Comparing health outcomes for care experienced children and children in the general population in Scotland using linked administrative data

Children who are in the care of their local authority (care experienced children, CEC) are one of the most vulnerable groups of people in the society. In 2017 approximately 15,000 children in Scotland were visited by social care workers at home or placed in kinship, residential or foster care. These children often experience disadvantage compared to other young people, such as having to move homes or change schools frequently. Currently, very little is known about the health of CEC or how this compares to other children in Scotland. The small amount of evidence there is suggests that this group of children are more likely to experience poor health, such as worse mental health compared to other children. Our research aims to provide the first national level evidence on the health, pregnancy and mortality rates for CEC in Scotland.

Our project links different administrative data sources, such as social care, hospitalisation, birth and death registrations data, for children who were in school and experiencing care in 2009. The care experiences (the type, length and number of placements) and health outcomes for these children will be followed over seven years up to 2016. The health of CEC will then be compared to the health of school children who did not experience care between 2009 and 2016.

We will investigate the following research questions:
1. Do the health, mortality and pregnancy rates of school-aged CEC differ from the general population of school-age children in Scotland?
2. Do the health, mortality and pregnancy rates of school-aged CEC differ from the general population of school-aged children within deprivation categories across Scotland?
3. Which care experiences (type, length and the number of social care placements) increase the risks of adverse health outcomes, mortality and pregnancy?
4. How do different care experiences interact with deprivation and family socioeconomic status (SES) to affect the risks of adverse health outcomes, mortality and pregnancy?

The first two questions provide an understanding of the health of CEC relative to other children. We will look at a wide range of health outcomes (hospitalization rates, the number and type of prescriptions) to identify the ones for which health disparities between the CEC and other children are the greatest. For hospitalizations, prescriptions and mortality we will first look at overall rates, followed by cause-specific analysis that groups the major causes of illness. The main causes of interest are mental-health related outcomes (hospitalization due to self-harm or anti-depressant use) and mortality due to causes that could have been prevented with effective medical treatment (e.g. asthma) or by other interventions (e.g. accidents). If possible, we will also study other major causes of illness, such as respiratory diseases. These outcomes will be analysed by small-area deprivation to see if and to what extent the health disparities are explained by socioeconomic inequalities.

After getting a sense of the broad differences between the two populations, questions 3 and 4 will investigate in detail how different care paths, family SES, past health and other factors impact health, mortality and pregnancy rates. These results can say whether children who have frequent changes in care placements experience more health problems or whether children in certain types of placements are more likely to have health problems. This will help identify the location and timing for early interventions among CEC in Scotland.

The research results will be published in academic journals, but we will also write a research report for non-academic audiences. This report will present the main findings and is aimed at policy makers, professionals and service providers working with CEC. We will collaborate with the Centre for Excellence for Looked After Children in Scotland to develop the report and present this at a knowledge exchange workshop at the end of the project.

Care experienced children (CEC) are a vulnerable group of population, but little is known about their health in Scotland. International evidence suggests that compared to other children CEC suffer higher rates of mental health illness and mortality from causes that could have been treated or otherwise avoided. To plan policy interventions in Scotland we need to know which illnesses CEC are likely to suffer from and which causes contribute most to the potential health inequalities between CEC and other children.

Our work can contribute towards evidence-based policy-making, inform practitioners, enhance public services, and most importantly, improve the health and other long-term outcomes for CEC. The main beneficiaries from this will be the Scottish Government, the practitioners and social service providers at the local authority level, and ultimately the care experienced children. In addition, much this work, such as the findings on teenage pregnancy, should also be of interest to policy makers and practitioners in the rest of the UK.

In their report Getting It Right for Looked After Children (GIRFLAC) the Scottish Government (2015a) has identified that better health and well-being are necessary to achieve better outcomes for CEC. Our research supports achieving these goals through the evidence we can provide on health. Once we know which are the major causes of illness among CEC and which outcomes contribute most to the health differences between CEC and other children, we may be able to make recommendations on which health services to provide for the CEC. The analysis of health outcomes by deprivation categories will allow us to judge the role deprivation plays in the health of CEC, providing evidence on what effect policies aimed at reducing deprivation may have on health for this group of children.

We will provide information on the effects of permanence of care (the number of different placements) on health. If those who experience a large number of episodes during the study period have more health problems, then our recommendation to the policy makers would be to improve care permanence, particularly in the case of children who already exhibit health problems when entering the care system. We will analyse how the type of care affects health. If it is found that those in a specific type of care experience more health problems, the recommendation may be to review this particular care type. Together, these results can be used to motivate policy efforts to improve permanence and provide the most appropriate type of care for CEC.

In addition, one of the high priority goals of the Scottish Government's (2015b) Looked after Children Data Strategy published alongside GIRFLAC is to understand the long-term outcomes of CEC by linking the Children Looked After Statistics return to health data. Our research directly achieves this.

Our work provides evidence to implement the Scottish Government's (2016) Pregnancy and Parenthood in Young People Strategy, aimed to support young women in pregnancy, and may also support the English Teenage Pregnancy Prevention Framework (Public Health England 2018). By analysing the effects of deprivation and care experience on pregnancy rates, we can identify the population of young women who might benefit the most from policy interventions. Finally, the results on mental health outcomes can help the Scottish Government implement the suggestions put forth by the recent Audit Scotland report (2018), such as identify the level of mental health services required and how to target funding to best meet the needs of children.

Our research is conducted in a time and context where there are both clearly stated policy objectives and sufficiently good data to have a real chance to influence policy making and to improve outcomes for CEC, including those beyond health. Better health of CEC can support the goals of improved school attendance and educational or employment outcomes later in life.