Reaching all children

In Britain the many initiatives to improve the wellbeing of children are operating against the backdrop of a government commitment to reduce health inequalities and improve access to services. Yet ensuring the right of all children to have equal access to services remains challenging.

In this week's issue Webb et al highlight the unmet health and developmental needs of children living with their mothers in a refuge for victims of domestic violence (p 210).¹ Not only are these children likely to have special needs associated with living in violent households²; they also have poor access to services, including “universal” services such as immunisation and health promotion. All children from marginalised populations face this double jeopardy. For many, such as travellers, homeless families, children living rough, and asylum seeking and refugee children,³ this is because of poor access to both mainstream and specialist services.⁴ For others, ironically, it is because a specific health or social care need has been identified and led to the provision of selective services. For example, children receiving specialist disability services may have less contact with general practitioners and health visitors⁵; children considered “in need” by social services may have less family support or community services⁶; and looked after (in care) children have less adequate health provision and poorer mental health and educational outcomes.⁷

In Britain primary healthcare services are based on registering with a general practitioner, which should provide continuity. The system breaks down when people move away from their general practitioner—for example, to escape domestic violence or because of a highly mobile life⁸—or when people cannot find one sympathetic to their lifestyle or where there are other language or cultural barriers. Others may be wary of registering with services if they do not want their whereabouts known to the authorities.

These issues of acceptability and accessibility of services are further complicated for children, who rely on others to ensure they receive the services they need. Children unknown to services or known only to some (who assume that others are being accessed appropriately) are being denied their rights. Parents may argue that they are in the best position to determine their children's needs, and the poor outcomes for children looked after by local authorities seem to confirm this view.⁷ Nevertheless, some children are at risk of abuse and neglect so the state must ensure that it can monitor the welfare of all children.⁹ There is inevitably a problem of doing this in a country where the identity of all residents is not known. A child from an extended family may be living across different continents with different cultures and laws. It is difficult for schools, general practitioners, and other services to know whether such a child is living in the area, accessing universal services, or in need of selective services. Similarly, it may be difficult to monitor the type of care experienced by these children, which may be life threatening. Parental care may also include practices such as female genital mutilation, which is illegal in the United Kingdom.

One strategy for managing these problems is a community based approach. Local strategies, particularly for areas of social deprivation, have a long history, though they are vulnerable to the criticism that many individuals in need live outside these areas.¹⁰ Current examples of such approaches in England and Wales include the Health and Education Action Zones and Sure Start. The action zones encourage community participation and are often designed to reach marginalised groups, such as the Lambeth, Southwark, and Lewisham young refugee project. The government's cross departmental Sure Start Unit was established in 1998 with £1.4bn over five years. By 2004 the aim is to have invested in extra resources for preschool children and their families in over 500 small (“pram pushing”) areas of social deprivation, reaching one third of all children living in poverty. The lessons learnt will be used to inform the development of mainstream services. Such initiatives have similarities to local patch based services provided by religious organisations, health workers, the police, and others in many other countries.

Yet in Britain these local strategies conflict with changes in the pattern of health visiting over the past 20 years: health visitors moved from having responsibility for all children in a geographical patch to being attached to general practices. Because their caseloads are diverse geographically health visitors have much less detailed knowledge of who is living in a specific local area.

National reforms can facilitate inclusive services at local level. Both primary care trusts and the joint planning and delivery of children's health and social services will provide opportunities. Nationally the “Quality protects” initiative aims to deliver better life chances for the most disadvantaged children.¹¹ It is based round a framework for assessing children's needs in three domains: the child's developmental needs, parenting capacity, and family and environmental factors.¹² By providing a way of conducting a detailed assessment of children's welfare it should encourage collaboration about a child's needs across agencies. It also provides an opportunity when a health or social worker sees a parent with problems from a family not engaged with health, education, or welfare services⁴ to consider the impact on the child. Not only can this promote positive parenting; it may identify children at high risk. The framework should also lead to a more coherent and needs based selection of services for children and families. As part of the same initiative local authorities will have to specify the needs of local children and how these needs will be met and reach centrally determined performance targets.

The use of systematic research synthesis is being extended to community based health, social, and educational services, as witnessed by the birth of a new Social Care Institute of Excellence, to be lanched this summer.¹³ The current challenge is to ensure an evidence based approach to the organisation of service delivery, not just for the majority of children and families but also to marginalised and minority groups.

Primary care p 210