The health of Care Experienced people

Background

“The term ‘care experienced’ refers to someone who, at any stage of their life and for any length of time, is currently or has been in care, i.e. looked after by the local authority (including children in foster care). We specifically refer to care received as a child or young person, not adult social care. Included in this are children currently looked after by local authorities and people who have experienced any form of children’s social care including those people who are legally defined as ‘care leavers’.

More than 80,000 children were in care in England at year ending March 2020, up 2% from 2019 and continuing a rise seen in recent years; this compares to 64,470 in 2010.

The health of children in care and care leavers is a long-standing concern, both in terms of their access to services and health outcomes:

• Care experienced people may have poorer mental and physical outcomes compared to their peers due: to the abuse, neglect or trauma that led them to enter care; poor experiences in care; and/or other pre-existing vulnerabilities, instability of relationships, loneliness, homelessness, poverty and unemployment.

• Care experienced people may also face additional challenges in accessing support for a range of reasons such as: financial vulnerability meaning they struggle to pay for some health services like opticians, dentists and prescriptions; the impact of trauma making it challenging to access routine services; transitions from children’s to adult services occurring at the same time as leaving care, breaking continuity of care; and a lack of join up between Local Authorities and health services meaning they fall through the cracks.

A key mission in the government’s 2023 children’s social care reform strategy, Stable Homes, Built on Love, is to reduce the disparities in long-term mental and physical health outcomes and improve wellbeing for care-experienced people. This includes a commitment to update the existing joint DfE/DHSC guidance on promoting the health and wellbeing of Children Looked After and extend it to cover care leavers up to age 25.

Several further commitments under the health mission were made at the February 2023 Care Leavers Ministerial Board, including improving understanding of data on physical and mental health and ensuring that all children in care and care leavers receive the universal healthy child programme offer. DHSC’s Permanent Secretary also has a specific interest in the health of children in care and care leavers, having established the Care Leaver Internship Scheme when Permanent Secretary at DfE and brought it to DHSC when he moved.

A comprehensive review of evidence is needed to inform policy development, and to inform ministerial briefings, other departments, and FOIs.

There is existing research on care experienced people which has indicated that:

• Children in care compare poorly to the general population regarding health. The rate of mental health disorders is much higher in looked after children in residential care compared to the general population.

• Adults who had been in care during childhood have a higher risk of morbidity and mortality

• The children of care experienced people may be more vulnerable to poor health outcomes. Teenage children of care-experienced mothers are more likely to have poorer health outcomes than their peers.

A comprehensive review of evidence (including an assessment of robustness and quality) is needed to a) give a clear understanding of the health of care experienced people, and b) identify where evidence is lacking and should be considered, with the aim to inform how policy can be developed to best support this group.

OHID has been working with other government departments to progress a Shared Outcomes Fund (SOF) project to create Extended ECHILD, a linked data source between education and health data. Once ready for use (expected summer 2023), Extended ECHILD will be an excellent resource to better understand the health of care experienced people. A comprehensive review of the evidence should identify evidence gaps and inform priorities to be investigated with the Extended ECHILD dataset.”

Aims and objectives

The overall aim is to undertake an evidence review, considering existing research which has investigated the health of care experienced people in England/the UK, specifically focused on evidence around children in care and care leavers:

Specific research objectives/questions:

• How does the health of care experienced people differ from their peers (ideally compared to those who don’t have experience of the care system, and those who were children in need but did not reach the threshold for social care), in terms of their health behaviours and outcomes, and healthcare access and usage (incl. patient experience and quality of care)?

• Why does the health of care experienced people differ from their peers (ideally both those who don’t have experience of the care system, and those who were children in need but did not reach the threshold for social care)? To what extent are differences due to experiences of care, or other factors?

• What are the factors (with a specific focus on health factors) that increase the likelihood of children going into care? (e.g. do different types of parental mental health issues affect whether or not children go into care?) What are the factors that mean that children of some at-risk parents do not go into care? This may include issues regarding both the child and their parent(s)/family.

For these questions and depending on the available existing research, the review will aim to answer the questions (where the relevant data exist):

• How does this vary by different population groups (e.g. ethnicity, deprivation, disability, sexual and gender identity, adverse childhood experiences, reasons for being taken into care, region)?

• How does this differ for people with different experiences of children’s social care and leaving care (e.g. length and type of placement)?

• How does the health of care experienced people change over time compared to their health status at entry into care?

Methodology

In the first phase we will undertake a rapid mapping exercise to address the main questions, using methods that we have applied in a previous PH-PRU project. We will search for relevant literature from the health, mental health, social care and social science fields. Sources of grey literature will be searched to capture research reviews from the websites of relevant organisations.

This evidence mapping will iteratively inform the development of protocols for the definitive umbrella reviews (systematic reviews of reviews) to address the questions outlined above. We will develop protocols and register these on PROSPERO. We will develop a logic model/conceptual framework to consider relevant exposures and outcomes of interest for each review question. These will be developed iteratively and used to determine inclusion/exclusion criteria and to help structure our synthesis. We anticipate that systematic reviews and other relevant research summaries from high-income countries that describe risk factors for care entry; and the health status of care experienced children will be included. The quality of these will be assessed using the most appropriate quality assessment tools, for example the Assessment of Multiple Systematic Reviews tool (AMSTAR 2). We will structure and write up the reviews in accordance with the