing the agenda of the National Programme for Improving Mental Health and Well-being, the Executive launched the Small Research Projects Initiative in 2004. Several of the projects funded to date focus on, or are relevant to children, including:

• a qualitative exploration of links between self-harm and suicide in children;
• an investigation of the role of school nurses in supporting mental health and well-being; and
• understanding stigma: children's experiences of mental health stigma.

TABLE 37 Number of deaths due to intentional self-harm and events of undetermined intent

Source: General Register Office Scotland

TABLE 37a Number of deaths due to intentional self-harm

Source: General Register Office Scotland

TABLE 37b Number of deaths due to events of undetermined intent

Source: General Register Office Scotland

HeadsUpScotland: National Project for Children and Young People's Mental Health

383 The philosophy for HeadsUpScotland is that good mental health underpins all activities that children engage in: learning, playing, interacting socially, communicating, and forming relationships. It works on mental health promotion for all; prevention of mental health difficulties for vulnerable groups such as children who are looked after and children of homeless families; and ensuring that children who are mentally ill not only have adequate services but also have their mental health improvement needs attended to. A key part of HeadsUpScotland's activity is to support the implementation of the 2005 Framework. As part of this, HeadsUpScotland has a participation project (led by Penumbra) to give a voice to children about mental health.

Scottish Health Promoting Schools Unit

384 The Scottish Health Promoting Schools Unit ( SHPSU) is a national joint project between health and education, which supports the Executive's commitment that every school in Scotland will become a health promoting school by 2007. This commitment has now been superceded by the Schools (Health Promotion and Nutrition) (Scotland) Act 2007. SHPSU which has a dedicated development officer for mental and emotional well-being supports a whole-school approach to promoting the physical, social, spiritual, mental and emotional well-being of all pupils and staff. The education sector has a vital role to play in promoting mental health awareness, emotional health and emotional resilience. SHPSU is providing information and guidance to schools on how to promote the mental health and well-being of pupils and staff; it also provides similar advice to parents and community groups.

see me…

385 The see me… campaign is Scotland's national campaign to eliminate the stigma and discrimination which can be associated with mental illness. The Executive funded campaign, launched in 2002, has undertaken a range of activities including general and targeted advertising. Targeted advertising has included two high-profile phases of campaign activity (in 2005 and 2006) specifically aimed at eliminating stigma and discrimination in children. see me…'s work is being evaluated independently, to report in early 2008.

Eating disorders

386 The Executive continues to work with NHS Boards, and their partners to ensure the best possible care, services, support and treatment for eating disorders. The Executive has published guidance on the best organisation of joint services for better supported and coordinated patient care and family involvement. NHS Quality Improvement Scotland has also published recommendations for healthcare professionals for the management and treatment of eating disorders in adults, adolescents and children.

Prevalence of mental health disorders

387Mental Health of Children and Young People in Great Britain 2004 presents the findings of a survey of the mental health of children aged 5-16 in Great Britain. The survey was jointly commissioned by the UK Department of Health and the Executive and contains considerable data on the prevalence of mental disorders in Scotland and describes the characteristics of children with emotional and conduct disorders living in Scotland. The Executive has funded a 12-month, a 24-month and a 3-year follow up to the study.

TABLE 38 Percentage of children with mental disorders in Scotland 1999 and 2004

Source: Office for National Statistics, The Mental Health of Children and Young People, Great Britain, 2004

TABLE 39 Age, sex and ethnicity of children with emotional or conduct disorder, 1999 and 2004 combined

Source: Office for National Statistics, The Mental Health of Children and Young People, Great Britain, 2004
*includes people of mixed black and white origin

TABLE 40 Family characteristics of children with emotional or conduct disorder, 1999 and 2004 combined

Source: Office for National Statistics, The Mental Health of Children and Young People, Great Britain, 2004

TABLE 41 Housing and income of families where children have emotional or conduct disorder, 1999 and 2004 combined

Source: Office for National Statistics, The Mental Health of Children and Young People, Great Britain, 2004

C) HEALTHY LIFESTYLES

Article 24

388 In Scottish schools the 5-14 National Guidelines on health education (published in 2000) encourage all local authorities to address all aspects of health education within a comprehensive programme of personal and social education. The guidelines provide a clear framework within which individual schools and teachers can develop programmes responding to the health education needs of children. The guidelines also provide schools with attainment targets for strands on physical, social and emotional health. The guidance is age graded and includes self care, personal hygiene and oral health. These guidelines will be reviewed as part of the Curriculum for Excellence programme of work, which includes Health & Well-Being as a cross-cutting curricular theme.

389 As discussed above, the Executive is committed to ensuring that all schools are health promoting by 2007. The Scottish Health Promoting School's Unit ( SHPSU) works to ensure that health education is integral to the curriculum and that school ethos, policies, services and extra-curricular activities foster mental, physical and social well-being and healthy development. SHPSU also works to provide strategic and practical support to partner organisations, councils, NHS health boards, Community Planning partnerships integration managers and other stakeholders as they work together to achieve the National Priorities in Education.

Nutrition and obesity

390 Tackling obesity requires action by government and its partners, but also requires individuals and families to take personal responsibility for their actions. Changing to a healthier lifestyle will not happen overnight, but the Executive has made a commitment to continuing action in the short and longer term, targeting specific groups where appropriate. The Executive is taking forward an integrated multi-sectoral implementation of a national physical activity strategy, Let's Make Scotland More Active, and the Scottish Diet Action Plan. The World Health Organization has strongly commended Scotland in adopting this preventive approach.

391 Increasing the uptake of physical activity is one of the major challenges in the Executive's drive to improve the health of the people of Scotland. Let's Make Scotland More Active was launched in February 2003. The Executive is tackling the problem of inactivity by supporting a range of initiatives addressing a wide variety of lifestyle changes that will enable children to get more active by doing everyday activities at home and at school as well as in the local environment. The Active Schools programme, introduced to encourage more participation in physical activity in primary and secondary schools, is one of the key initiatives designed to achieve the aims of the strategy. Other projects address activities ranging from play and dance, to walking and cycling to school.

392 The Executive has set a target for 80% of children to meet the minimum recommended levels of physical activity by 2022. The Scottish Health Survey 2003 reported that 74% of boys and 63% of girls achieved the minimum recommended level of activity. This is an increase from the 1998 survey which showed 72% of boys and 59% of girls were meeting the recommended levels. It is encouraging that things were moving in the right direction even before full implementation of initiatives to increase physical activity. If the trend from these two data points is continued, the target of 80% by 2022 will be met.

393 Changing children's dietary habits is also a challenge. Good nutrition in the early years is vital as children's early experiences of food plays an important part in shaping later eating habits. Nutritional guidance addressing food choices for children aged 1-5 in early education and childcare settings has been developed and made available to all providers. For school age children, a school meals programme, Hungry for Success, was launched in 2002. It set tough new standards for the provision of school meals including:

• new nutrient-defined standards for school meals and detailed mechanisms for monitoring them;
• larger portions of more nutritious food (as a consequence of the nutrient standards);
• fresh, chilled drinking water available free in school dining halls;
• introduction of measures to anonymise recipients of free school meals and raising awareness of the entitlement to free school meals to drive up take-up of free school meals by eligible families;
• active promotion and marketing of healthier options along with improved atmosphere and ambient facilities in dining halls to drive up take-up;
• connecting school meals with the curriculum as a key aspect of health education and health promotion within the development of health promoting schools; and
• product specifications developed by the Food Standards Agency Scotland to set levels for fat, salt and sugar in processed food to be used in Scottish schools.

394 Habits beyond the dining hall are also being tackled with schools being expected to change their vending and tuck shop policies to healthier choices, for example removing carbonated, full sugar drinks. In addition the Executive is also funding the provision of free fruit in schools for P1 and P2 children.

395 The Schools (Health Promotion and Nutrition) (Scotland) Act 2007 builds on the success of existing work in schools. The Act makes health promotion a central purpose of schooling and will ensure that schools have a central role in helping children make healthy choices through a range of actions and activities. It will also ensure that all food and drinks provided by schools comply with nutritional requirements, specified by regulations. The regulations will include school meals, tuck shops, vending and food or snacks served at other times of the day.

Data on children's weight

TABLE 42 Percentage of pre-school aged children in Scotland receiving a review who are overweight, obese or severely obese

Source: NHS: Information Services Division - Child Health Surveillance Programme
Pre-school children are approximately 3 years old
1. Includes severely obese children only (ie all children >=98th centile)
2. Includes obese and severely obese children (ie all children >=95th centile)
3. Includes overweight, obese and severely obese children )ie all children >=85th centile)
p provisional

TABLE 43 Percentage of pre-school aged children in Scotland receiving a review who are underweight or very underweight

Source: NHS: Information Services Division - Child Health Surveillance Programme
Pre-school children are approximately 3 years old
1. Includes severely obese children only (ie all children >=98th centile)
2. Includes obese and severely obese children (ie all children >=95th centile)
3. Includes overweight, obese and severely obese children )ie all children >=85th centile)
p provisional

TABLE 44 High BMI distribution in pre-school children by Scottish Index of Multiple Deprivation - year of birth 2001

Source: NHS: Information Services Division - Child Health Surveillance Programme
Pre-school children are approximately 3 years old
1. Includes severely obese children only (ie all children >=98th centile)
2. Includes obese and severely obese children (ie all children >=95th centile)
3. Includes overweight, obese and severely obese children )ie all children >=85th centile)
*Scottish Index of Multiple Deprivation

TABLE 45 High BMI distribution in school children in Scotland

Source: NHS: Information Services Division - Child Health Surveillance Programme
1. Includes severely obese children only (ie all children >=98th centile)
2. Includes obese and severely obese children (ie all children >=95th centile)
3. Includes overweight, obese and severely obese children )ie all children >=85th centile)
P1 children are aged approximately 4-5 years old, P7 children 11-12 years old, S3 children 14-15 years old.

TABLE 46 Percentage of school children in Scotland receiving a review who are overweight, obese or severely obese, by gender 2004-05

Source: NHS: Information Services Division - Child Health Surveillance Programme
1. Includes severely obese children only (ie all children >=98th centile)
2. Includes obese and severely obese children (ie all children >=95th centile)
3. Includes overweight, obese and severely obese children )ie all children >=85th centile)
P1 children are aged approximately 4-5 years old, P7 children 11-12 years old, S3 children 14-15 years old.

TABLE 47 Low BMI distribution in school children in Scotland

Source: NHS: Information Services Division - Child Health Surveillance Programme
1. Includes very low BMI children only (ie all children <=2nd centile)
2. Includes low BMI and very low BMI children (ie all children,=5th centile)
P1 children are aged approximately 4-5 years old, P7 children 11-12 years old, S3 children 14-15 years old.

TABLE 48 High BMI distribution in school children by Scottish Index of Multiple Deprivation - year of birth 2004/05

Source: NHS: Information Services Division - Child Health Surveillance Programme
1. Includes severely obese children only (ie all children >=98th centile)
2. Includes obese and severely obese children (ie all children >=95th centile)
3. Includes overweight, obese and severely obese children )ie all children >=85th centile)
P1 children are aged approximately 4-5 years old, P7 children 11-12 years old, S3 children 14-15 years old.
*Scottish Index of Multiple Deprivation

Sexual health

Articles 14,16,19 and 34

396 Scottish Ministers launched Respect and Responsibility: Strategy and Action Plan for Improving Sexual Health in January 2005. Scotland fares badly in comparison with other countries in terms of good sexual health, for example, sexually transmitted infections are on the increase, and prior to the launch of the Strategy there had been no agreed strategic framework to tackle sexual health issues.

397Respect and Responsibility sets out clear challenges for Government, NHS Boards, local authorities and other agencies to deliver better sexual health services across the country. It sets out an action plan to deliver:

• a balance between what government should do to help people avoid contracting or spreading sexually transmitted disease or an unintended pregnancy and the individual's responsibility for their own health and the safety of others;
• a strong focus on respect and responsibility as the cornerstones of mature and loving relationships and the guiding principle for action;
• national leadership through the creation of a National Sexual Health Advisory Committee chaired by the Minister for Public Health;
• local leadership. NHS Boards and local authorities must identify strategic leaders for sexual health so that there is better planning for the future; and
• continued education to raise awareness of the issues relating to good sexual health and improvement in access to services.

398 The school curriculum in Scotland is not in statute. Current health education policy is to give schools and local authorities guidelines from which they develop programmes to suit the health education needs of children.

399 In nursery and the early years of primary school the emphasis is on family relationships and friendships and developing an understanding of how we care for one another. For older children, the focus is on the understanding of rights and responsibilities and a knowledge and understanding of the impact health choices can have on the quality of life. The Executive is seeking to promote a culture of respect, for oneself and for others; that children should not feel they have to have a sexual relationship until they are ready and that when they do they are safe.

400 The Executive is committed to striking a balance between a child's right to sex and relationship education and the right to freedom of thought and religion. For example, the Executive is currently funding a pilot project between Healthy Respect and the Scottish Catholic Education Service to develop appropriate sex and relationships education programmes in Catholic secondary schools. Healthy Respect is the Lothian based National Health Demonstration Project which provides a test bed for implementing evidence-based practice and innovative actions to improve children's sexual health.

401Respect and Responsibility also reiterates the need to involve parents, carers and the wider community in the development and revision of sex and relationships education programmes. This builds on the existing involvement of children in the development of sexual health education within schools.

402 In November 2006 the Executive launched the first annual report on Respect and Responsibility. The annual report provides an overview of progress since the Strategy was launched and contains examples of good practice from across Scotland. The report also outlines examples of joint working with NHS Boards, local authorities, the voluntary sector and faith groups taking a true partnership approach to implementing the strategy and action plan.

403 Sexual Health is a controversial subject, where deeply held views on moral issues meet cultural and lifestyle diversity and a tradition of tolerance. Respect and Responsibility sets out the Scottish Executive's proposals in a way which is respectful to both children's rights and parental and personal responsibility, and which recognises religious, cultural and gender diversity.

Sexually-transmitted infections

404Respect and Responsibility seeks to ensure that children are fully informed about the dangers of sexually-transmitted infections, including HIV. The Executive funds a number of voluntary organisations such as Caledonia Youth, Waverly Care, Healthy Gay Scotland and HIV Scotland to undertake promotional campaigns, provide services including access to condoms to at risk groups, including to children.

405 The tables below set out data on the prevalence of sexually transmitted infections amongst children and young people in Scotland. There has been a rise in chlamydia infection statistics, however this is likely to be in part a result of more comprehensive and flexible testing arrangements, plus a greater awareness of the dangers of STIs, leading to greater numbers of young people coming forward for tests. At present more females present for testing than males, the figures in the table therefore reflect this. One of the key aims of Respect and Responsibility is to address Scotland's poor sexual health statistics.

TABLE 49 Sexually-transmitted infections in under 20 year olds diagnosed at Scottish GUM clinics by diagnostic group - males

Source: NHS: Information Services Division - STISS

TABLE 50 Sexually-transmitted infections in under 20 year olds diagnosed at Scottish GUM clinics by diagnostic group - females

Source: NHS: Information Services Division - STISS

Teenage pregnancy

406 Paragraph 44(a) of the 2002 Concluding Observations recommended that the UK take the necessary measures to reduce the rate of teenage pregnancies. A wide range of measures are in place in Scotland to help provide children and families with education and information about the implications of teenage pregnancy and to discourage teenagers from becoming parents. Schools have a crucial part to play and are expected to provide high-quality sex and relationships education in an objective, balanced and sensitive manner. The Executive is developing policies to ensure better access to sexual health services, including addressing problems of access in rural areas and address underage drinking and drug abuse, which can lead to risk taking behaviours including underage and unprotected sex which in turn can lead to unintended pregnancies.

407Respect and Responsibility also seeks to ensure that local inter-agency strategies are developed which reflect the key components of the national strategy. Access to free contraception is available from Family Planning Clinics, Pharmacies, GP practices and voluntary organisations. Confidential support for children is available from the statutory and voluntary sectors across Scotland.

TABLE 51 Teenage pregnancies in Scotland by age of mother at conception

Source: NHS: Information Services Division
*Pregnancy rate is per 1000 population

TABLE 52 Teenage pregnancies in Scotland by age group and deprivation, as at 31 March 2004

Source: NHS: Information Services Division
*Includes one case where SIMD was not recorded
‡Rate per 1000 women in each age group, 2003 population estimates.

Drug misuse

Article 33

408 All schools in Scotland are required to provide health education, of which drug education is an integral part. The Executive supports the Scottish Crime and Drug Enforcement Agency's Choices for Life events, which deliver positive lifestyle messages to children aged 10-12 throughout Scotland. Issues about drugs, alcohol, tobacco, exercise and healthy eating are included in the activities and messages in the programme, which encourages children to make informed lifestyle choices and to resist peer pressure.

409Know the Score, launched in March 2002, was a response to comprehensive public research which revealed widespread concern about drugs, and a desire for factual and non-judgemental information about the various drugs circulating in Scottish communities. A key finding from the research is that authoritarian messages tend to alienate people, particularly young people, and do not convince them to stay away from drugs. The campaign aims to raise awareness, tell people where help is available and provide a range of factual information about drugs. Media advertising campaigns, a website, a 24-hour information line and drug information materials are available - the core message is that all drugs are potentially dangerous.

410 There has been a significant change in reported drug use since information was first collected in 1998. Between 2004 and 2006, prevalence of drug use in the last month among 15-year-old boys dropped from 21% to 14%. Although this has continued to drop, it is too early to tell whether this is a short-term change or the start of a trend. There was a small decline among 13-year-olds from 7% to 4%. There was no significant difference between boys' and girls' reported drug use.

411 The Scottish Drug Misuse Database offers a profile of drug misuse in Scotland. In 2004-05 it found that 214 under 16s and 1016 16-19 year-olds were reported by drug treatment services for the first time for their drug misuse. Cannabis was reportedly the most commonly used drug. Hospital records for the same year showed there were 20 discharges of under 16s reporting drug misuse and 349 discharges of 16-19 year-olds. Again, use of cannabis was most commonly recorded. The Scottish Schools Adolescent Lifestyle and Substance Use Survey, a national survey of smoking, drinking and drug use among secondary school pupils, found that in 2006, 21% of 15-year-olds and 7% of 13-year-olds reported using drugs in the last year.

412 1,426 children were referred to the Children's Reporter in 2005-06 for alcohol and/or drug misuse. Also in 2005-06, 2% of the 59,600 offences referred to the Reporter were for possession of drugs. Problematic substance misuse is prevalent in over half (56%) of children who persistently offend, according to research conducted during the fast-track children's hearings pilots ( SCRA (2006) On the Right Track. A study of children and young people in the Fast Track pilot).

Alcohol

413 The Executive is committed to tackling alcohol-related problems amongst children. Parents, schools, retailers and many others have a role as well. The health consequences of alcohol misuse are significant and there is justified concern over associated anti-social behaviour. An estimated 80-100,000 children in Scotland are living in houses affected by parental alcohol misuse.

414 Reducing harmful drinking by children is one of the key priorities in the Executive's updated Plan for Action on Alcohol Problems - aiming for a Scotland in which alcohol is treated responsibly. There are two strands to this: reducing binge drinking and harmful drinking by children; and recognising the need to instil a culture of sensible drinking in children that serves them well in later life. The Executive is also looking to improve school and community based education, improve support for parents and ensure children affected by alcohol problems have access to appropriate prevention, education and treatment services.

415 The Executive is working with the media, the alcohol industry and the licensed trade to tackle the irresponsible promotions which can foster binge drinking; and are also ensuring that people have access to information, support and advice to help them make and sustain healthy choices. The long term aim is to create a culture in which the safe and sensible consumption of alcohol is recognised as being compatible with a healthy lifestyle.

416 Measures have been introduced in the Licensing (Scotland) Act 2005 which will tackle under-age drinking. It will be a condition of holding a licence for all licensed premises that they operate a no-proof no-sale system. This means requesting proof where age is in doubt and displaying nationally approved signage. In addition, since June 2006 a trial test-purchasing scheme has been in operation in one Scottish police area. This has been a great success and as a result test purchasing has been rolled out and will be available to all police forces in Scotland later in 2007.

417 Examples of the range of initiatives the Executive has supported include helping to reduce harmful drinking by children and young adults by providing alternative activities through the support of Youth CAFEs, helping to reduce potential availability through the piloting of test purchasing of alcohol by young people and helping to ensure they have access to appropriate services through local activities run by Alcohol and Drug Action Teams. In addition, there are school based education initiatives, such as Choices for Life.

418 Hospital records indicate that in 2005-06 there were 381 alcohol related discharges of under 15s and 1462 discharges of those aged 15-19. The Scottish Schools Adolescent Lifestyle and Substance Use Survey found that, in 2004, 84% of 15 year olds and 57% of 13 year olds had had an alcoholic drink. 43% of those 15 year olds and 15% of those 13 year olds reported drinking in the last week. Both 13 year olds and 15 year olds who are regular drinkers are more likely to smoke or use drugs than those who don't drink.

Smoking

419 Smoking remains the most important preventable cause of premature death and ill health in Scotland. Although smoking rates have been falling, around 13,000 Scots are still dying each year of smoking related diseases. In January 2004, the Executive published A Breath of Fresh Air for Scotland, which set out a comprehensive programme of action covering prevention and education; protection and controls to reduce the availability and attractiveness of cigarettes, particularly to children; and the expansion of high quality cessation services. It also addressed the issue of second hand smoke, proposing a widespread public consultation exercise which led to the Scottish Parliament passing the Smoking, Health and Social Care (Scotland) Act 2005. Under these new laws, which came into effect on 26 March 2006, Scotland became the first part of the UK to introduce comprehensive restrictions on smoking in substantially enclosed public places.

420 The new law is widely regarded as the most important piece of public health legislation for a generation and is expected to reduce the cultural acceptability of smoking and reducing the occasions on which children will be exposed to second hand smoke. Moreover, there is clear evidence to suggest smoking bans enable substantial numbers of people to quit smoking. As many of these quitters will be parents, and children of non-smokers are less likely to become smokers themselves, this new legislation may also well prove to have a powerful preventative effect.

421 Smoking rates in the UK are higher among 15 year old girls than in most European countries but, among boys of the same age, are among the lowest in Europe. Scotland and Wales are 2 of the 4 European Countries where smoking among boys has declined since 1998. On the other hand, in only Greenland and Scotland is the average onset of both weekly and daily smoking among girls earlier than boys. Latest Scottish surveys results for 2006 suggest smoking prevalence among 15 year olds has declined since its peak in 1996 from 30% for both boys and girls to 12% and 18% respectively.

422 While the decline in smoking prevalence is welcome, the Scottish government is determined to reduce these figures even further by preventing children and young people becoming smokers in the first place. In November 2006, the Executive published a report by a short-life expert group, the Smoking Prevention Working Group, which has made a series of recommendations aimed at preventing children from becoming smokers, including through more effective schools educational programmes and measures to reduce the availability, affordability and attractiveness of cigarettes. A multi-faceted tobacco control programme is essential and the Scottish government will put in place a new 5-year Smoking Prevention Action Plan based upon the Working Group's recommendations. As a first step, legislation has been laid before the Scottish Parliament to raise the age of purchase for tobacco products from 16 to 18 with effect from 1 October 2007. It is considered that raising the age of purchase, as part of a range of measures, will reinforce to the population in general and young people in particular that tobacco is a highly dangerous substance which should be avoided.

D) SURVIVAL AND DEVELOPMENT

Article 6

Child road safety

423 The Executive is committed to cutting the number of children killed and injured in road accidents. The child pedestrian fatal and serious casualty rate in Scotland is considerably higher than in England. Research has shown that the relatively high number of pedestrian casualties is mainly explained by exposure to traffic. Lower levels of car ownership in Scotland than in England mean that people walk more and are, therefore, exposed to greater risk. Research has also shown that child pedestrians in the lowest socio-economic group are 4 times more likely to be killed on the roads than children in the highest socio-economic group. In addition, young drivers are over-represented in road accidents, with 1 in 5 involved in an accident within one year of passing the driving test.

424 The Executive has set a target for a reduction of 50% in child fatal and serious injuries by 2010, compared with the average for 1994-98 and a number of initiatives are underway to help achieve this target, for example Road Safety Scotland ( RSS) which has developed key road safety education initiatives and publicity messages. RSS is implementing a strategy for road safety education in the Scottish curriculum, the aim of which is to ensure that a core of road safety is taught at all stages of a child's formal education. The Executive funds free membership of the Children's Traffic Club in Scotland, which offers road safety training to all 3-year-old children in Scotland. The Executive is providing funding for the introduction of 20 mph speed limits around schools and safer routes to school projects. As at the end of 2006, 20 mph limits were in place at three-quarters of schools. Efforts have also been made to give new drivers a better understanding of road safety. The Executive is funding a pilot scheme to reduce the cost of the Pass Plus driver training course for newly qualified drivers aged between 17 and 25 years, with the aim of improving young driver safety by increasing uptake of the course.

425 Considerable progress towards the 50% reduction target has been made. In 2006, child fatal and serious casualties were 56% below the baseline and child pedestrian fatal and serious casualties were also 56% below. The Executive has committed to further casualty reductions in the period to 2010 and was associated with a child road safety strategy published by the UK Government in February 2007. The Executive also plans to set up an expert panel to consider what more can be done to improve road safety and is to develop a 10 year road safety strategy for Scotland.

426 A Child Safety Action Plan for Scotland covering all forms of accidental injury is also being taken forward by RoSPA and the Child Accident Prevention Council as part of a European Child Safety Alliance initiative.

Measures to combat harmful traditional practices

427 Female Genital Mutilation ( FGM) has been a specific criminal offence in the UK since the passage of the Prohibition of Female Circumcision Act 1985. The Prohibition of Female Genital Mutilation (Scotland) Act 2005 repeals and re-enacts for Scotland the provisions of the 1985 Act, gives extra-territorial effect to those provisions and increases the maximum penalty for FGM in Scotland from 5 to 14 years' imprisonment and makes additional forms of FGM unlawful.

428 The Executive was aware during the development of the 2005 Act that high levels of engagement with community groups would be vital. The Scottish Refugee Council and the Somali Women's Action Group were closely involved, enabling them to plan and run awareness raising seminars and workshops in local communities. In addition to this, fact sheets outlining the proposed changes in the law and the rationale behind them were prepared and translated in to a number of different languages. Since the Act was passed, a successful conference has been held and guidance has been developed and circulated to police forces, social work, education and health professionals and those like the Scottish Refugee Council who work with representatives of the communities where FGM is most likely to be practiced. This has provided an opportunity to communicate the changes in the law as well as highlighting issues around the practice of FGM, such as child protection and health.

E) CHILDREN WITH DISABILITIES

Article 23

429 The Disability Discrimination Act was amended in 2005 to include a duty on the public sector to promote equality of opportunity for disabled people. Regulations under the Act require specified public authorities - including all health boards - to publish a disability equality scheme by December 2006, to implement the action set out in the scheme, and to report annually. The regulations include a requirement that public authorities must gather information on the effect of their policies and practices on disabled people and state how they will use that information to assist the promotion of equality. The disability equality duty has been warmly welcomed by disabled people and disability organisations as well as by public authorities and by the Scottish Parliament.

430 The Executive supports the Scottish portion of the Family Fund (just under £3m in 2007-08), an independent UK-wide charitable organisation, wholly funded by government, which makes small grants to families on low incomes with severely disabled children. Grants are provided to enable families to pay for items that are not generally provided by the health service or local authorities. Grants were awarded for holidays or breaks within the UK, white goods, driving lessons, clothing, footwear and bedding, support for attending hospital appointments and so on. The Executive also supports a range of voluntary organisations delivering information and services to families with children with disabilities. These include Capability Scotland, Contact a Family, CCNUK, SENSE and The Butterfly Trust.

431 In addition, the Executive has established a cross-departmental Direct Payments Working Group, engaging extensively with the voluntary sector, whose purpose is to further promote the uptake of Direct Payments by local authorities to families with disabled children. This will empower parents of disabled children to improve outcomes for their children through a greater degree of financial control and personal autonomy.

F) HIV/ AIDS PROGRAMMES AND STRATEGIES

432 In relative terms the number of people in Scotland with HIV is small. However, recent figures show that HIV in certain communities within Scotland is increasing. HIV disproportionately affects some communities, and in the case of the community most affected - gay/bisexual men - the Executive provides support for both the statutory health and voluntary sector services to engage in preventative and reactive health promotion work with young men in this community.

433 In 2003, Universal Antenatal Testing was implemented in Scotland which has reduced considerably the number of babies born to HIV infected mothers who did not know their HIV status during pregnancy. Inevitably, there will be an extremely small number of children who are born with HIV or contract it in childhood and anti-retroviral therapy is available for those who require it including children originally from countries outside the UK.

434 However, children whose parents/carers are HIV positive are also affected. In addition to gay/ bisexual men who are parents, other parents/carers disproportionately affected by HIV in Scotland are men and women from some African communities, men and women who are intravenous drug users and women working in the sex industry. The Scottish Executive provides funding to voluntary organisations who work specifically with these groups/communities.

435 School based sex and relationships education - through programmes such as Sex and Relationships Education ( SHARE) provides learning opportunities for young people in the school sector, including learning about HIV and sexually transmitted infections ( STI). The Executive's Health Demonstration Project Healthy Respect works to promote learning and development of accessible services in response to concerns about rising STIs amongst young people.

G) STANDARD OF LIVING

Articles 26 and 27

Closing the Opportunity Gap

436 Closing the Opportunity Gap has been one of the Executive's key priorities. Its central aims are to: prevent individuals or families from falling into poverty; provide routes out of poverty and sustain individuals or families in a lifestyle free from poverty. In relation to children, the Executive is committed to improving the confidence and skills of the most disadvantaged children - to give them every chance of avoiding poverty when they leave school.

437 Four of the 10 specific Closing the Opportunity Gap targets are aimed towards helping children challenge and overcome some of the barriers to opportunities that they face as a result of being disadvantaged or living in a deprived area. The four targets are:

• to reduce the proportion of 16-19 year olds who are not in education training or employment ( NEET) by 2008;
• by 2008, to ensure that children and young people who need it have an integrated package of appropriate health, care and education support;
• to increase the average tariff score of the lowest attaining 20 per cent of S4 pupils by 5% by 2008; and
• by 2007, to ensure that at least 50% of all looked after young people leaving care have entered education, employment or training.

Tackling child poverty

438 Paragraph 46(a) of the 2002 Concluding Observations urged the UK to take all measures to the "maximum extent of available resources" to accelerate the elimination of child poverty. The new Scottish Government has committed to sharing the UK Government's long term target to eradicate child poverty by 2020. In Scotland, the 2005 target has been achieved ahead of the rest of the UK, but with 1 in 4 children still living in poverty there is still much more to do. Since 1998-99, 80,000 children have moved out of relative low income - a reduction of 26%. In terms of children in absolute low income, for the same period the number has more than halved.

439 Efforts are continuing to tackle poverty by investing in and supporting deprived and vulnerable children and their families. For example, Sure Start Scotland aims to ensure every child has the best possible start in life by targeting support for families with very young children in areas of greatest need. By 2008, every child who needs it should have an integrated package of appropriate health, care and support.

440 The health improvement policy aims to improve health for all but has a special focus on reducing the gap between the most affluent and most deprived communities. Challenging targets have been set for reducing health inequalities, eg a 15% rate of improvement in health for deprived populations. The Children and Young People's Health Support Group recently reviewed the range of policy initiatives relating to child health in Scotland against an assessment tool designed for this purpose by WHO Europe and a series of recommendations will emerge from this process. There is a particular focus on children that are vulnerable through poverty and other life circumstances.

441 Working for Families funding of £50m for 2004-08 has been allocated to a selection of local authorities with the highest concentration of children in workless households. Ten authorities received funding for 2004-08 with a further ten receiving funding for 2006-08. The funding aims to support parents to break down childcare and other barriers in order for them to access education, training or employment opportunities. Up to December 2006 nearly 12,000 parents had engaged with the fund with the majority drawn from groups far from the labour market or requiring sustained support to progress.

442 In further education, each college has a Childcare Fund which is used to pay for registered childcare. In higher education, a £1,240 lone parents grant and a £1,155 lone parents childcare grant ( LPCG) for childcare costs are available for students in academic year 2007-08. Over 6,100 LPCGs have been awarded over the period from 2002-03, when the LPCG was introduced, to 2005-06. There is also a higher education hardship fund that students can apply to in addition to any grant they receive.

Youth homelessness

443 Paragraph 46(b) of the 2002 Concluding Observations urged the UK to better coordinate and reinforce its efforts to address the causes of youth homelessness and its consequences. Scotland has a relatively progressive approach to homelessness - households eligible for assistance need not be roofless and rights under homelessness legislation are more comprehensive than in other parts of the UK. A child under 16 who is seeking assistance apart from their parents/carers would be assisted under the Children (Scotland) Act 1995 rather than under homelessness legislation in most cases.

444 Part I of the Housing (Scotland) Act 2001 and the Homelessness etc (Scotland) Act 2003 have introduced a number of relevant changes to the way homelessness is tackled:

• all local authorities have to develop and publish a homelessness strategy, based on an assessment of homelessness within their area. Guidance issued by the Executive in March 2002 emphasises that local authorities should work with local partners to develop their strategy and highlights that children often have particular difficulty in accessing housing. Strategies are now being implemented across Scotland;
• all households with dependent children who present as homeless are deemed to have a priority need for accommodation;
• all 16-17 year olds who present as homeless are deemed to have a priority need for accommodation;
• all persons aged 18-20 who were in care at the time that they left school are deemed to have a priority need for accommodation;
• all people with a priority need for accommodation have the right to permanent accommodation if they are found to be unintentionally homeless (true for the vast majority of cases); and
• local authorities are required to take the best interests of children into account in discharging their homelessness duties to homeless households with children.

445 The Homeless Persons (Unsuitable Accommodation) (Scotland) Order 2004 prevents the routine use of unsuitable temporary accommodation, such as bed and breakfast establishments, for households with children or pregnant women. The effect of this legislation has been tracked using official statistics, which has showed that the number of local authorities complying with it has increased since it was brought into force, and that about one third did not comply as of the latest date that the statistics were collected. Difficulties on compliance are largely due to local authorities not having temporary accommodation of a good enough standard in the places where people want to stay. These difficulties are being overcome by local authorities continuing to develop temporary accommodation and putting more resources into managing it effectively. The Executive will issue guidance in the near future on the strategic use of temporary accommodation.

446 A number of local authorities and voluntary organisations have taken action focussed on youth homelessness within the context of their local strategy - e.g. family mediation schemes and social networks. There has also been a particular focus on preventing homelessness amongst young people leaving care. Recent research on prevention of homelessness by Pawson et al ( http://www.scotland.gov.uk/publications/2007/03/26095144/17) shows that the majority of local authorities have put in place actions to ensure that young people leaving care do not become homeless. These actions range from ensuring that protocols exist between homelessness and social work departments to developing routine procedures for planning for future accommodation needs with young people about to leave care. New regulations and guidance came into force on 1 April 2004 which state that children's assessments and plans must set out what kind of accommodation best meets their needs and how this is to be obtained.

447 A number of local authorities, and particularly voluntary organisations, have involved children in the development of local policies and tools to prevent youth homelessness for example by acting as peer educators or being involved in producing training materials and information packs. Prevention of youth homelessness was also reported on in the research by Pawson et al referred to above and service user input was used to help evaluate different approaches to this. This research will be used to develop statutory guidance on prevention of homelessness for local authorities by the Executive over the coming year.

448 Over the next year, the Executive will issue guidance for local authorities on their duties to take account of the best interests of children in discharging their homelessness duties. This guidance has been based on research amongst local authorities and their partners and will emphasise the requirement to work together across different departments to meet children's needs as defined in the Executive's guidance on Integrated Children's Service Plans. Discussions with key stakeholders on this are ongoing.

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