Appendix C The evidence

This appendix lists the evidence statements from 5 evidence reviews and 4 commissioned reports provided by external contractors and the public health collaborating centre (see appendix A). It links them to the relevant recommendations. (See appendix B for the key to quality assessments.) The evidence statements are presented here without references – these can be found in the full reviews (see appendix D for details). It also lists 22 expert papers and their links to the recommendations (see additional evidence). This appendix also sets out a brief summary of the cost-effectiveness evidence.

The 5 evidence reviews are:

  • Review E1: 'The effectiveness of support services for transition to adulthood/leaving care on the adult outcomes of looked after young people'

  • Review E2: 'The effectiveness of training and support for carers/professionals/volunteers working with looked-after children and young people on the physical and emotional health and wellbeing of looked-after children and young people'

  • Review E3: 'The effectiveness of interventions aimed at improving access to health and mental health services for looked-after children and young people'

  • Review E4: 'A correlates review: factors associated with outcomes for looked-after children and young people: a review of the literature'

  • Review E5: 'A qualitative review of the experiences, views and preferences of looked-after children and young people and their families and carers about the care system'.

The 4 commissioned reports are:

  • Report C1: 'Qualitative research to explore the priorities and experiences of practitioners working with looked-after children and young people'

  • Report C2: 'The health and wellbeing of looked-after children and young people: a brief review of strengths and weaknesses in service provision from inspection and review data'

  • Report C3: 'Practice survey: the physical, emotional health and wellbeing of looked-after children and young people'

  • Report C4: 'Consultation on draft recommendations: the physical, emotional health and wellbeing of looked-after children and young people'.

Evidence statement E1.5 indicates that the linked statement is numbered 5 in review 1. Evidence statement E2.7 indicates that the linked statement is numbered 7 in review 2. Evidence statement C3.6 indicates that the linked statement is numbered 6 in commissioned report 3. C1 indicates that the whole of commissioned report 1 is linked to the recommendation. EP1 indicates that the whole of expert paper 1 is linked to the recommendation.

See the reviews, commissioned reports, expert papers and economic analysis for details.

Where the PDG has considered other evidence, it is linked to the appropriate recommendation below. It is also listed in the additional evidence section of this appendix.

Recommendation 1: evidence statements E4.3, C3.1, C3.2, C3.18; C1, C2, C4, EP6, EP10, EP11, EP13, EP16

Recommendation 2: evidence statements E4.3, C3.1, C3.7, C3.12, C3.18; C2, EP4, EP6, EP11, EP13

Recommendation 3: evidence statements E4.3, C3.1, C3.2, C3.12, C3.18; C2, EP1, EP2, EP6, EP8

Recommendation 4: evidence statements C3.7, C3.12, C3.18; C4,EP6

Recommendation 5: evidence statements E4.2.7, E4.2.11, E4.3, C3.4, C3.7, C3.12, C3.18; C1, C2, C4, EP12

Recommendation 6: evidence statement C3.18; C1, C2, C3, EP11

Recommendation 7: evidence statement C3.1; C1, C2, EP6, EP12, EP13, EP15

Recommendation 8: evidence statements E5.3, E5.4, E5.16, C3.3, C3.7, C3.10, C3.11; C1, C2, EP6, EP9, EP11, EP22

Recommendation 9: evidence statements E4.2.1, E5.16, C3.7, C3.18

Recommendation 10: evidence statements E5.16, C3.7, C3.16, C3.18

Recommendation 11: evidence statement C3.7; EP3

Recommendation 12: evidence statements E4.2.6, C3.5, C3.12, C3.19; C4, EP2, EP6, EP14, EP16, EP19

Recommendation 13: evidence statements E4.2.6, E5.2, E5.9, C3.5, C3.7, C3.19; EP2, EP6, EP14, EP16, EP19

Recommendation 14: EP3, EP14

Recommendation 15: evidence statements E3.12, E4.2.5, E5.14, E5.15, C3.18; C4, EP2, EP11, EP16, EP18, EP19

Recommendation 16: evidence statement C3.12;C1, EP11, EP21, EP22

Recommendation 17: C1, EP11, EP21, EP22

Recommendation 18: C1, EP11, EP21, EP22

Recommendation 19: evidence statements C3.12; C1, EP11, EP21, EP22

Recommendation 20: evidence statements E3.1, E3.2, E3.3, E4.2.13, C3.2, C3.7, C3.8, C3.12, C3.14, C3.15; C1, C2, EP8, EP12, EP18, EP21

Recommendation 21: evidence statements C3.2, C3.12; C1, EP6, EP19

Recommendation 22: evidence statements E3.3, E5.12, C3.2; C1, C2, EP8, EP18

Recommendation 23: evidence statement C3.2; C1, EP6, EP19

Recommendation 24: evidence statements E5.5, E5.18, C3.7, C3.12, C3.18; C4, EP15, EP16

Recommendation 25: evidence statements E5.2, C3.7, C3.13, C3.18; C4, EP11

Recommendation 26: evidence statements E5.2, C3.7, C3.16; C1, C4, EP11, EP18

Recommendation 27: evidence statements E5.2, C3.4, C3.7; C4, EP10, EP18

Recommendation 28: EP14, EP18, EP23

Recommendation 29: evidence statements C3.7, C3.12, C3.16; EP18

Recommendation 30: evidence statements E5.2, C3.5, C3.7, C3.12; C4, EP18

Recommendation 31: evidence statements E5.2, C3.7, C3.12; C4, EP18

Recommendation 32: EP14, EP18, EP23

Recommendation 33: evidence statements E5.12, C3.16, C3.17; C1, C4, EP8, EP23

Recommendation 34: evidence statements C3.17, C3.20; C4, EP18, EP23

Recommendation 35: evidence statement E5.12, C3.12, C3.17, C3.20; C1; EP2, EP9, EP13

Recommendation 36: evidence statements E2.1, E4.2.8, E4.2.12, E4.3, E5.1, E5.2, E5.3, E5.14, E5.15, C3.7, C3.12, C3.17, C3.20; C2, EP6, EP9, EP11, EP13, EP18, EP23

Recommendation 37: evidence statements E2.1, E4.2.12, E4.3, E5.8, E5.11, E5.14, E5.15, C3.8, C3.12, C3.20; C1, C2, EP6, EP9, EP11, EP18, EP21, EP23

Recommendation 38: evidence statements E5.10, E5.13; EP1, EP3, EP6, EP9, EP11, E5.14, E5.15, EP21

Recommendation 39: evidence statements E4.2.6, E4.3, E5.17; EP18, EP19

Recommendation 40: evidence statement E4.2.6; C4, EP18, EP19

Recommendation 41: evidence statements E5.1, E5.3, E5.6, C3.7, C3.12; C1, C4

Recommendation 42: evidence statements E5.7, E5.8; C1

Recommendation 43: evidence statement E5.7; C1

Recommendation 44: evidence statements E1.1, E5.9, C3.6; C1, C4, EP20

Recommendation 45: evidence statements E1.1, E5.9, C3.6; C1, EP20

Recommendation 46: evidence statements E1.1, E1.2, E1.3, E1.4, E1.5, E1.6, E1.7, E1.8, E1.9, E4.2.10, C3.7; C1, C4, EP6, EP14, EP20

Recommendation 47: evidence statements E1.1, E1.2, E1.3, E1.4, E1.5, E1.6, E1.7, E1.8, E1.9, E5.9, C3.7; C1, C2, C4, EP6, EP14, EP20

Recommendation 48: evidence statement C3.6; C1, C4, EP20

Recommendation 49: evidence statements C3.7, C3.11

Recommendation 50: evidence statements E2.1, E4.2.4, E4.2.12, E5.7, E5.8, E5.14, E5.15, C3.1, C3.2, C3.7,C3.8, C3.12, C3.18, C3.20; EP1, EP3, EP6, EP9, EP11, EP21

Recommendation 51: evidence statements E5.3, E5.7, C3.18; EP1, EP3, EP6, EP9, EP11, EP21

Recommendation 52: evidence statements E5.3, E5.7, C3.7, C3.9, C3.12, C3.18; EP1, EP3, EP6, EP9, EP11, EP21

Evidence statements

Please note that the wording of some evidence statements has been altered slightly from those in the review team's report to make them more consistent with each other and NICE's standard house style. This does not alter the meaning.

Evidence statement E1.1

There is moderate evidence of mixed quality from 4 retrospective US cohort studies (1 [++], 1 [+], 2 [-]) to suggest that looked-after children and young people who received transition support services (TSSs) were more likely to complete compulsory education with formal qualifications than those who had not received these TSSs; whereas 1 prospective US cohort study (+) reported a non-significant finding in favour of the comparison group.

Evidence statement E1.2

There is moderate evidence of a positive effect of TSSs on current employment from 1 prospective (+) and 2 retrospective US cohort studies (1 [+], 1 [-]) although 1 retrospective US cohort study reported no difference between those who had and had not received TSSs on current employment (++).

Evidence statement E1.3

There is moderate evidence of a mixed effect with regard to the effect of TSSs on employment history. Two retrospective US cohort studies (1 [++],1 [-]) reported that those who had received TSSs were more likely to have a better employment history than those who had not received TSSs, whereas 1 prospective UK cohort study (-) reported that those who had received TSSs were less likely to have taken an employment/academic career path than those who had not.

Evidence statement E1.4

There is moderate evidence of a mixed effect with regard to the effect of TSSs on employment at case closing. Two US cohort studies, 1 prospective (+) and one retrospective (-) reported that those who had received TSSs were more likely to be employed at case closing than those who had not received TSSs, whereas 1 retrospective US cohort study (-) reported that those who had received TSSs were less likely to be employed at case closing than those who had not.

Evidence statement E1.5

There is moderate evidence of a mixed effect with regard to the effect of TSSs on crime/offending behaviour. One retrospective US cohort study (-) reported that those who had received TSSs were less likely to have a problem with the law and 1 retrospective cohort study (++) reported that those who had received TSSs were more likely to have a problem with the law than those who had not received TSSs. One retrospective US cohort study (+) found no difference between those who had and had not received TSSs on never being arrested. Those who had received TSSs were less likely to have been arrested for serious crimes but more likely to be arrested for moderate crimes than those who had not received TSSs. However those who had received TSSs were less likely to receive short jail sentences and more likely to receive long jail sentences than those who had not received TSSs.

Evidence statement E1.6

There is moderate evidence for a positive effect of TSSs on parenthood from 1 prospective (+) and 2 retrospective US cohort studies (1 [++] and 1 [+]), in that those who had received TSSs were less likely to be parents than those who had not.

Evidence statement E1.7

There is moderate evidence for a positive effect of TSSs on housing and independent living from 6 studies: 1 prospective UK cohort study and 5 retrospective US cohort studies. Those who had received TSSs were more likely to have a place to live (1 [-] and 1 [++]) and were more likely to be living independently (2 [+] and 2[-]) than those who had not received TSSs.

Evidence statement E1.8

There is moderate evidence of a mixed effect with regard to the effect of TSSs on homelessness. Two retrospective US cohort studies reported that those who had received TSSs were less likely to have had a homeless episode at discharge (1 [++]) or to have ever been without a place to sleep (1 [-]) than those who had not received TSSs. However 2 retrospective US cohort studies (1 [+] and 1 [-]) reported no difference between those who had and had not received TSSs on homelessness.

Evidence statement E1.9

There is evidence of mixed quality to suggest no evidence of effect of TSSs on mental health outcomes. Three retrospective US cohort studies (1 [++], 1 [-] and 1 [+]) reported no difference on general satisfaction, life satisfaction and depression. However 1 retrospective US cohort study (-) reported that those who had received TSSs were more likely to be hopeful about the future than those who had not.

Review 1: applicability of non-UK studies to UK care system and populations

The majority of studies included in this review were conducted in the US, with only 1 UK study and this will have implications for the applicability of the review findings to the UK context. The UK study reported very little quantitative data with no statistical comparisons. The findings from this review are based on studies that are small and furthermore some of the studies have been outdated by current legislation (for example, the studies from the 1990s will not have considered the recommendations of the Children's [Leaving Care] Act 2001) so the study conclusions may not reflect current policy and practice. The small number of studies reviewed and their poor methodological quality and rigour are also of concern when considering the applicability of the findings of this review.

Evidence statement E2.1

There is evidence of mixed quality to suggest a mixed effect of training and support for foster carers on child problem behaviours. Three US RCTs reported that children looked after by carers who had received a training and support intervention had lower rates of problem behaviour at follow-up than children of carers who had not received an intervention, among the whole sample (1 [+] and 1 [-]) and in older infants (1 +). However, 1 UK RCT (-) and 1 UK prospective cohort study (-) reported no differences on child problem behaviours between children of carers who had and had not received a training and support intervention. One US RCT (+) reported that the younger infants looked after by carers who had received a training and support intervention had higher rates of problem behaviours than children of carers who had not received an intervention. The findings of this review are moderately applicable to the UK care system, given that half of the studies reviewed were conducted in the UK and all were conducted in recent years.

Review 2: applicability to the UK

Half of studies included in this review were conducted in the UK with the other half conducted in the US, which may have implications for the applicability of the review findings to the UK context. Many of the studies had small sample sizes, which is a concern; as is the poor methodological quality of some of the studies, despite the use of RCT methodology. However, all studies included were conducted in recent years, with many conducted in the last 4 years, which increases the applicability of the findings of this review.

Evidence statement E3.1

There is mixed evidence of reasonable quality from 1 US prospective cohort study (+) on the effectiveness of a comprehensive multidisciplinary assessment compared with usual assessment on access to services in general. This study also reported that looked-after children and young people who received a comprehensive multidisciplinary assessment and were referred to a service were more likely to have received a service at 6-month follow-up than those who received usual assessments and were referred to a service; however this difference was not apparent at 12-month follow-up. These findings may have limited applicability to the UK care system as this was a US study and was conducted 9 years ago.

Evidence statement E3.2

There is mixed evidence of reasonable quality from 1 US prospective cohort study (+) on the effectiveness of a comprehensive multidisciplinary assessment compared with usual assessment on access to services in general. This study reported that looked-after children and young people who received a comprehensive multidisciplinary assessment were more likely to be referred to a service than those who received usual assessments. Regarding referral to specific services, there is evidence from the same study to suggest no significant difference in referral rates to mental health services between looked-after children and young people who received a comprehensive multidisciplinary assessment with an identified need for the specific service and those who received usual assessments with an identified need for the specific service. These findings may have little applicability to the UK care system as this was a US study and was conducted 9 years ago.

There is evidence of reasonable quality from 1 US study (+) to suggest a mixed effect of a comprehensive medical case management programme. One US study reported that looked-after children and young people who received a comprehensive medical case management programme were more likely to receive psychiatric clinic services than those looked-after children and young people receiving usual service but slightly less likely to receive mental health services. This finding may be of medium relevance to the UK care system as this was a US study published 5 years ago.

Evidence statement E3.3

There is mixed evidence of reasonable quality from 1 US prospective cohort study (+) on the effectiveness of a comprehensive multidisciplinary assessment compared with usual assessment on access to services in general. This study reported that looked-after children and young people who received a comprehensive multidisciplinary assessment were more likely to be referred to a service than those who received usual assessments. Regarding referral to specific services, there is evidence from the same study to suggest no significant difference in referral rates to medical services between looked-after children and young people who received a comprehensive multidisciplinary assessment with an identified need for the specific service and those who received usual assessments with an identified need for the specific service. These findings may have little applicability to the UK care system as this was a US study and was conducted 9 years ago.

There is evidence of reasonable quality from 1 US study (+) to suggest that looked-after children and young people who received a comprehensive medical case management programme were more likely to receive physician services, hearing examinations and eye examinations services than those looked-after children and young people receiving usual service. This finding may be of medium relevance to the UK care system as this was a US study published 5 years ago.

There is evidence of reasonable quality from 1 US study (+) to suggest that providing all reasonably available medical records to the professional undertaking initial health assessment at entry into care increases uptake within 14-day, 30-day and 1-year periods. This finding may be of medium relevance to the UK care system as this was a US study published 2 years ago.

There is evidence of poor quality from 1 UK non-comparative study (-) to suggest no significant difference in immunisation uptake rates among looked-after children and young people before and 12 months after providing social services with information on immunisation status. This finding may be moderately applicable to the UK care system as this was a UK study and was published 6 years ago.

Review 3: applicability to the UK

One non-comparative study included in this review was conducted in the UK with 4 prospective cohort studies conducted in the US, which may have implications for the applicability of the review findings to the UK context, although there is likely to be much similarity in medical assessments for looked-after children and young people in the UK and US. Many of the studies had small sample sizes, which is a concern, as is the poor methodological quality of some of the studies. However, all studies included were conducted within the last 9 years.

Evidence statement E4.2.1

There is evidence of mixed quality (5 cohort studies and 2 reviews [all -], 4 cohort studies [all +]) for an association between older age at first placement and [increases in] placement breakdown or behavioural problems. [General direction is positive.]

Evidence statement E4.2.4

There is evidence of mixed quality (1 review [-] and 2 cohort studies [both +]) for an association between professional foster care and [increased] placement stability. [General direction is positive.]

Evidence statement E4.2.5

There is evidence of mixed quality (2 reviews and 1 cohort study [all -] and 1 cohort study [+]) for an association between sibling co-placement and placement stability and emotional and behavioural problems (small effect size). There is evidence of good quality (2 cohort studies [both +] and 1 [++]) for an association between sibling co-placement and emotional and behavioural problems. [General direction of association is positive.]

Evidence statement E4.2.6

There is evidence of mixed quality (2 cohort studies and 1 review [all -] and 4 cohort studies [all +]) for an association between kinship care [now termed 'family and friends care'] and placement stability.(There is evidence of mostly good quality [1 cross-sectional study {-} and 3 cohort studies {all +}] for an association between kinship care and emotional and behaviouralproblems). [General direction is positive.]

Evidence statement E4.2.7

There is evidence of weak quality (2 cohort studies [both -]) for a [positive] association between concurrent planning and placement stability).

Evidence statement E4.2.8

There is very good quality evidence (1 RCT [++]) for a positive association between a shared parenting programme and externalising problems. [Externalising problems decrease.]

Evidence statement E4.2.10

Mixed results of associations between outcomes and transitional planning were reported. One review did not identify any evidence for an association between transitional planning (for example, independent living programmes) and placement stability or emotional and behavioural problems. There is evidence of good quality (1 cohort study [+]) for an association between transitional planning and drug and alcohol misuse as an adult. There is evidence of mixed quality (2 cohort studies [both -] and 1 review [+]) for an association between transitional planning and education and employment as an adult (general direction of associations where reported is positive).

Evidence statement E4.2.11

This review identified mixed results for associations with adult mentorship. No evidence was identified of an association between adult mentorship and placement stability or emotional and behavioural problems, but there is evidence of good quality (1 cohort study [+]) for a [positive] association between adult mentorship and self-esteem, level of good health and participation in higher education, and a negative association between adult mentorship and suicide ideation.

Evidence statement E4.2.12

There is evidence of mixed quality (2 cohort studies and 1 RCT [all -], 2 RCTs [both +] and 1 systematic review [++]) for an association between training for foster carers and emotional and behavioural problems. There is evidence of good quality (2 RCTs [both +]) for an association between training for foster carers and permanent placement). [General direction of associations is positive.]

Evidence statement E4.2.13

This review reported mixed results for associations with physical and mental health assessments. No evidence was identified for an association between a full physical and mental health assessment and emotional and behavioural problems. There is evidence of weak quality (1 cohort study [-]) for an association between a full physical and mental health assessment and mental health service use.

Evidence statement E4.3

There is evidence of varying quality from 17 studies (8 cohort studies and 1 RCT [all +], 6 cohort studies and 2 cross-sectional studies [all -]) to suggest that the number of placements is a risk factor associated with a reduced likelihood of a positive outcome, and that placement stability is a protective factor that is associated with fewer placement moves and fewer emotional and behavioural problems. However, it should be noted that this is not an exhaustive review and not all evidence on these factors and outcomes has been identified and assessed.

Evidence statement E5.1

There was evidence in 7 studies (1 [++] and 6 [+]) that looked-after children and young people had the view that:

  • love and affection is desired but is often lacking in their lives

  • love, or the lack of it, has a significant impact on their emotional wellbeing, in particular their self-esteem

  • for some, training and payment for foster carers undermines the sense that they are wanted or loved

  • an unmet need for love and affection is perceived by some to have a profound and lasting impact on their future outcomes.

Evidence statement E5.2

Statements from looked-after children and young people in 13 studies (1 [++] and 12 [+]) provide strong evidence that looked-after children and young people feel that:

  • a sense of belonging is desirable, yet often lacking in their lives

  • their sense of identity is compromised by the lack of sense of belonging

  • frequent moves and lack of permanence are a characteristic of being looked after that undermines any sense of belonging and therefore has a negative emotional impact for them

  • a potential barrier to achieving the desired state of belonging is the conflict that arises of being part of 2 families simultaneously, their birth family and their carer's family

  • achieving a sense of belonging and identity is compromised further when they are placed with carers from different ethnic and cultural backgrounds.

Evidence statement E5.3

Evidence that being supported is important to looked-after children and young people was reported in 10 studies (all +):

  • they expressed a need to feel that there is someone to support them

  • emotional support is an important type of support they felt they needed

  • encouragement to achieve in education and other aspects of their life is also needed

  • practical support, such as help with homework and provision of materials, was also seen as essential for achieving success in their lives.

Evidence statement E5.4

Evidence on the importance for looked-after children and young people of having someone to talk to in confidence was found in 8 studies (all +). Looked-after children and young people reported that:

  • opportunities to talk to someone about their concerns were often not available, but they appreciated when they were

  • they were often mistrustful of talking to professionals as they could not be sure what they said would be kept confidential.

Evidence statement E5.5

The significance for looked-after children and young people of contact with their birth families was revealed in 11 studies (1 [++]; 10 [+]). Studies reported that:

  • many have a strong desire to maintain contact with their birth families

  • maintaining contact with birth families is important for supporting their self-identity

  • they felt that social workers and care providers can obstruct their efforts to maintain contact with their families, and were resentful of this

  • a lack of contact causes significant emotional upset

  • contact with birth families is a complex issue. Although an overwhelming majority [of participants] saw it as positive, not all felt the same.

Evidence statement E5.6

Looked-after children and young people identified stigma and prejudice as a significant problem in their lives in 7 studies (1 [++] and 6 [+]). They reported that:

  • negative attitudes towards them are common

  • curiosity and pity are also attitudes commonly experienced and disliked

  • a common and unwelcome experience was being singled out and made to feel different because of their status when what they particularly wanted was to feel 'normal'.

Evidence statement E5.7

Evidence about important issues for looked-after children and young people in relation to education was reported in 11 studies (1 [++] and 10 [+]). This evidence revealed that:

  • encouragement to attend and do well at school is lacking for many, yet those who have achieved success in education feel it is a key factor in their success

  • the provision of practical support and resources is felt to be another key facilitator of success, yet is frequently lacking, particularly in residential care

  • another source of support often felt to be pivotal was education-specific support, in the form of educational advice

  • emotional support during education, particularly higher education was noted as a need

  • stereotyping and stigma on the part of others, including teachers, was seen as a common barrier to educational success

  • a lack of continuity in placements and schooling is a further barrier to educational success

  • being placed in residential care was seen as particularly disadvantaging in terms of education

  • looked-after children and young people who had achieved success in education cited their self-reliance as the key factor which helped them overcome the barriers mentioned above.

Evidence statement E5.8

There was evidence from 7 studies (all [+]) about looked-after children and young people's relationship with professionals. They raised similar concerns to carers. These include:

  • the issues of continuity in their relationships with professionals

  • the negative impact of a lack of continuity

  • a desire to form a personal relationship with professionals

  • to have professionals who listen, who are accessible

  • to have professionals who can be relied upon to be there and have the ability to get things done.

Evidence statement E5.9

Seven studies (1 [++] and 6 [+]) provide evidence that preparation and support for leaving care is an important issue for looked-after children and young people. In order to improve the process of leaving care, looked-after children and young people said they needed:

  • improved and more timely preparation for independent living prior to leaving care to improve this transition

  • a network of support to provide ongoing practical help and emotional support after leaving care

  • greater and more appropriate information and advice about entitlements to help to make better use of services available to them on leaving care

  • a higher level of financial support and more advice for managing finances to prevent serious financial problems for care leavers

  • access to better quality and more appropriate housing.

Evidence statement E5.10

There was evidence in 5 studies (1 [++] and 4 [+]) about carers' relationship with social workers. Carers said they wanted:

  • reliable, supportive and communicative relationships with social workers based on mutual trust and respect

  • continuity in their relationships with social workers

  • social services to be honest about the background of looked-after children and young people before a placement commences.

Evidence statement E5.11

There was evidence from 4 studies (1 [+] and 3 [-]) on carers' views about whether they are 'being a parent' or 'doing a job'. Carers' views across the 4 studies indicate that they:

  • view their role as both professionally demanding and personally rewarding. This impacts on whether they consider payment to be financial compensation or an incentive or both

  • are more satisfied with their role when they are paid appropriately and on time

  • did not agree with payment banding according to the age or behavioural assessment of individual children.

Evidence statement E5.12

There was evidence from 4 studies (2 [+] and 2 [-]) on carers' relationships with looked-after children and young people. Carers stated that they were:

  • concerned with being able to support looked-after children and young people to make a difference in their lives and assist them in achieving better short and long-term outcomes

  • dissatisfied with trying to build supportive relationships with them when there are high levels of placement instability.

Evidence statement E5.13

There was evidence from 5 studies (1 [++], 1 [+] and 3 [-]) about carers' use of a wider support network. The views of carers indicated that:

  • they benefit from the support of others who share similar experiences which can impact on the quality of care they provide looked-after children and young people

  • support can include their own professional networks, often bypassing the assigned link to services

  • although looked-after children and young people may be fostered by individuals or couples in many cases the wider family are providing support to them to ensure they feel 'love', and provide them with a sense of belonging which can act as an additional resource for carers.

Evidence statement E5.14

There was evidence from 4 studies (2 [+] and 2 [-]) about carers' views on training. Carers say they want:

  • access to training on topics that are important to them

  • to be trained to the same standard as social workers

  • to be trained in particular areas as this provides them with greater confidence in their abilities as carers.

Evidence statement E5.15

There was evidence from 3 studies (1 [+] and 2 [-]) on carers' views about birth parents. Carers held strong views and felt that:

  • birth parents had a disruptive impact on the lives of looked-after children and young people

  • often they were left with the responsibility of dealing with any negative effects of birth parent contact.

Evidence statement E5.16

There was evidence from 4 studies (3 [+] and 1 [-]) about the accessibility and acceptability of services. Studies asked carers about services they wanted or would like to have access to. Three of the 4 studies included carers' views on the acceptability of services they had received or had been in contact with. By comparing the participants' direct quotes and author analysis across the 4 studies it was possible to identify 3 barriers to accessing services:

  • lack of information about services available to looked-after children and young people and carers

  • difficulty navigating the mental health referral system

  • stigma about mental health.

In terms of acceptabilityof services, all 3 studies included both positive and negative experiences of the services they received with no strong implications for the improvement of services being made by carers.

Evidence statement E5.17

There was evidence from 2 (++) studies on being a kinship carer. Participants described what it was like being a kinship carer which provided insight into the uniqueness of their experiences. The following emerged from their views:

  • they often have to manage both their relationship with the child in their care and biological parent of child(ren) in their care and may need additional support do this

  • they may have additional support needs because they are often older (grandparents) and looking after a child may be an added burden.

Evidence statement E5.18

There was evidence in 2 (+) studies on parents' views about maintaining contact with their children. Parents specifically stated that:

  • they wanted to maintain continuity in contact with their children

  • they wanted to be a source of support to their children

  • they needed support from professionals while their children are in care in order to have useful contact with them.

Evidence statement C3.1

Communication between professionals and services is undoubtedly aided by co-location, integrated front-line working and effective communication structures including regular consultation meetings, joint strategic planning and pooled resources.

Evidence statement C3.2

Effective practice in improving the health and wellbeing of looked-after children and young people relies on effective information sharing, communication across organisational boundaries and a shared commitment to improving their health and wellbeing. In describing effective information sharing and communication activity, the sites talked about the importance of having a range of structured and forward planned, information sharing meetings that had clear agendas and purpose, some of which were topic led and related to specific or emerging issues. Other examples were given as regular email correspondence between professionals and regular telephone conversations to discuss individuals or issues.

Evidence statement C3.3

In sites where Children and Mental Health Services (CAMHS) workers are co-located for part of the week, or where they are fully integrated into looked-after children and young people teams, the result is better and speedier access to CAMHS for looked-after children and young people.

Evidence statement C3.4

Effective strategy and planning is crucial in promoting productive partnership working at all levels. Joined-up, corporate and strategic planning impacts upon all other planning activity within the services, and ultimately improves the direct services to looked-after children and young people and their families.

Evidence statement C3.5

The evidence gathered in all sites and across the professional groups strongly suggests that the most important factors in influencing looked-after children and young people's health and wellbeing outcomes are stability and consistency. The child or young person's placement is of paramount importance and the characteristics of a quality placement are good matching of carer and child at the point of placement. Good matching is characterised by the matcher having robust and detailed information about the child, their characteristics and preferences so that they can match these against the lifestyle and characteristics of the foster carers at the point of matching. The matching process is also aided by timely planning, with the child and carers experiencing introductory meetings and agreeing to the time frame for the planned move. Additional characteristics of a quality placement are thought to be the consistent approach that the carer brings to the relationship, having commitment, staying power and demonstrating unconditional positive regard for the child. In summary, the quality of the relationship between the carer and child is crucial. Alongside this, stability of school placement and consistency in key workers are also thought to be highly influential in promoting health and wellbeing in looked-after children and young people.

Evidence statement C3.6

Good transition management is characterised by timely planning to ensure that young people are fully supported through the transition process. Young people voiced concern at the stark contrast between the lifestyle and support they had experienced in foster or residential care and the situation they face when leaving care. The significant reduction in their financial means, coupled with the added responsibilities of independent living affect their diet, opportunities for exercise and adds to their stress.

Evidence statement C3.7

Looked-after children and young people do not want to be identified as different from other children and young people and therefore it is important to offer them the same interventions and support services as their counterparts in universal settings, wherever possible. Evidence suggests that this is even more important for disabled looked-after children and young people who generally have a strong wish to access services alongside their able-bodied peers.

Evidence statement C3.8

Early interventions that focus on preventing adverse behaviours such as offending behaviour, substance misuse, smoking, obesity, and bullying are key to improving children and young people's health and wellbeing in the future. Evidence suggests that activities and interventions that positively promote health and wellbeing – such as diet, exercise, emotional health and forming friendships, are the most engaging and successful. Such interventions are delivered to varying degrees in schools and universal settings with all children, but often, looked-after children and young people miss out on sessions or do not benefit from the consistent approach to these issues from a school, due to their frequent moves during care or the periods of school absence they experienced prior to coming into the care system.

Evidence statement C3.9

Specialist services do play an important role in improving health and wellbeing outcomes for some young people. Respondents felt strongly that the needs of every looked-after child or young person are different and that a range of universal and specialist services are needed to meet their bespoke needs.

Evidence statement C3.10

CAMHS support to the carers of looked-after children and young people with complex needs is highly valued by the recipients. In sites where carers are accessing this type of support, respondents spoke positively about the benefits. However, the evidence suggests that support to carers should be an additional service to the therapeutic intervention that should also be on offer to looked-after children and young people and not an alternative to this.

Evidence statement C3.11

Respondents in 3 sites named [reported] that there should be consistency in the ages that all [agencies] work to [for example, there are different cut-off points for points of access services] in responding to the needs of looked-after children and young people. In particular they felt CAMHS interventions should continue [after] when young people reach 18 years and should mirror the longer-term responsibilities of education and social care staff.

Evidence statement C3.12

Looked-after children and young people's access to dental care is a concern to respondents. Sometimes they need to travel considerable distances to access a dentist that has the capacity to take them. A looked-after child or young person may not attend a planned dental check for reasons relating to unplanned placement moves, fear, phobias or confidence issues. Missed appointments result in some dental practices de-registering them. Some dentists are reluctant to embark on a treatment programme if a child is in a short-term placement. There are particular needs around meeting the specialist dental needs of disabled children and young people.

Evidence statement C3.13

Life-story work takes place inconsistently with looked-after children and young people. Evidence suggests that they would benefit from having access to consistent information about their history and the reasons for their being looked after. This needs to be an ongoing process with information updated as the child or young person moves through developmental stages. There appears to be little consistency in approach to life-story work and there is a tendency for it to be resource-driven rather than needs-led.

Evidence statement C3.14

Respondents at some sites reported 'models of good practice' in helping children and young people placed out-of-area access services. However, this was not the case across all sites which means that some children and young people are not receiving the same level services. Evidence suggests that this inconsistency in service delivery impacts on their future health and wellbeing.

Evidence statement C3.15

Sites would welcome national guidance to support the delivery of care to children placed out-of-area, and to children placed in area when they are looked after by another local authority.

Evidence statement C3.16

Evidence suggests that there has been a significant change in the demographics of the looked-after children and young people population in the last 5 years. Sites have accommodated increasing numbers of asylum seeking children and young people, a good proportion of which are unaccompanied (UASCYP). There appears to be a lack of appropriate mental health services for UASCYP and furthermore, services are unable to meet the complex needs of this vulnerable group. Young people express concern at the poor quality of accommodation in which some UASCYP are placed and considered that their eligibility and access to support did not match that provided to other care leavers.

Evidence statement C3.17

The high levels of support and in-depth training provided to foster carers on specialist schemes was seen as a benchmark that mainstream foster carers would welcome. In particular, out-of-hours support from a mental health (CAMHS) worker was seen as an effective way to manage a crisis and help prevent breakdown.

Evidence statement C3.18

In the main, looked-after children and young people interviewed did not speak positively about their relationships with social workers. Social workers are considered to have control and to make decisions, however they are not trusted by young people to carry through agreed actions. Evidence suggests a high degree of turnover in social workers working with looked-after children and young people. Children and young people say that they do not feel listened to by their social workers and that they are hard to reach. More typically, children and young people named foster carers, staff at school, independent reviewing officers and independent visitors as a source of trusted support.

Evidence statement C3.19

Evidence suggests that in circumstances where respectful relationships are built between carers and birth parents, this will assist in enabling a looked-after child or young person to thrive in their placement. Ongoing work with birth parents appears to be a neglected area although the likelihood is that looked-after children and young people are likely to return back to their care at some stage in their lives.

Evidence statement C3.20

Although most looked-after children and young people express high levels of satisfaction with their current placement, some were critical of the motivation of their previous foster carers and of the care that they had received. Young people advocate that there should be more regulation, inspection and spot checks of foster care placements.

Expert testimony

  • Expert paper 1: 'Patterns of instability in the care system'

  • Expert paper 2: 'Stability and wellbeing in the care system'

  • Expert paper 3: 'Learning from Sheffield: services to meet the needs of the most challenging children'

  • Expert paper 4: 'The role of the Healthcare Commission in improving outcomes for looked-after children'

  • Expert paper 5: 'Social pedagogy – an example of a European approach to working with looked-after children'

  • Expert paper 6: 'Improving outcomes for looked-after children and young people'

  • Expert paper 7: 'Revised government guidance and policy developments on the health of looked-after children'

  • Expert paper 8: 'The contribution of inspection to the health and wellbeing of looked-after children'

  • Expert paper 9: 'The physical and emotional health and wellbeing of children and young people growing up in foster care: support and training for carers'

  • Expert paper 10: 'Making sense of performance problems in public organisations'

  • Expert paper 11: 'Working with complex systems and networks around looked-after children and young people'

  • Expert paper 12: 'Care planning – the social work task for looked-after children'

  • Expert paper 13: 'Multi-agency partnerships'

  • Expert paper 14: 'Labels that disable – meeting the complex needs of children in residential care'

  • Expert paper 15: 'Siblings in care'

  • Expert paper 16: 'Participatory approaches to involving looked-after children and young people in the design and delivery of services'

  • Expert paper 17: 'Social pedagogy in children's residential care: DCSF pilot programme'

  • Expert paper 18: 'Pathways to permanence for black, Asian and mixed ethnicity children; dilemmas, decision-making and outcomes'

  • Expert paper 19: 'Kinship care'

  • Expert paper 20: 'Promoting the resilience and wellbeing of young people leaving care: messages from research'

  • Expert paper 21: 'Improving health and wellbeing outcomes of children under five years of age looked after in the care of local authorities'

  • Expert paper 22: 'Mental health of looked-after children in the UK: summary'

  • Expert paper 23: 'The Health Needs of Unaccompanied Asylum Seeking Children and Young People'

Cost-effectiveness evidence

The cost-effectiveness modelling for review 1 (see appendix B) estimated that interventions that support the transition of looked-after children and young people to adulthood are likely to be cost effective. Helping young people to find employment or continue with higher education improves health and social outcomes and is estimated to make long-term cost savings.

In line with the approach outlined in appendix B, the recommendations that were agreed by the PDG to result in more good than harm compared with current practice, which were of relatively small additional cost and which would probably yield cost savings in the long run, were considered to be cost effective. Indeed, the recommendations would in many cases be less expensive and more effective than current practice.

The PDG examined 1 draft recommendation – ensuring that all looked-after children and young people had a complete assessment of their physical, mental and emotional health at the time of entry to the care system – in some detail. The PDG concluded that the recommendation was likely to do more good than harm compared with current practice and, since resources should already be in place, the level of resources need not change, or need not change by very much.

As a result of data limitations, there is uncertainty regarding the cost effectiveness of the remaining recommendations, in particular those that relate to system-level changes, training, auditing/monitoring, multi-agency working and information sharing. For these, the PDG judged that they would do more good than harm compared with current practice, based on evidence it was presented with. In addition, the PDG judged that many of the recommendations were likely to have low or no additional cost, and so were very likely to be cost effective.

However, the PDG expected that some of the recommendations were likely to be costly. For these recommendations, the PDG did not have enough evidence on the magnitude of the costs and/or the effects to reach an informed conclusion about their cost effectiveness. This does not mean that these recommendations are not cost effective, just that the extent, if any, of their cost effectiveness is not known.

Fieldwork findings

Fieldwork aimed to test the relevance, usefulness and feasibility of putting the recommendations into practice. The PDG considered the findings when developing the final recommendations. For details, see the fieldwork section in appendix B and the fieldwork report.

Fieldwork participants who work with looked-after children and young people were positive about the recommendations and their potential to help promote the physical and emotional health and wellbeing of these children and young people. Many participants stated that they exemplify best practice.

For clarity, they felt it would be best if the recommendations were grouped together according to who should be taking action. Generally, greater clarity was needed on who should take action – wherever possible, specific job roles should be included.

Participants also wanted more explicit links to existing guidance and policy. In addition, they expressed a need:

  • for more emphasis on children and young people in residential care

  • for more robust suggestions on how to achieve inter-agency working

  • to promote the social and emotional wellbeing of parents and carers

  • to acknowledge drug and alcohol abuse in families and its potential impact on looked-after children and young people.

The recommendations were seen to reinforce aspects of the Department of Children, Schools and Families 'Statutory guidance on promoting health and wellbeing of looked after children'.

Practitioners and commissioners said the recommendations did not offer a new approach, but agreed that the measures had not been implemented universally. They believed wider and more systematic implementation would be achieved if there were:

  • more resources and more training for practitioners

  • greater administrative support for social workers to help manage policy and procedural requirements.

Consultation with looked-after young people and care leavers

The guideline was well received by looked-after young people. In particular, there was strong support for the recommendations on life-story work, access to personal information and health assessments.

In addition, there was strong support for recommendations that aim to make 'the voice of the child heard', with participants stressing the need for clarity about their role in decision-making. They also stressed the need for greater involvement and control in terms of decisions made about and for them.

They were pleased to see the issue of stigma and prejudice addressed – violence and bullying was a particular concern. Participants suggested expanding this group of recommendations to include, for example, assertiveness training for looked-after children.

The question about whether or not it would be possible to implement the recommendations was also raised, with some recognising that limited resources and heavy caseloads get in the way of best practice.

  • National Institute for Health and Care Excellence (NICE)