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Standard 1: Promoting Health and Well-being Identifying Needs and Intervening Early

The National Service Framework for Children, Young People and Maternity Services establishes clear standards for promoting the health and well-being of children and young people; and for providing high quality services that meet their needs. There are eleven standards, of which this is the first.

Vision

We want to see:

  • All children and young people achieving the best possible physical and emotional health and well-being, both in childhood and into adulthood.
  • Children, young people and families supported and able to make healthy choices in how they live their lives.
  • A measurable reduction in inequality of health outcomes for children and young people.
  • Integrated services which provide effective checks and more targeted support for children and young people who need it.

Standard:

The health and well-being of all children and young people is promoted and delivered through a co-ordinated programme of action, including prevention and early intervention wherever possible, to ensure long term gain, led by the NHS in partnership with local authorities.

Markers of Good Practice

  1. The Child Health Promotion Programme is offered to all children and young people and their families in a range of settings.
  2. By the child's first birthday, a systematic assessment of their physical, emotional and social development and family needs is carried out. Information resulting from assessments and interventions is recorded in the Parent-Held Child Record.
  3. Screening and immunisation programmes within the Child Health Promotion Programme are delivered to all children through partnership working.
  4. Where there are concerns about a child or young person's health and development, they receive timely and effective assessment and response.
  5. Therapy services are available for all children and young people who require them, and systems are in place to minimise waiting times for access to these services.
  6. Health promotion, in terms of awareness raising, information giving and support services, including the Child Health Promotion Programme, is reflected in improved outcomes for children and young people.
  7. All schools work towards becoming part of the Healthy Schools Programme, and are responsive to their school population's needs.
  8. Primary Care Trusts and Local Authorities tailor health promotion services to the needs of disadvantaged groups, including children in special circumstances, identified through a local population needs assessment.

Rationale

2.1 Children and young people say that they want to be healthy and stay safe. Parents are the main providers of health care for their children, particularly in the early years. This standard addresses health promotion activities delivered by professionals from health, social care, education and other agencies, working in partnership with parents, to improve outcomes for children and young people. Services offered may be universal, targeted or specialist, as needed by individual children and young people. Good communication and joint working between agencies is essential.

2.2 An important component of promoting the health of children and young people is the early identification of illnesses, environmental factors or individuals' activities that may contribute to disease, ill health or injury. Children, young people and their parents can then make informed choices and be properly supported.

2.3 There are several areas in the lives of children and young people where being able to make healthy choices will make a real difference to their life chances and/or health, social and economic outcomes. These include a healthy diet and physical activity for children and young people, maximising social and emotional wellbeing, keeping children and young people safe, avoiding smoking, or using volatile substances and other drugs and minimising alcohol intake, and reducing the risk of teenagers getting pregnant or acquiring sexually transmitted infections.

2.4 Specific actions which promote health for children and young people include:

  • The implementation of the Child Health Promotion Programme;
  • The identification of, and early intervention in children and young people with health and social care needs;
  • Promoting healthy lifestyles and safe communities;
  • Co-ordinated health promotion activities in schools and early years settings;
  • Promoting healthy lifestyles for children in special circumstances (e.g. implementing the DfES funded Healthy Care Programme1 (NCB 2002) for looked after children); and
  • Addressing inequalities in child health.

2.5 Family poverty is one of the most important factors influencing children's attainment. It can be a key link in a chain of poor health and social outcomes throughout childhood and the teenage years, resulting in social exclusion in adulthood.

2.6 Families living in poverty are less likely than other families to access health and other supportive services. Their children have higher than average rates of overweight and obesity, tooth decay, unintentional injury, and although death is a rare event in childhood it occurs more frequently in disadvantaged families. Similarly there are higher than average rates of substance misuse, smoking, teenage pregnancy, poor educational attainment, unemployment and social exclusion, but have lower breastfeeding rates. See also Standard 11.

2.7 To make a real difference to these families, health promotion activities must be tailored to their specific needs and circumstances. The Child Poverty Review sets out the Government's plans to tackle child poverty over the next decade.

Interventions: 3. The Child Health Promotion Programme

3.1 The Child Health Promotion Programme provides a framework to ensure the promotion of the health and well-being of individual children and young people. Promoting the local community's health through raising awareness, information provision and improving access is key to meeting the aims of this standard.

3.2 The Child Health Promotion Programme is part of the overall strategy the Government set out in Every Child Matters to strengthen early intervention by enabling children to receive help at the first onset of problems and to prevent any children from slipping through the net.

3.3 Evidence suggests that a revised approach to child health surveillance is now required. Health for All Children stresses that the social, economic and environmental context in which children grow up can have a very significant effect upon their health. This indicates a need to move away from a narrow focus on health screening and developmental reviews to a more broad-based programme of support to children and their families, that helps to address the wider determinants of health and to reduce health inequalities.

3.4 The Child Health Promotion Programme (see Figure 1) replaces the current Child Health Surveillance Programme, and puts in place a comprehensive system of care that encompasses:

  • The assessment of the child and family's needs;
  • Health promotion (See also Section 4 of this Standard);
  • Childhood screening;
  • Immunisations;
  • Early interventions to address identified needs.

Figure 1 Overview of the Child Health Promotion Programme

This table sets out health promotion services that will be offered to all pregnant women and children and for which there is evidence of effectiveness. Services may change as new evidence emerges, particularly in the area of adolescent health, and in response to new health concerns (including priorities that may be identified in the White Paper on public health). See Standards 6 and 11 for pre-conception care and advice.

This schedule is underpinned by a health promotion programme, based on best available evidence, that focuses on priority issues such as healthy eating, physical activity, safety, smoking, sexual health and mental health, and is delivered by all practitioners who come into contact with children and young people, and in all settings used by this age group.

3.5 The Child Health Promotion Programme is delivered by multi-agency child and family support services, and addresses the needs of children from preconception through to transition to adulthood. It offers a structure for the provision of essential activities to promote the health and development of children and young people.

3.6 Improved outcomes for children and young people are more likely to be achieved if effective health promotion interventions, as outlined in section 4 of this standard, are delivered as an integral part of the programme.

3.7 More intensive and targeted health promotion and surveillance should also be offered where particular community needs are identified. The provision of new targeted services, using the new flexibilities in primary care contracting, in areas of poverty and deprivation, will provide more opportunities for health promotion, early identification and intervention.

3.8 Working towards this standard will meet the national target (jointly set for DfES and the Department for Work and Pensions) to improve children's communication, social and emotional development, so that by 2008, 50% of children reach a good level of development at the end of the reception year in primary school (end of the Foundation stage of the National Curriculum). It will also help to achieve the target to reduce inequalities between the level of development achieved by children in the 20% most disadvantaged areas and that of the rest of England, and to achieve the DH and DfES obesity target See section 4. See Standard 11

Primary Care Trusts ensure that:

  • The Child Health Promotion Programme is offered to all children using all suitable settings (e.g. children's centres, early years providers, general practices, extended schools etc). The programme actively promotes good health through prevention and early interventions See Figure 1. A quality assurance system for the programme is in place.
  • The Programme is a universal service that is personalised as appropriate to meet the needs of the child and family. More support is available on a targeted basis to children and families that are vulnerable or have complex needs. The Programme is delivered in partnership with parents to help them to make healthy choices for their children and family.
  • Sections of the population where take-up has been lower (for example, lower socio-economic groups, minority ethnic communities and mobile populations) are actively encouraged to participate in the development of the Child Health Promotion Programme and in planning local service delivery. Issues concerning rural communities and local transport provision are also considered.
  • Based on local needs assessments, Primary Care Trusts consider the use of new flexibilities to develop primary care teams targeting services on communities with particular need.

Opportunities are taken to review the needs of children who have entered the country or those who have moved area.

Screening

3.9 Screening is an integral component of the Child Health Promotion Programme, as set out in Figure 1. The current screening tests offered to pregnant women and children are outlined in Health for All Children4 and on the National Electronic Library for Health website.

3.10 Specific population-based screening programmes can result in the early detection of certain health problems in babies and children. Where this is followed by effective timely intervention, such a programme can improve outcomes. For health problems where curative treatment is not available, early detection and early intervention can maximise life chances and improve the quality of life of children and their families through, for example, the early provision of therapy, social support, financial support, special educational needs input and physical aids.

3.11 Screening programmes are more effective where they are an integrated part of children's services with clear referral arrangements for children who 'fail' screening tests. When new screening tests are introduced, consideration should be given to the implications for the wider delivery of children's services (e.g. neonatal screening for hearing loss has major implications for ear, nose and throat services).

3.12 Parents require clear information, in a format that is sensitive to their social, cultural and educational needs. Duties under the Disability Discrimination Act need to be taken into consideration when considering the provision of information in appropriate formats and language. Information should cover the purpose of the test, its reliability, and what happens if a child "fails" the test.

All screening programmes are undertaken in accordance with the UK National Screening Committee's recommendations on what constitutes safe, effective, evidence-based child health screening. See www.nsc.nhs.uk

Primary Care Trusts monitor uptake of screening programmes and refine them where appropriate.

Primary Care Trusts ensure that:

  • Screening programmes are commissioned to meet national standards.
  • Parents have access to clear and comprehensive information, which is available in a format that meets their social, cultural and educational needs;
  • Parents and appropriate health professionals receive the findings of screening tests in a timely manner.

Preventing Infectious Diseases

3.13 Routine childhood immunisations have had a significant impact on the rate of preventable infectious diseases in England. In order to prevent outbreaks of diseases such as measles from returning, at least 95% of the population need to be immunised. This also helps to protect families and the wider community, including those children who have not yet been, or cannot be, immunised.

3.14 Parents' perceptions of the seriousness of many diseases that are preventable by immunisation decline as the rate of the diseases themselves continues to drop. Measles, for example can be a serious illness which can lead to complications that can sometimes kill. In 1987 (the year before MMR was introduced in England), 86,000 children caught measles and 16 died. Today, the number of babies in parts of England who are taken for their MMR vaccination has now dropped to a level where there could be local outbreaks of these diseases again. In 2002-03, 82% had been immunised against measles, mumps and rubella with the combined vaccine: well below peak coverage of 92% achieved in 1995-966. Effort is needed to maintain, and at times boost, coverage, both within the main population and among subgroups.

There is good evidence to show that targeting parents and children with appointment cards and reminders is effective in increasing immunisation rates and among children who are not up-to-date. Personalised reminders i.e.  from the general practitioner or health visitor, are likely to be more effective than those from an organisation.

3.15 Locally, child health information systems that automate immunisation appointments and reminders can help to maximise uptake by identifying non-immunised children for community nurses to follow up. Some children and young people coming from abroad may not have been immunised, or their immunisation history is unknown; they should be assumed to be unimmunised and a full course of immunisation should be planned. Routine distribution of immunisation information, in all appropriate languages, around the time of immunisation, can allow parents to make informed choices.

All children receive immunisation against major vaccine-preventable infectious diseases. The current schedule of childhood immunisations can be found at the website www.immunisation.nhs.uk. Opportunities are taken to check the immunisation status of children (based on the Parent-Held Child Record and the child's record within the NHS Care Record Service) when they are in contact with services in any health setting, and to refer them for 'catch-up' immunisation. Programmes are supported by good quality information and advice about the evidence base for immunisation and the risks involved. Parents and professionals have access both to national sources of information including www.mmrthefacts.nhs.uk and www.immunisation.nhs.uk, and to local information sources.

Immunisation programmes are co-ordinated by a named 'immunisation coordinator' within each Primary Care Trust, who works with the Local Authority and monitors coverage rates against current national target rates. Specific approaches are developed for groups with below target coverage. Failure to attend for a scheduled immunisation triggers a contact to find out and assess the reasons.

Professionals ensure that the immunisation history of all children and young people who enter the country or who move into the area is ascertained. Children who are not immunised, or whose history is unknown, are offered a full course of immunisations and transferred to the routine programme appropriate for their age. Specific immunisations are targeted at high risk groups, as recommended by the Department of Health. (See www.dh.gov.uk, which is updated as new immunisations or evidence become available.)

Assessing Needs and Intervening Early
Assessing and Identifying Individual and Family Needs

3.16 The Child Health Development Programme (outlined in Figure 1) provides a framework for a formal planned assessment of children's needs. The purpose of these assessments is to allow early identification of health problems (physical, emotional or developmental) for an individual child, to identify families who may require additional input, and to ensure that parents have sufficient support in their parenting role. The framework also provides an opportunity to identify those children and their families who need considerably greater input.

3.17 Many children will receive more contacts with a variety of primary health care professionals than the minimum set out in Figure 1, and professionals need to be alert to possible concerns. It is important that primary care professionals take opportunities to discuss a child's physical and emotional development with parents during consultations which may take place as a result of parental concerns or during immunisation or well-baby clinics.

3.18 The health visitor, in consultation with the parents, the midwifery service and other professionals and agencies working with the family starts the process of assessing the needs of the child and family before the birth. This will help to ensure a smooth transition from the midwifery to the health visiting service.

3.19 The child and family needs assessment will be reviewed in the light of changes in family circumstances. A review may be triggered at any time by the parents or carers or by professionals. It is proposed that the Common Assessment Framework (currently being developed) will be used where there are concerns which may require support to be provided by more than one agency. It is important that the various professionals who are involved in assessing the child's and the family's needs work in partnership and share relevant information as required. See Standard 3

3.20 People looking after children such as child minders and nursery staff are in an excellent position to identify children whose social, physical, emotional or behavioural development falls outside the norm. Improved training will enhance their contribution. Health Visitors have a key role to play in working with early years staff to raise awareness and understanding of children's health and development needs and to provide a referral point for further assessment.

3.21 It is equally important to identify school-age children who are experiencing difficulties relating to their health, development and their ability to learn. In particular, support is needed to help children manage transitions such as starting school and moving to secondary school. In addition, some children will have medical needs and disabilities that require specific support or even nursing care.

3.22 The school nursing service plays an essential role in promoting the health of school age children. The Chief Nursing Officer's review of the nursing, midwifery and health visiting contribution to vunerable children and young people has suggested that Primary Care Trusts, Children's Trusts and local authorities work towards having a minimum of one full-time, whole year, qualified school nurse in every secondary school and its cluster primary schools.

3.23 Additional funding has been made available to increase overall NHS capacity, where needed, additional school nurses. The availability of a range of staff in schools who can support children and young people will support the attainment of several Department of Health national targets and the Department for Education and Skills PSA targets, including those on child and adolescent mental health services and those addressing teenage pregnancy, child obesity and school attendance. (See Standard 3) Also see Standard 4 for the Government's target for reducing teenage pregnancy.

Planning Care

3.25 The importance of any assessment, whether it is carried out at the designated times specified in Figure 1 or during other consultations with professionals who work with children, is that it leads to planning in partnership with families, and the provision of appropriate and timely interventions. Assessment may lead to one or more of a number of outcomes outlined in Box 1.

Box 1: Possible outcomes from child and family assessments

  • Outcomes of individual assessments may include planning for:
  • Continuing regular contacts on a long term basis;
  • Short term input;
  • Parents to request a review of their child's progress at a time of their choosing;
  • Parents to call their health visitor if they have any further worries; and
  • For referral to other services and specialist assessments when required.

3.26 Planning in partnership with parents or carers is key to enabling a family to address their health and parenting needs. Planning identifies:

  • The family's needs as they see them;
  • How they wish to address these needs;
  • Agreement with the family about the support to be provided by the midwife, health visitor and others, and
  • What has been achieved.

3.27 In some areas, Family Health Plans are used to record the outcome of the dialogue between the health care professional and the family. Further information on Family Health Plans is set out in the Heath Visitor Development Resource Pack 20018. A summary of the main issues identified and key actions can also be recorded in the Parent-Held Child Record.

Intervening Early

3.28 Where referral to other services is required, prompt access is key to addressing parental concern and improving children's and young people's chances of achieving their full potential. Children with developmental delay should receive early interventions to address their needs, provided by a range of health, education and social care professionals, in a variety of settings.

3.29 Where Primary Care Trusts identify the need to increase capacity locally to enable them to intervene early, additional staff, including allied health professionals may be needed (See The NHS Improvement Plan, paragraph 2.7). An increase in staffing should be coupled with innovative practice to improve the effectiveness and efficiency of these services, and will include role and service redesign in order to ensure the most effective and efficient use of skills available within the whole team, including any administrative staff.10 (See also Standard 8.)

Primary Care Trusts ensure that:

  • A systematic assessment of each child's physical, emotional and social development and family needs is completed by their first birthday. The process starts before the birth of the child and involves the parents, the midwifery service, the health visitor and any other professional or agencies working with the family.
  • The assessment identifies key risk factors such as parental mental health problems or domestic violence.
  • A summary of the key issues identified and interventions required is documented in the Parent Held Child Record (or Family Health Plan where these are used). This will include agreeing future contact between the family and the service
  • Practitioners take every opportunity, including during immunisation clinics and well baby clinics, to discuss the progress of a child's development with their parents or carers. Practitioners have the time, capacity and skills to undertake this role and are aware of referral routes where there are concerns about the child.
  • Parents know whom to contact if they have concerns about their child's health and development. Face-to-face contact with the health visiting team is available, if requested.
  • The child's and family's needs assessment is updated, where appropriate, in the light of changes in the family's circumstances. A formal review of the assessment (unless regular contact is already in place) takes place between the child's second and third birthday. The health visitor will make contact through a variety of means, such as at child health clinics and early years providers, or direct with parents, by post, phone or e-mail.
  • Health visitors work in partnership with other early years staff to raise awareness and understanding of children's health and development needs, and act as a referral contact for them to the primary care team, or other services such as therapy services, if they or the parents are concerned about a child.
  • The Health Visiting service promotes Bookstart to enable all children to access reading materials at the appropriate developmental stages.
  • Health visitors access information held by general practitioners when assessing the progress of children on their list.
  • All professionals working with children and young people are aware of health and developmental problems and are proactive in identifying opportunities to promote a child's health and well-being. Systems are in place to ensure that signs of physical or mental ill health or developmental difficulties are identified and appropriate referrals made.
  • Education and social care professionals are able to refer children directly to health visitors and primary care providers trained to identify children who need referral to Child Development Centres or specialist paediatricians.
  • School age children are able to access advice and support in a range of settings. This includes school-based clinic or drop-in sessions provided by school nurses or other healthcare provider. Using additional funding made available to increase overall NHS capacity, Primary Care Trusts can, if a local priority, increase the school nursing workforce and carry out the required redesign of the service to school aged children.7

Primary Care Trusts and Local Authorities review local therapy services in order to:

  • Promote self-referral, and other means of simplifying the care pathway, and reduce excessive waits that may affect a child's development; and
  • Improve administrative systems and processes for referral and discharge, and the effectiveness of outcomes of different therapeutic regimes, such as group sessions.

In developing and implementing assessment and planning processes, Primary CareTrusts and local authorities use the forthcoming Common Assessment Frameworkwhere there are concerns which may require support being provided by more than one agency. See Standard 3

4. Health Promotion

4.1 Health promotion involves a wide range of activities at every level in societyf rom Government policies, through local community strategies, to individualsm aking healthy choices. To achieve improved health outcomes for childrena nd tackle health inequalities, interventions need to begin before conception,and continue throughout childhood and adolescence.

4.2 Healthy mothers are key to giving babies a healthy start. Maternal and neonatal outcomes are poorer for women from disadvantaged, vulnerable or excluded groups. Low birthweight is a major cause of infant mortality in the UK, and can also have a long-term impact on the health and well-being of children. Low birthweight rates vary widely according to socio-economic status. Two key interventions reduce the risk of low birthweight: promoting stopping smoking and optimum nutrition during pregnancy. See Standard 11

4.3 Parents value advice and support on key health and behavioural issues such as breastfeeding, establishing a routine, sleep, nutrition, safety issues (e.g. the prevention of sudden infant death etc). The guide Birth to Five11 gives practical advice on a wide range of issues relating to the care, health and development of children.

All Primary Care Trusts and local authority have in place child and family health promotion programmes. As well as addressing individual needs, these include targeted programmes for vulnerable children and community-based programmes addressing local and national public health priorities such as accident prevention, nutrition, and physical activity. Multi-agency strategies for health promotion reflect the particular needs and characteristics of all babies, children and young people and their families.

Staff in all agencies use opportunities for promoting the health and well-being of pregnant women, parents or carers, and babies, children and young people. These may include national and local health promotion campaigns and materials designed for particular groups known to under-use services. Community pharmacists are already involved in health promotion activities and this role will be enhanced with the proposed new pharmacy contract.

The guide Birth to Five is distributed to all parents or carers. Health promotion activities for children and young people are tackled imaginatively in order to appeal to children and young people, on their terms and in their language (e.g. using high quality, evidence-based websites such as 'Diary of a teenage health freak').

Positive Mental Health of Children and Young People

4.4 All children and young people need to feel secure and supported if they are to achieve their full potential. Parents (both mothers and fathers) or carers are fundamental to creating a nurturing environment, particularly in the early years. See Standard 2

4.5 There are some children and young people who will be at greater risk of developing mental health or behavioural problems. For these children and their parents, assessment of their needs and provision of early intervention can make a significant difference, although facilitating their use of the services requires planning and skill. They include children:

  • whose parents are mentally ill, have learning disabilities or have personality difficulties;
  • whose parents misuse drugs or alcohol;
  • whose parents are unsupported by wider family;
  • who are abused (whether emotionally, physically or sexually);
  • who experience inadequate parenting or neglect;
  • who have learning difficulties and or disabilities;
  • who smoke, use illegal drugs, volatile substances and/or misuse alcohol;
  • who are living in a household where there is domestic violence;
  • who are looked after by a Local Authority, and/or
  • who are homeless and living in temporary accommodation.

4.6 There is a body of evidence available about the approaches that are most effective in reducing the risk of a problem or disorder occurring, or enabling it to be identified and treated before symptoms become too severe, these are outlined in Box 2.

Box 2: Prevention and Early Identification and Treatment of Mental Health Problems

  • The earlier in a child's life that a problem is identified and intervention starts, the more likely it is to be effective;
  • Multiple-component, multi-year programmes, which focus on a range of risk factors using a range of strategies, are more likely to be effective;
  • Early years settings and school based/community-based programmes which simultaneously focus on family and environmental factors within which children live as well as on the child are more likely to be successful than programmes which focus on the child alone;
  • Prevention programmes focussed on first-time mothers/parents are particularly effective because of their need for social support and child-rearing assistance;
  • Extended home visiting reduces the risk of physical maltreatment and neglect in high-risk groups (e.g. low socio-economic status, young single mothers); and finally
  • Effective programmes have the following features in common: (a) comprehensiveness, (b) systemic orientation, (c) relatively high intensity and long duration, (d) structured curriculum, (e) early commencement, (f) specific to particular risk factors, and (g) provide specific training.

Mental health promotion is delivered through partnership working between all relevant agencies, including health, education, social services, youth justice, youth and community and voluntary organisations.

Children's mental health is promoted in a structured way using the DfES Guidance Promoting Children's Mental Health in Early Years and School Settings12 at www.dfes.gov.uk/mentalhealth/pdfs/ChildrensMentalHealth.pdf

Child and family teams identify and work with vulnerable women and families, providing continuity of support both before and after birth. They work to a structured programme of proven efficacy, giving priority to mothers who have themselves had a history of poor parenting or mothers who are at risk of forming poor attachments to their young children. See Standard 2

Parenting education, focussed on enhancing sensitivity, is provided for parents in a high risk group in the first six months of the child's life, to improve attachment security. Parenting education can also be provided early on to children in schools by families and parents from the local community, as part of the Department of Health's self-care support strategy. See Standard 9

Healthy Diets and Active Lives - Early Years

4.7 A healthy diet and regular physical activity are important determinants of general health and well-being. The Health Survey for England 200213 has studied overweight and obesity in children. In summary, the survey found that:

  • obesity is continuing to increase in children;
  • overweight and obesity combined increased by over 25% between 1995 and 2002;
  • 28% girls and 22% of boys, aged 2-15 years, were overweight or obese, and
  • overweight and obesity increased with age and are more common in children and young people from manual households.

4.8 Poor diet and inactivity in childhood are associated with increased risk of cardiovascular disease, several cancers, musculoskeletal problems and tooth decay, as well as overweight and obesity in later life. Overweight and obesity increase the risk of type 2 diabetes, and can have an adverse impact on emotional well-being and self-esteem.

4.9 The best long-term approach to tackling obesity is prevention, particularly in childhood. Critical to this is improving diet and increasing physical activity levels which will help deliver the national (DH/DfES/DCMS) target to halt the year-on-year rise in obesity among children under 11 by 2010 in the context of a broader strategy to tackle obesity in the population as a whole. Action needs to take a 'lifecourse' approach, which starts from birth and tackles the inequalities that exist between social groups. Breastfeeding is the best nutrition for infants and is associated with better health outcomes for the mother and her infant. See Standard 11 for initiatives to support breastfeeding

4.10 The DH national target on improving the health of the population identifies current challenges including the need to focus on improving nutrition in women of childbearing age, particularly those who are pregnant or breastfeeding. Primary Care Trusts in partnership with local authorities, will wish to focus on some of these in setting local targets.

4.11 Healthy Start (which replaces the Welfare Food Scheme) offers Primary Care Trusts and health professionals a tool for identifying local disadvantaged pregnant women and their families, and for ensuring that local services meet their needs. This will assist effective local delivery of services in a way that reduces inequalities.

4.12 The Royal College of Paediatrics and Child Health and the National Obesity Forum have published guidance on weight management in children and adolescents, available at:

Professionals provide pregnant women, mothers with infants and young children from low income families with health advice through the Healthy Start scheme.

Primary Care Trusts and health care professionals ensure that efforts are made to improve nutrition in women of childbearing age, particularly those who are pregnant or breastfeeding.

Children in early years learn about health, personal, social and emotional development, physical development, creative development and communication, language and literacy, using the Birth to Three Matters framework at the foundation stage curriculum.

Early years settings promote health promotion to improve diet and nutrition and activity levels. Health professionals provide parents with advice and support on the growth of their children. Professionals can access information on the evidence base for the provision of advice, and support the management of overweight and obesity in children.

Unintentional Injury: Staying Safe in the Community and at Home

4.13 Unintentional injury is an important cause of morbidity and mortality in children and young people. In 2002 in England and Wales, over 200 children under 15 died as a result of injury or poisoning, and approximately half of all accidental deaths among children under five occurred as a result of accidents in the home14. In the UK in 2002, over 26,000 children under five were taken to hospital after suspected poisoning. Almost one million children aged 5-14 were taken to hospital following an accident outside the home (not including road traffic and work accidents).

4.14 Unintentional injury affects children from poorer families disproportionately. It is therefore important that parents or carers are supported to protect their pre-school children. Road accidents are also a significant cause of death among children and young people.

Primary Care Trusts and Local Authorities ensure that childhood injuries and accidents are reduced through the development and monitoring of injury prevention strategies that target priority areas where there are marked inequalities.

A named lead in each locality develops, co-ordinates and monitors initiatives for tackling injury prevention. This would contribute to the national target to reduce the number of children killed or seriously injured by 2010 (see Department for Transport's PSA floor target). Parents with very young children receive advice from home visitors and other family advisers regarding the practical steps to take to protect their children against falls, scalding, burns, drowning, choking and poisoning.

Early years settings, schools and local authorities ensure that school-age children are encouraged to participate in safety training schemes run by schools, local authorities or voluntary organisations, such as cycling proficiency, and effective safety training should be provided for those who work with children and young people.

Local Authorities provide clear guidance on the effective use of equipment, such as cycle helmets, child car seats, seat belts, fireguards and stair gates, thermostat controls on hot water taps, and smoke alarms. Primary Care Trusts and Local Authorities, in partnership with other local agencies, work together to make the local environment safer for children and young people, including undertaking injury surveillance, and sharing data effectively.

Good Oral Health

4.15 Good oral health is an integral part of general health promotion and oral/dental care is frequently an integral part of any care pathway. The four main areas of concern for oral health are tooth decay (dental caries), dental erosion, gum disease, and unintentional injury causing tooth fracture or loss.

There is considerable evidence that untreated decay is concentrated in children from deprived areas and, as a result, there are inequalities across the country with young children in the North of England having as much as twice the amount of decay compared with children in some areas of the South. In a recent survey, on average, 39 per cent of 5 year olds had one decayed, missing or filled tooth, with wide geographical variation.

4.16 Dental decay is an almost entirely preventable disease. The fluoridation of public water supplies should be promoted as a public health measure to reduce dental caries and inequalities in dental health. The 2003 Water Act will enable local water supplies to be fluoridated providing there is clear local support for this. Commissioners of children's services need to consider techniques (such as fissure sealing) as a preventive health measure, particularly for vulnerable groups of children.

4.17 Disabled children tend to have the same dental diseases as other children, but are less likely to have their treatment needs met. Children on long-term medication are more prone to developing dental caries unless the medication is sugar-free See Standard 10. Commissioners of children's services may need to consider the need for specialist dental services for these vulnerable groups.

4.18 The Government is committed to the reform of NHS dentistry. A new contract for dentists will be introduced from October 2005. An extra £368 million has been allocated to recruiting the equivalent of 1,000 more dentists, by October 2005 funding an extra 170 training places for undergraduates in dental schools and increasing the overall expenditure on primary care NHS dental services over two years by 19%. From 2005, all dental services will be commissioned locally by Primary Care Trusts who will have a duty to provide and secure Primary Dental Services to the extent it considers necessary to meet all reasonable requirements.

The oral health needs of children and young people, particularly those who are vulnerable, are identified in local health promotion programmes. This includes encouraging early registration with a dentist and the provision of effective and appropriate oral health promotion and treatment policies and reducing sugar consumption.

Primary Care Trusts plan the transfer of responsibility for dental services to ensure adequate service provision for all children and to address any access issues identified through local needs assessment.

Healthy School Settings for Children and Young People

4.19 Schools and colleges have a key role in shaping the habits and behaviour of children and young people and are in a unique position to encourage and facilitate healthy eating and active lifestyle and to promote self esteem. A partnership approach, linking early years settings and schools to other relevant local agencies such as social services, youth offending teams and Connexions, is essential to maximise the impact of these settings in changing children's lifestyles. There is some evidence that education programmes to promote healthy eating in schools are effective in changing diet. The Healthy Schools Programme (to commence in 2005) replaces the National Healthy Schools Standard, and will lead to more structured health promotion in schools, with an emphasis on targeting the needs of local school populations of children and young people.

4.20 The Healthy living blueprint for schools (DfES 2004) sets out ideas on how schools and early years settings might develop so that children and young people are supported in becoming healthier. The intention is to tackle lifestyle through the Curriculum, through the Healthy School Programme and through policies on what children and young people eat in schools, for example, and on a full range of opportunities for promoting physical activity and sport. A web portal www.teachernet.gov.uk/healthyliving has been launched to bring together a wide range of helpful resources for schools.

4.21 Access to organised sport needs to be improved and a range of affordable activities to suit all ages and abilities needs to be provided throughout the year. Local authorities have a key role in providing safe and accessible outdoor play spaces and other recreational facilities. An increasing number of schools are working together in school sport partnerships (as a response to the national strategy) to increase opportunities.

Working towards this standard will help to meet two national targets: one, set by the Department of Culture, Media and Sport (DCMS) to, by 2008, increase the take-up of sporting activities by adults and young people aged 16 and above from priority groups by increasing the number who engage in at least 30 minutes of moderate intensity level sport at least three times a week. The second is a joint DfES/DCMS target to enhance the take-up of sporting opportunities by 5 to 16 year olds so that the percentage of school children in England who spend a minimum of two hours each week on high quality PE and school sport within and beyond the curriculum increases from 25% in 2002 to 75% by 2006 and to 85% by 2008, and to at least 75% in each School Sport Partnership by 2008.

Children and young people have access to confidential, accessible and supportive health services that may be made available as part of the DfES

Extended Schools programme. Primary Care Trusts, with their Local Authorities and Children's Trusts, support schools in becoming part of the Health Schools Programme, and work towards achieving the objectives outlined in the Healthy Living blueprint for schools. Personal, Social and Health Education (PSHE) and citizenship policies and programmes are developed. They are informed through consultation with the whole school community - parents, pupils, staff, governors and external partners.

These programmes, in line with (and with support from) the Healthy Schools Programme, in partnership with school health teams, bring together policies on:

  • Strengthening awareness of safety and emotional health and well-being, including tackling bullying;
  • Healthy eating, healthy weight and physical activity;
  • Drug education (including alcohol, volatile substances and other drugs, and tobacco);
  • Responding to, and managing drug-related incidents;
  • Provision on other health related matters, such as injury prevention; bullying (following the best practice set out in the DfES Anti-bullying pack at www.dfes.gov.uk/bullying/pack/02.pdf) and bereavement
  • Sex and relationship education, and
  • Staying safe in the sun.

Where appropriate, these issues are also addressed within the general curriculum. A 'Whole School' or 'Whole Setting' Approach is taken to health promotion in schools, to improve diet and nutrition and activity levels which includes:

  • Ensuring minimum nutritional standards are met, where applicable, and monitoring the nutritional quality of meals in early years settings and schools;
  • Raising parents' awareness of their entitlement to claim free school meals, and implementing "smart card" schemes and other initiatives to reduce stigma and promote greater take-up;
  • Raising parents' awareness of nurseries' ability to claim reimbursement for provision of free milk or fruit through the Healthy Start scheme;
  • Taking action to 'de-brand' the school environment and to follow guidance on commercial activities in schools (including voucher schemes, vending, taste testing and classroom materials);
  • Encouraging schools to implement the School Fruit and Vegetable Scheme to provide a piece of fruit daily to 4-6 year olds and look at ways to increase the intake of fruit and vegetables amongst children outside the scope of the scheme, for example, through fruit in tuck shops;
  • Walking to school with parent or as part of a 'walking bus'.

Local organisations take steps to ensure that each secondary school or college, and its cluster of feeder primary schools, has a named and appropriately trained school nurse to assess health needs and lead the delivery of effective public health programmes.

Children and young people who are overweight are referred to appropriate services, such as family-orientated therapy and excercise referred schemes.

Primary Care Trusts and local authorities ensure that local plans and services provide children and young people with a range of recreational facilities and opportunities to build physical activity into their daily lives (e.g. play schemes, "school travel plans"). These may need to be adapted for those in rural communities. Children and young people are involved in planning local activities and amenities. Schools have strategies for helping children and young people to achieve at least sixty minutes of moderate intensity physical activity each day. At least twice a week, this should include activities that promote bone health, muscle strength and flexibility.

All agencies actively focus on children and young people who have not traditionally engaged in sufficient physical activity (e.g. teenage girls, minority ethnic groups). Disabled children and young people are able to participate as far as possible in the range of activities available to other children. Every school has a school travel plan that addresses concerns about safety and health.

Health Promotion to Address Inequalities

4.22 All children, regardless of their background or social circumstances, have the right to receive services and information which gives them the maximum potential to grow up to be healthy adults.

4.23 Children and young people born into poverty - those in disadvantaged groups or areas, including those living in temporary accommodation and those living in areas of high unemployment or in areas with fragile social networks - have worse health and social outcomes than those from affluent backgrounds. They are more likely to be born prematurely, have low birth weight, die in the first year of life, or die from an accident in childhood.

4.24 In 2003, there were 3,145 deaths in infants under one, two in three of which occurred within the first 28 days of life18. The main causes of death were conditions relating to prematurity such as low birth weight, breathing difficulties and congenital abnormalities. There is a significant gap in rates of infant mortality between those people living in disadvantaged groups or areas, and other groups in the population - the socio-economic classification Class 3 (routine and manual) group was 16% higher than in the total population and 67% higher than in SEC Class 1 (managerial and professional group) in 2000-02. Infant mortality rate is also higher among certain minority ethnic groups. Deaths from injury and poisoning are more common in disadvantaged families.

4.25 Marked differences exist in the prevalence of mental disorders among children and young people in different social classes, with the most disadvantaged (social class V) being three times more likely to have a mental health problem than those from families in social class I: 16% compared with 6%.

4.26 There is also a social gradient associated with teenage pregnancy and daughters of teenage mothers are most likely to become teenage mothers themselves.

4.27 Similarly, although breastfeeding is associated with better cognitive development in childhood, less childhood obesity and a lower risk of cardiovascular disease, there are wide socio-demographic differences in the extent to which women breastfeed immediately after birth. A much higher proportion of women with partners in non-manual occupations breastfeed their babies. They are also less likely to smoke during pregnancy.

4.28 Many disabled children have greater health needs than the rest of the population. They are more likely to experience mental health problems and are more prone to chronic health problems, epilepsy and, later in life, agerelated diseases such as stroke, heart diseases, chronic respiratory disease and cancer. There is also an above average death rate amongst learning disabled younger people. See Standard 8

Primary Care Trusts and Local Authorities ensure that universal and targeted health promotion arrangements are in place, based on local health needs assessments and local health equity audits. These utilise creative approaches to engage children, young people and their families who have not traditionally engaged with services. Health promotion strategies include or link to programmes to tackle the impact of poverty and the environment on children's health and well-being, in particular to:

  • Help parents find and stay in learning or work as appropriate, including access to high-quality, affordable childcare (for both pre-school and school age children) and child-friendly working practices;
  • Ensure families with low incomes are encouraged to take part in the Healthy Start scheme which provides local advice and support to eat healthily and vouchers to buy healthy food;
  • Ensure families with low incomes are supported to claim all benefits to which they are entitled;
  • Undertake targeted activity with groups especially likely to be living on low incomes and have greater health needs, for example, teenage parents and families with disabled children and those who are homeless;
  • Ensure as far as possible that accommodation allocated by local authorities to families with children is not damp or cold (in line with the cross-Government fuel poverty strategy), has adequate space for play and privacy, and at least one working smoke alarm and a carbon monoxide detector, where appropriate;
  • Minimise environmental pollution, in residential areas and around early years settings and schools, and
  • Ensure equitable access to local leisure and recreational opportunities.

Health Promotion for Children in Special Circumstances

4.29 Primary Care Trusts have a duty to improve the health of their whole population. This will require working in partnership with other key agencies. Priority needs to be given to children, young people and families living in special circumstances who may need targeted health promotion interventions. There are some children and young people who are not registered with a general practice and particular consideration will need to be given to identifying, reaching and providing for this population.

4.30 Health Equity Audits are a key tool in tackling health inequalities. They can be used by Primary Care Trusts in partnership with other agencies to target resources or implement changes in practice to tackle local health inequalities.

Local planning includes targeted promotion of the health and well-being of children in special circumstances, including those from refugee and asylum-seeking families, young people in supported housing and young carers. Primary Care Trusts work with other agencies to identify children and families who are not registered with a general practice, to ensure that they are known to services and that their needs are met.

Services are reviewed and developed with the involvement of children, young people and their families or carers.

Primary Care Trusts and Local Authorities work in partnership with other agencies to develop health promotion strategies (such as the Healthy Care Programme1) for all settings providing services for children and young people in special circumstances.

4.31 Children and Young People who are looked after by local authorities are amongst the most socially excluded groups. They have profoundly increased health needs in comparison with children and young people from comparable socio-economic backgrounds who are not looked after. For example, looked after children are five times more likely than their peers to have a mental health problem. These needs, however, are often unmet, which results in these children and young people experiencing poor health, educational and social outcomes.

Local arrangements are in place to ensure that the Department of Health guidance on Promoting the Health of Looked After Children is implemented. The Healthy Care Programme is used to audit and continually improve the health and well-being of children and young people looked after.

4.32 Juvenile prisoners have higher rates of mental illness and levels of drug and alcohol misuse. They are at serious risk from self-harm, suicide and poor mental health. A significant proportion of these young people will previously have been looked after by a local authority. See Standard 4

Primary Care Trusts have arrangements in place to ensure access to appropriate local health services for juveniles and work in partnership with the Local Authority and the Prison Service to improve standards of health care and access for young offenders, including health promotion.

5. Training and Development

All staff who work with or come into contact with children, young people and their families in all agencies have the common core skills, knowledge and competencies outlined in Standard 3.

Multi-disciplinary and targeted training programmes ensure that staff have the capacity, skills and knowledge to support effective delivery of local health promotion strategies.

Teachers and school nurses who are engaged in PSHE participate in the DfES continuing development programme that certificates effective PSHE teaching.

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1 Chambers H., Howell S., Madge N. and Ollie H. Healthy Care Building an Evidence Base for Promoting Health and Well-being of Looked After Children and Young People National Children's Bureau 2002 www.ncb.org.uk

2 HM Treasury The Child Poverty Review The Stationery Office 2003 www.hm-treasury.gov.uk

3 Department for Education and Skills Every Child Matters The Stationery Office. 2003 www.dfes.gov.uk/everychildmatters/

4 Hall D. M. B and Elliman D. (Editors) Health for All Children, 4th Edition. Oxford: Oxford University Press 2003 www.health-for-all-children.co.uk

5 1979-1993 OPCS Communicable Disease Statistics (Series MB2) Annual Review of Communicable Diseases; England and Wales

6 NHS Immunisation Statistics, England 2002-03; Bulletin 2003/16, September 2003, National Statistics, Department of Health

7 Department of Health The Chief Nursing Officer's review of the nursing, midwifery and health visiting contribution to vulnerable children and young people August 2004

8 Department of Health The Health Visitor and School Nurse Development Programme: Health visitor practice development resource pack 2001 www.dh.gov.uk

9 Department of Health NHS Improvement Plan- putting People at the Heart of Public Services The Stationery Office June 2004 www.dh.gov.uk

10 Modernisation Agency - 10 High Impact Changes for Service Improvement and Delivery September 2004

11 Department of Health Birth to Five 2004 www.dh.gov.uk

12 Department for Education and Skills Promoting Children's Mental Health in Early Years and School Settings 2001 www.dfes.gov.uk/mentalhealth/index.shtml

13 Department of Health Health Survey for England 2002 Crown Copyright 2004 www.dh.gov.uk

14 Office for National Statistics Mortality statistics 2002, Injury and poisoning, England and Wales Series DH4 No. 27. www.ons.org.uk

15 Department of Trade and Industry 24th (Final) Report of the Home and Leisure Accident Surveillance System (2000, 2001 and 2002 data)

16 Office for National Statistics National Child Dental Health Survey 2003 - Preliminary Findings June 2004 www.statistics.gov.uk

17 Department for Education and Skills Healthy living blueprint for schools 2004

18 Office for National Statistics Childhood and Infant Death in 2002 March 2004 www.ons.gov.uk

19 Office for National Statistics The Health of Children and Young People March 2004 www.ons.gov.uk

20 Department of Health Promoting the Health of Looked After Children London: The Stationery Office. 2002

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