Healthy Child Programme Schedule of Interventions Guide
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Lifecourse stage
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16 to 24 years
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Screening
Immunisation
Mental and emotional health and wellbeing
Healthy weight, nutrition and physical activity
Maintaining healthy relationships including sexual health
Alcohol, drugs and tobacco
Oral health and dental care
Improving self-care and health literacy
Inequalities and disparities
Safeguarding
Young people with additional health and development needs including SEND
Intensive parenting support
Ensure that young people with diabetes have been offered annual Diabetic Retinopathy Screening – DES (diabetic eye screening). Ensure that young migrants, refugees, asylum seekers and young people released from custody are aware of the screening programme and the benefits it can offer.
Provide evidence-based information, advice and guidance to support young people, and their parents and carers where appropriate, to make an informed decision about attending screening.
Diabetic eye screening: programme overview
Children with additional health and development needs
Metrics and outcomes indicators
Use evidence and data to monitor screening. Compare local data with similar areas, within a region and nationally, to identify opportunities for improvement. Use evidence and data to evaluate and demonstrate improvements in population health and other outcomes resulting from targeted intervention.
OHID Fingertips Child and maternal
OHID Fingertips Child and maternal health long-term conditions and complex needs
OHID Fingertips Public Health Outcomes Framework
OHID Fingertips user guidance
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Review the immunisation status of young people and other family members eligible to be vaccinated according to the national routine and selective immunisation programmes (hepatitis B and tuberculosis). Ensure that young migrants, refugees, asylum seekers and young people released from custody are aware of the national routine and selective immunisation programme and the benefits it can offer.
Provide assessment to highlight any specific needs related to vaccination. Ensure that eligible young people including individuals with long-term health needs or additional needs have been offered vaccination.
UKHSA Immunisation against infectious disease (Green Book)
UKHSA Routine childhood immunisation schedule
Vaccination of individuals with uncertain or incomplete immunisation status
UKHSA Hepatitis B: the green book, chapter 18
NICE Hepatitis B quality standard (QS65)
NHS.UK BCG tuberculosis (TB) vaccine overview
NICE Tuberculosis
NHS.UK Tuberculosis
Where young people have not received recommended immunisations refer to the guide for uncertain or incomplete vaccinations.
UKHSA Immunisation against infectious disease (Green Book)
UKHSA Routine childhood immunisation schedule
Vaccination of individuals with uncertain or incomplete immunisation status
Provide evidence-based information, advice and guidance to support young people including for those young people with long-term health or additional needs and where appropriate parents and carers to make an informed decision about immunisation.
NHS.UK Hepatitis B vaccine overview
NHS.UK BCG tuberculosis (TB) vaccine overview
NHS.UK Tuberculosis
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Metrics and outcomes indicators
Use evidence and data to monitor immunisations. Compare local data with similar areas, within a region and nationally, to identify opportunities for improvement. Use evidence and data to evaluate and demonstrate improvements in population health and other outcomes resulting from targeted intervention.
OHID Fingertips Child and maternal vaccines and immunisations
OHID Fingertips TB Strategy monitoring indicators
OHID Fingertips Health Protection indicators
OHID Fingertips Public Health Outcomes Framework
OHID Fingertips user guidance
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Young people’s mental health and wellbeing
Where there are concerns about a young person’s mental health and wellbeing, provide an assessment to identify needs, strengths and vulnerability.
Based on need, provide personalised clinical interventions, for example targeted advice and support to help them to manage symptoms through individual or group-based interventions.
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral, and support young people and families to access specialist services. Work in partnership with other agencies including Child and Adolescent Mental Health Services (CAMHS), Mental Health Support Teams (MHSTs) and education settings to support young people awaiting intervention from specialist services or when stepping down from specialist to targeted services or targeted to universal services.
Wellbeing and mental health: applying all our health
Solihull Approach
Healthy beginnings: applying all our health
No child left behind: a public health informed approach to improving outcomes for vulnerable children
School-aged years high impact area 1: Supporting resilience and wellbeing
NHS.UK Every mind matters
Universities UK Stepchange: mentally healthy universities
Association of Colleges Mental Health Charter
Student Minds – UK’s student mental health charity
Mind Moving from child to adult mental health services
School aged years high impact area 6: Supporting self-care and improving health literacy
Improving self-care and health literacy (Universal)
Improving self-care and health literacy (Targeted)
Community cohesion, social networks and cultural activities
DfE Promoting and supporting mental health and wellbeing in schools and colleges
NHS England Mental health children and young people
NHS England Mental health support in schools and colleges and faster access to NHS care
Every mind matters self-care tool
Future Learn Psychological First Aid: supporting children and young people
Minded Support available for parents
NHS Looking a child or young person’s mental health
Where health or additional needs have been identified, provide an assessment to inform planning to prepare for a seamless transition to further education, apprenticeship, work or higher education.
Work with the multidisciplinary team including school nurses, education settings, Child and Adolescent Mental Health Services (CAMHS) and Mental Health Support Teams (MHSTs), to support young people including identifying individuals requiring health care plans in their education setting.
Provide information, advice and guidance to support young people to prepare for the transition to further education, apprenticeship, work or higher education. Where appropriate, support parents and carers to prepare their young person for the transition.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School-aged years high impact area 5: Supporting additional and complex health needs
No child left behind: a public health informed approach to improving outcomes for vulnerable children
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Vulnerability in childhood: a public health informed approach
Safeguarding
Parental mental health and wellbeing
Where there are concerns about parental mental health and wellbeing, such as where the young person has complex needs and disabilities, provide an assessment to identify needs, strengths and vulnerabilities.
Based on need, offer personalised clinical interventions to support positive parental and family mental health.
Use strengths-based approaches to empower parents and carers to meet the needs of their young person, and access targeted services appropriately.
School-aged years high impact area 1: Supporting resilience and wellbeing
NHS.UK Every mind matters
Mental Health Foundation Black, Asian and minority ethnic communities
Community cohesion, social networks and cultural activities
Where there are concerns that a young person has caring responsibilities as a result of parental mental health and wellbeing, provide an assessment to identify needs, strengths and vulnerabilities.
Based on need, provide personalised clinical interventions, for example build a trusted relationship with young carers and use strengths-based approaches to enhance their skills, confidence and aspirations and access targeted services appropriately to avoid poorer outcomes.
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School aged years high impact area 6: Supporting self-care and improving health literacy
No child left behind: a public health informed approach to improving outcomes for vulnerable children
Care Act 2014
Children’s Commissioner The support provided to young carers in England
ADCS No wrong doors working together to support young carers and their families
Barnardo’s Young carers
Carers’ Trust Help and information
Children’s Society Young carer services
NHS England Today on Young Carers Awareness Day – How can you help a young carer in just 5 minutes?
DHSC You’re Welcome: Quality criteria for young people friendly health services
RCPCH State of child health young carers
Young Minds Young carers
Children’s Society Advice and support for young carers
Carers Trust Young carers in schools toolkit (PDF)
Youth Access
NHS.UK Mental health and self-care for young people
AYPH Helping parents and carers of young people with mental health problems: What can we do?
Mental and emotional health and wellbeing
Safeguarding (Universal)
Safeguarding (Targeted)
Safeguarding (Community)
Inequalities and disparities including young carers
Follow local pathways for referral and management of parental mental health needs where appropriate.
Targeted services may include those offered in the wider community such as local therapy groups.
School-aged years high impact area 1: Supporting resilience and wellbeing
NHS.UK Every mind matters
Mental Health Foundation Black, Asian and minority ethnic communities
Community cohesion, social networks and cultural activities
When assessing and supporting young people’s, parental and family mental health, use strength-based approaches to provide support or onward referral and avoids the potential for re-traumatisation by recognising when people may have experienced trauma or adverse childhood experiences.
Scottish Government Trauma-informed practice: toolkit
South Yorkshire Violence Reduction Unit Trauma-informed practice
Gloucestershire County Council Frameworks for being trauma-informed
Early Intervention Foundation Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care
Adverse Childhood Experience Support Hub Cymru and Wrexham University ‘Trauma-informed’: Identifying key language and terminology through a review of the literature
Working definition of trauma-informed practice
Ensure there is recognition and awareness of mental ill health and its signs and symptoms and raise awareness of the possible impact of adult mental ill health on young people.
School-aged years high impact area 1: Supporting resilience and wellbeing
NHS.UK Every mind matters
Mental Health Foundation Black, Asian and minority ethnic communities
Community cohesion, social networks and cultural activities
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Vulnerability in childhood: a public health informed approach
Safeguarding
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Metrics and outcomes indicators
Use evidence and data to monitor mental health and wellbeing. Compare local data with similar areas, within a region and nationally, to identify opportunities for improvement. Use evidence and data to evaluate and demonstrate improvements in population health and other outcomes resulting from targeted intervention.
OHID Fingertips Children and young people's mental health and wellbeing
OHID Fingertips Public Health Outcomes Framework
OHID Fingertips user guidance
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Where diet and nutrition or physical activity have been identified as requiring targeted intervention, work with young people to carry out an assessment to identify need.
Offer personalised clinical interventions and evidence-based information in response to identified need. Use strengths-based approaches to empower young people, and where appropriate parents and carers to adopt healthy lifestyles, and access targeted services appropriately.
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
School-aged years high impact area 3: Supporting healthy lifestyles
The Eatwell Guide
NHS.UK The Eatwell Guide
NICE Obesity in children and young people: prevention and lifestyle weight management programmes
NICE Obesity: identification, assessment and management
Family weight management: changing behaviour techniques
Promoting a healthier weight for children, young people and families: consistent messaging
Childhood obesity: applying all our health
E-Learning for Healthcare All our health: childhood obesity
Healthier Together I’m worried about…
Where there are concerns about a young person’s weight, carry out an assessment to identify need, measuring and recording the young person’s height, weight and body mass index (BMI) and considering the wider impact on mental health and wellbeing.
Offer personalised clinical interventions and evidence-based information in response to identified need. Use strengths-based approaches to empower young people, with support from their parents and carers where appropriate, to adopt healthy lifestyles, and access targeted services appropriately.
RCPCH Growth charts
RCPCH BMI charts
School-aged years high impact area 3: Supporting healthy lifestyles
NHS.UK The Eatwell Guide
Eatwell Guide
NICE Obesity in children and young people: prevention and lifestyle weight management programmes
NICE Obesity: identification, assessment and management
Promoting a healthier weight for children, young people and families: consistent messaging
Childhood obesity: applying all our health
E-Learning for Healthcare All our health: childhood obesity
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Ensure staff are aware of local support services and referral guidance relating to healthy weight, nutrition and physical activity.
Metrics and outcomes indicators
Use evidence and data to monitor healthy weight, nutrition and physical activity. Compare local data with similar areas, within a region and nationally, to identify opportunities for improvement. Use evidence and data to evaluate and demonstrate improvements in population health and other outcomes resulting from targeted intervention.
OHID Fingertips Obesity profile
OHID Fingertips Public Health Outcomes Framework
OHID Fingertips Physical activity
OHID Fingertips user guidance
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Where young people, parents and carers have been identified as requiring targeted intervention for family relationship issues, provide an assessment to identify health needs and vulnerability.
Offer personalised clinical interventions and evidence-based information in response to need, for example support to reduce parental conflict. Use strengths-based approaches to empower parents and carers to meet the needs of their young person, and access targeted services appropriately.
Provide information about local services, such as adult social care, youth services children’s centres or family hubs, where young people or their parents and carers can seek additional support and advice, where appropriate.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
DWP Reducing Parental Conflict programme and resources
Race Equality Foundation Reducing Parental Conflict
Home Office Tackling violence against women and girls strategy
DfE Working together to safeguard children
Vulnerability in childhood: a public health informed approach
NICE Domestic violence and abuse
NHS.UK Domestic violence and abuse
Home Office Domestic abuse how to get help
NHS.UK Sexual health
NICE Domestic violence and abuse: multi-agency working
Safeguarding
Safeguarding including domestic violence and abuse
Intensive parenting support
Where there are emotional health and wellbeing concerns, provide an assessment to identify needs and inform planning to support young people, parents and carers to develop positive and appropriate relationships and build emotional resilience to support engagement with education and positive peer relationships.
Health visiting and school nursing delivery model
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 5: Supporting additional and complex health needs
Use strength-based approaches to assess and support young people, and where appropriate their parents and carers, to avoid the potential for re-traumatisation by recognising when people may have experienced trauma or adverse childhood experiences.
Scottish Government Trauma-informed practice: toolkit
South Yorkshire Violence Reduction Unit Trauma-informed practice
Gloucestershire County Council Frameworks for being trauma-informed
Early Intervention Foundation Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care
Adverse Childhood Experience Support Hub Cymru and Wrexham University ‘Trauma-informed’: Identifying key language and terminology through a review of the literature
Working definition of trauma-informed practice
Where young people have been identified as requiring targeted intervention for sexual health issues, such as repeated sexually transmitted infections, offer an assessment to identify health needs and vulnerability.
Based on need, provide personalised clinical interventions, for example targeted advice and support for sexual health concerns such as contraception or sexually transmitted infections. Encourage all sexually active young people under the age of 25 to be tested for chlamydia annually or whenever there is a change of sexual partner.
Provide information about sexual health services and pharmacies where additional support and advice can be sought, where appropriate.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
NHS.UK Sexual health
NHS.UK Guide to sexual health services
National Chlamydia Screening Programme
NHS.UK Chlamydia
DHSC You’re Welcome quality criteria for young people friendly health services
OHID Sexual and reproductive health and HIV: applying All Our Health
Healthier Together I’m worried about…
Where young people have questions about their gender identity or sexuality or where life choices will impact on wider family functioning, provide an assessment to identify health needs and vulnerability to reduce disparities and improve health outcomes.
Based on need, provide personalised clinical interventions, for example provide information about support services available locally and nationally, or targeted advice and support to help individuals to overcome any barriers to accessing services, working in partnership with other agencies, including schools or other education settings.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
NHS.UK Every mind matters mental health and self-care for young people
Healthier Together I’m worried about…
LGBT Foundation
Inequalities and disparities
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Safeguarding
Safeguarding including domestic violence and abuse
Metrics and outcomes indicators
Use evidence and data to monitor sexual and reproductive health. Compare local data with similar areas, within a region and nationally, to identify opportunities for improvement. Use evidence and data to evaluate and demonstrate improvements in population health and other outcomes resulting from targeted intervention.
OHID Fingertips Child and maternal health pregnancy and birth
OHID Fingertips Teenage pregnancy and young parents reports
OHID Fingertips Sexual and reproductive health profiles
OHID Fingertips Public Health Outcomes Framework
OHID Fingertips user guidance
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Alcohol
Where appropriate and there are concerns about parental alcohol use, provide an assessment to identify needs and vulnerabilities.
Based on need, provide personalised clinical interventions, for example support parents to understand the risks and impact of alcohol use on their ability to provide safe, consistent care for the young person.
Alcohol use should be reviewed at each session. The Alcohol, Smoking and Substance Involvement Screening Tool - Lite (ASSIST-Lite) is a short screening tool for use with adults (aged 18 or over) covering alcohol, tobacco, cannabis, stimulants, sedatives, opioids, and other psychoactive substances including use of medicines not as prescribed.
Parents with alcohol and drug problems: support resources
ASSIST-Lite alcohol and drug use, and tobacco smoking screening tool
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School aged years high impact area 6: Supporting self-care and improving health literacy
E-Learning for Healthcare Alcohol Identification and Brief Advice
UK Chief Medical Officers’ low risk drinking guidelines
Talk to Frank Honest information about drugs
Talk to Frank Find support near you
Alcohol: applying all our health
E-Learning for Healthcare All our health: alcohol
Keeping safe and accident prevention
Inequalities and disparities including parents in contact with the criminal justice system
Safeguarding
Provide information to parents and carers about local community delivered support groups such as Alcoholics Anonymous (AA) where appropriate.
Alcoholics Anonymous (AA)
Alcoholics Anonymous Younger people in AA (PDF)
E-Learning for Healthcare Alcohol Identification and Brief Advice
UK Chief Medical Officers’ low risk drinking guidelines
Talk to Frank Honest information about drugs
Talk to Frank Find support near you
Alcohol: applying all our health
E-Learning for Healthcare All our health: alcohol
Where there are concerns about young people’s alcohol use, work with the young person to undertake an assessment to identify needs and vulnerabilities.
Based on need, work with young people to identify personalised clinical interventions, for example support young people, and where appropriate their parents and carers, to understand the risks and impact of alcohol use on safety, relationships and physical health.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School aged years high impact area 6: Supporting self-care and improving health literacy
E-Learning for Healthcare Alcohol Identification and Brief Advice
UK Chief Medical Officers’ low risk drinking guidelines
Talk to Frank Honest information about drugs
Talk to Frank Find support near you
Alcohol: applying all our health
E-Learning for Healthcare All our health: alcohol
Keeping safe and accident prevention
Alcohol, drugs and tobacco: commissioning support pack
RCGP Practice standards for young people with substance misuse problems
YoungMinds Supporting your child with drugs and alcohol
Safeguarding
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Use strength-based approaches to assess and support young people, and where appropriate their parents and carers, to avoid the potential for re-traumatisation by recognising when people may have experienced trauma or adverse childhood experiences.
Scottish Government Trauma-informed practice: toolkit
South Yorkshire Violence Reduction Unit Trauma-informed practice
Gloucestershire County Council Frameworks for being trauma-informed
Early Intervention Foundation Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care
Adverse Childhood Experience Support Hub Cymru and Wrexham University ‘Trauma-informed’: Identifying key language and terminology through a review of the literature
Working definition of trauma-informed practice
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
Health visiting and school nursing delivery model
Universal
Community
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Targeted)
Drugs
Where appropriate and there are concerns about parental or carer illicit drug and medicine misuse, provide an assessment to identify needs and vulnerabilities.
Based on need, provide personalised clinical interventions, for example support parents and carers to understand the risks and impact of illicit drug and medicine misuse on their ability to provide safe, consistent care for the young person’s safety and development.
Parental or carer drug use should be reviewed at each contact. The Alcohol, Smoking and Substance Involvement Screening Tool - Lite (ASSIST-Lite) is a short screening tool for use with adults (aged 18 or over) covering alcohol, tobacco, cannabis, stimulants, sedatives, opioids, and other psychoactive substances including use of medicines not as prescribed.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School aged years high impact area 6: Supporting self-care and improving health literacy
Alcohol and drug prevention, treatment and recovery: why invest?
Misuse of illicit drugs and medicine: applying all our health
ASSIST-Lite alcohol and drug use, and tobacco smoking screening tool
DHSC Drug misuse and dependence: UK guidelines on clinical management
Talk to Frank Honest information about drugs
Parents with alcohol and drug problems: support resources
Talk to Frank Find support near you
Drugs commissioning support: principles and indicators
DHSC Drug misuse and dependence: UK guidelines on clinical management
NICE Drug misuse prevention: targeted interventions
Safeguarding
Where there are concerns about young people’s illicit drug and medicine misuse, provide an assessment to identify needs and vulnerabilities.
Based on need, work with young people to identify personalised clinical interventions, for example support young people, and where appropriate their parents and carers, to understand the risks and impact of drug use on safety, relationships and physical or mental health.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School aged years high impact area 6: Supporting self-care and improving health literacy
Misuse of illicit drugs and medicine: applying all our health
Talk to Frank Honest information about drugs
Talk to Frank Find support near you
Keeping safe and accident prevention
Alcohol, drugs and tobacco: commissioning support pack
Drugs commissioning support: principles and indicators
DHSC Drug misuse and dependence: UK guidelines on clinical management
NICE Drug misuse prevention: targeted interventions
RCGP Practice standards for young people with substance misuse problems
YoungMinds Supporting your child with drugs and alcohol
Safeguarding
Where additional targeted or specialist services are required and follow local pathways to complete appropriate and timely referral.
Use strength-based approaches to assess and support young people, and where appropriate their parents and carers, to avoid the potential for re-traumatisation by recognising when people may have experienced trauma or adverse childhood experiences.
Scottish Government Trauma-informed practice: toolkit
South Yorkshire Violence Reduction Unit Trauma-informed practice
Gloucestershire County Council Frameworks for being trauma-informed
Early Intervention Foundation Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care
Adverse Childhood Experience Support Hub Cymru and Wrexham University ‘Trauma-informed’: Identifying key language and terminology through a review of the literature
Working definition of trauma-informed practice
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Targeted)
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Tobacco and vaping
Where appropriate and there are concerns about parental tobacco use or vaping, provide an assessment to identify needs and vulnerabilities.
Based on need, provide personalised clinical interventions, for example brief interventions to support individuals to quit and help them understand the impact of smoke free homes, second-hand smoke and vaping on the young person’s health, development and safety.
Smoking should be reviewed at each contact. The Alcohol, Smoking and Substance Involvement Screening Tool - Lite (ASSIST-Lite) is a short screening tool for use with adults (aged 18 or over) covering alcohol, tobacco, cannabis, stimulants, sedatives, opioids, and other psychoactive substances including use of medicines not as prescribed.
ASSIST-Lite alcohol and drug use, and tobacco smoking screening tool
E-Learning for Healthcare Supporting a smokefree pregnancy and smokefree families (SCP)
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School aged years high impact area 6: Supporting self-care and improving health literacy
Smoking and tobacco: applying All Our Health
NHS.UK Local stop smoking services
NICE Smoking cessation interventions and services
Health matters: Stopping smoking - what works?
NHS.UK Live well quit smoking
NHS.UK Passive smoking
Where there are concerns about a young person’s tobacco use or vaping, provide an assessment to identify needs and vulnerabilities.
Based on need, work with young people to identify personalised clinical interventions, for example brief interventions to support individuals to stop and helping them understand the impact of smoke free homes, second-hand smoke and vaping on their health, development and safety.
Smoking should be reviewed at each contact. The Alcohol, Smoking and Substance Involvement Screening Tool - Lite (ASSIST-Lite) is a short screening tool for use with adults (aged 18 or over) covering alcohol, tobacco, cannabis, stimulants, sedatives, opioids, and other psychoactive substances including use of medicines not as prescribed.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School aged years high impact area 6: Supporting self-care and improving health literacy
Smoking and tobacco: applying All Our Health
NICE Smoking cessation interventions and services
Health matters: Stopping smoking - what works?
NHS.UK Local stop smoking services
Scottish Government Trauma-informed practice: toolkit
South Yorkshire Violence Reduction Unit Trauma-informed practice
Gloucestershire County Council Frameworks for being trauma-informed
Early Intervention Foundation Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care
Adverse Childhood Experience Support Hub Cymru and Wrexham University ‘Trauma-informed’: Identifying key language and terminology through a review of the literature
Working definition of trauma-informed practice
Keeping safe and accident prevention
Alcohol, drugs and tobacco: commissioning support pack
Safeguarding
Provide information about the local smoking cessation offer for young people and adults.
E-Learning for Healthcare Supporting a smokefree pregnancy and smokefree families (SCP)
NHS.UK Local stop smoking services
NICE Smoking cessation interventions and services
Health matters: Stopping smoking - what works?
NHS.UK Live well quit smoking
Where additional targeted or specialist services are required and follow local pathways to complete appropriate and timely referral.
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Universal
Community
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Safeguarding (Universal)
Safeguarding (Targeted)
Metrics and outcomes indicators
Use evidence and data to monitor alcohol, drug and tobacco use. Compare local data with similar areas, within a region and nationally, to identify opportunities for improvement. Use evidence and data to evaluate and demonstrate improvements in population health and other outcomes resulting from targeted intervention.
OHID Fingertips Local alcohol profiles for England
OHID Fingertips Local tobacco control profiles
OHID Fingertips Public Health Outcomes Framework
OHID Fingertips user guidance
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Where young people, including those most at risk of poor dental health such as young people in care, in contact with the youth justice system, with special educational needs or disabilities (SEND) or refugees, asylum seekers or migrants, have been identified as requiring targeted intervention for oral health or dental care, provide an assessment to identify health needs and vulnerability.
Based on need, provide personalised clinical interventions, for example targeted advice and support where there are oral health and dental care concerns such as dental caries, poor diet or smoking.
School aged years high impact area 6: Supporting self-care and improving health literacy
DHSC Delivering better oral health
NICE Dental checks: intervals between oral health reviews
All Our Health: Child oral health
Interactive townscape on child oral health
Oral health and dental care
Specialist
Provide information about dental services where young people, parents and carers can seek additional support and advice, where appropriate.
Oral health and dental care
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Metrics and outcomes indicators
Use evidence and data to monitor oral health and dental care. Compare local data with similar areas, within a region and nationally, to identify opportunities for improvement. Use evidence and data to evaluate and demonstrate improvements in population health and other outcomes resulting from targeted intervention.
OHID Fingertips Child and maternal health oral health
OHID Fingertips Public Health Outcomes Framework
OHID Fingertips user guidance
Close pop-up
Where young people have been identified as requiring targeted intervention for allergies or anaphylaxis, provide an assessment to identify health needs and vulnerability.
Based on need, work with young people to provide personalised clinical interventions, for example targeted advice and support to help individuals to manage symptoms and access specialist services appropriately and develop a healthcare plan for managing allergies or anaphylaxis in education settings where appropriate.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School aged years high impact area 6: Supporting self-care and improving health literacy
Anaphylaxis Campaign
NICE Allergies
RCPCH Allergy care pathways – education resources for healthcare professionals (2011)
NHS.UK Allergies
Healthier Together I’m worried about…
Specialist
Where young people, including those with special educational needs or disabilities (SEND), have been identified as requiring targeted intervention for long-term conditions such as asthmas, diabetes or epilepsy, offer an assessment to identify health needs and vulnerability.
Based on need, provide personalised clinical interventions, for example targeted advice and support to help individuals to manage symptoms and access specialist services appropriately.
Based on need, work with young people, parents, carers and the multidisciplinary team including school nurses and education settings to provide personalised clinical interventions. Examples include targeted advice and support to help individuals to manage symptoms, access specialist services appropriately and develop a healthcare plan or education healthcare plan (EHCP) for managing medial conditions in education settings.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School aged years high impact area 6: Supporting self-care and improving health literacy
NICE Epilepsy
BMJ Epilepsy: putting NICE guidelines into practice
NHS.UK Epilepsy
Epilepsy Action
Epilepsy Society
NHS England National bundle of care for children and young people with asthma
NHS.UK Asthma
NICE Asthma
RCPCH Allergy care pathway for asthma and/or rhinitis
Beat Asthma
Asthma UK
NHS.UK Diabetes
NICE Diabetes (type 1 and type 2) in children and young people: diagnosis and management
Diabetes UK
NHS.UK Sickle Cell Disease
Sickle Cell Society
NICE Sickle Cell Disease
NHS.UK Cystic Fibrosis
Cystic Fibrosis Trust
Healthier Together I’m worried about…
Specialist
Where young people, including those with special educational needs or disabilities (SEND), have been identified as requiring targeted intervention for complex needs and disabilities, provide an assessment to identify health needs and vulnerability.
Based on need, work with young people, parents, carers and the multidisciplinary team including school nurses and education settings to provide personalised clinical interventions. Examples include targeted advice and support to help individuals to manage symptoms, access specialist services appropriately and develop a healthcare plan or education healthcare plan (EHCP) for managing medial conditions in education settings.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School aged years high impact area 6: Supporting self-care and improving health literacy
Downs Syndrome Association
SCOPE Support groups for parents with disabled children
Specialist
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Where agreed with young people, acting as advocates for young people, parents and carers, offer information to families about additional targeted and specialist services and voluntary sector agencies. Where appropriate, work in partnership with these services.
School aged years high impact area 6: Supporting self-care and improving health literacy
GOV.UK Find a local support group for children, young people and families
SCOPE Support groups for parents with disabled children
Metrics and outcomes indicators
Use evidence and data to monitor self-care and health literacy. Compare local data with similar areas, within a region and nationally, to identify opportunities for improvement. Use evidence and data to evaluate and demonstrate improvements in population health and other outcomes resulting from targeted intervention.
OHID Fingertips Child and maternal health
OHID Fingertips Public Health Outcomes Framework
OHID Fingertips user guidance
Close pop-up
Minority groups
Where young people, from minority groups have been identified as requiring a targeted intervention, provide an assessment to identify health needs and vulnerability to reduce disparities and improve health outcomes. This may include Gypsy, Traveller and Roma (GRT) and Boater communities who may have difficulty understanding and navigating the system to access health and care services appropriately.
Based on need, provide personalised clinical interventions, for example targeted advice and support to help individuals to overcome any barriers to accessing services.
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
No child left behind: a public health informed approach to improving outcomes for vulnerable children
NHS.UK Children and young people’s services
Inclusion health: applying All Our Health
Healthy equity
Voluntary, Community and Social Enterprise (VCSE) Inclusion Health Audit Tool
Friends, Families and Travellers
Where young people have been identified as requiring a targeted intervention because their ethnicity represents an increased risk of specific health conditions, provide an assessment to identify health needs and potential vulnerability.
Based on need, provide personalised clinical interventions, for example targeted advice and support to help individuals to access services appropriately.
Consider cultural practices, particularly when working with families from ethnic minority groups and provide a sensitive and supportive response to their implications for health, including female genital mutilation (FGM), and where parents are blood relations (consanguinity).
Where there are safeguarding concerns, for example relating to female genital mutilation (FGM) follow statutory guidance and local safeguarding procedures.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
Inclusion health: applying All Our Health
Mental and emotional health and wellbeing
NICE Diabetes (type 1 and type 2) in children and young people: diagnosis and management
NHS.UK Sickle Cell Disease
Sickle Cell Society
NICE Sickle Cell Disease
NHS.UK Thalassaemia
GOV.UK Female genital mutilation
NHS.UK Female genital mutilation
Young people with additional health and development needs including SEND
E-Learning for Healthcare Cultural competence
Safeguarding (Universal)
Safeguarding (Targeted)
Safeguarding (Community)
Where young people, and where appropriate their parents or carers, who are asylum seekers, refugees or vulnerable migrants are identified as requiring a targeted intervention, provide an assessment to identify health needs and vulnerability to reduce disparities and improve health outcomes. This may include those who may have difficulty understanding and navigating the system to access health and care services appropriately.
Based on need, provide personalised clinical interventions, for example targeted advice and support to help individuals to overcome any barriers to accessing services.
Consider referring families whose first language is not English to English as a second language services.
No child left behind: a public health informed approach to improving outcomes for vulnerable children
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
School-aged years high impact area 1: Supporting resilience and wellbeing
Inclusion health: applying All Our Health
Modern slavery and public health
Home Office Modern slavery collection
Voluntary, Community and Social Enterprise (VCSE) Inclusion Health Audit Tool
DfE Safeguarding unaccompanied asylum seeking and refugee children
NHS entitlements: migrant health guide
Safeguarding
Where young people have questions about their gender identity or sexuality or where life choices will impact on wider family functioning, provide an assessment to identify health needs and vulnerability to reduce disparities and improve health outcomes.
Based on need, provide personalised clinical interventions, for example provide information about support services available locally and nationally, or targeted advice and support to help individuals to overcome any barriers to accessing services.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
LGBT Foundation
NHS.UK Every mind matters mental health and self-care for young people
Healthier Together I’m worried about…
Inequalities and disparities
Young people and families with family members in the armed forces and who are veterans may need additional support to manage stress around deployment, separation, isolation, caring responsibilities, moving between locations and access to health services.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
Mental and emotional health and wellbeing
Inequalities and disparities including 'housing and living conditions including tenure'
NHS service families: welfare and support
Ministry of Defence what the covenant means to you: leaflets
Inclusion health: applying All Our Health
Where young people from vulnerable groups have been identified as requiring a targeted intervention, provide an assessment to identify health needs and vulnerability to reduce disparities and improve health outcomes. This may include young people living in care, living away from home or rough sleepers who may have difficulty understanding and navigating the system to access health and care services appropriately.
Based on need, provide personalised clinical interventions, for example targeted advice and support to help individuals to overcome any barriers to accessing services.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
No child left behind: a public health informed approach to improving outcomes for vulnerable children
NHS.UK Children and young people’s services
Inclusion health: applying All Our Health
Healthy equity
Voluntary, Community and Social Enterprise (VCSE) Inclusion Health Audit Tool
Where additional targeted or specialist services are required and follow local pathways to complete appropriate and timely referral.
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Young carers
Young people who have caring responsibilities can be more vulnerable to poorer health and wellbeing outcomes and can negatively impact on education outcomes and achievement. Where young people have been identified as young carers and require targeted intervention, provide an assessment to identify health needs, strengths and vulnerability.
Based on need, provide personalised clinical interventions, for example build a trusted relationship with young carers to enhance their skills, confidence and aspirations and avoid poorer outcomes.
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School aged years high impact area 6: Supporting self-care and improving health literacy
No child left behind: a public health informed approach to improving outcomes for vulnerable children
Care Act 2014
Children’s Commissioner The support provided to young carers in England
ADCS No wrong doors working together to support young carers and their families
Barnardo’s Young carers
Carers’ Trust Help and information
Children’s Society Young carer services
NHS England Today on Young Carers Awareness Day – How can you help a young carer in just 5 minutes?
DHSC You’re Welcome: Quality criteria for young people friendly health services
RCPCH State of child health young carers
Young Minds Young carers
Children’s Society Advice and support for young carers
Carers Trust Young carers in schools toolkit (PDF)
Youth Access
NHS.UK Mental health and self-care for young people
AYPH Helping parents and carers of young people with mental health problems: What can we do?
Mental and emotional health and wellbeing
Safeguarding (Universal)
Safeguarding (Targeted)
Safeguarding (Community)
Provide information about local services, such as youth services, children’s centres or family hubs, where young people, parents and carers can seek additional support and advice.
Children’s Commissioner The support provided to young carers in England
ADCS No wrong doors working together to support young carers and their families
Barnardo’s Young carers
Carers’ Trust Help and information
Children’s Society Young carer services
NHS England Today on Young Carers Awareness Day – How can you help a young carer in just 5 minutes?
DHSC You’re Welcome: Quality criteria for young people friendly health services
RCPCH State of child health young carers
Young Minds Young carers
Children’s Society Advice and support for young carers
Carers Trust Young carers in schools toolkit (PDF)
Youth Access
NHS.UK Mental health and self-care for young people
AYPH Helping parents and carers of young people with mental health problems: What can we do?
Mental and emotional health and wellbeing
Where additional targeted or specialist services are required and follow local pathways to complete appropriate and timely referral.
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
Safeguarding (Universal)
Safeguarding (Targeted)
Safeguarding (Community)
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Local authorities are required to consider the needs of young carers if, during the assessment of an adult with care needs, or of an adult carer, it appears that a child is providing, or intends to provide, care.
Ensure young carers and their family are aware of their right to a young carer’s needs assessment.
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
No child left behind: a public health informed approach to improving outcomes for vulnerable children
Care Act 2014
Children’s Commissioner The support provided to young carers in England
ADCS No wrong doors working together to support young carers and their families
Work together across partner organisations including adults’ and children’s services to offer young carers and their families an effective service and respond to the needs of a young carer, the person cared for, and others in the family.
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
No child left behind: a public health informed approach to improving outcomes for vulnerable children
Care Act 2014
Children’s Commissioner The support provided to young carers in England
ADCS No wrong doors working together to support young carers and their families
Where agreed with young people, acting as advocates for young carers, provide information to families about additional targeted and specialist services and voluntary sector agencies. Where appropriate, work in partnership with these services.
Barnardo’s Young carers
Carers’ Trust Help and information
Children’s Society Young carer resources
Children’s Society Young carer services
Community cohesion, social networks and cultural activities
Children or parents in contact with the criminal justice system
Where parents or other close family members are involved with the criminal justice system, young people can be more vulnerable to poorer health and wellbeing outcomes.
Where young people, parents and carers in contact with the criminal justice system have been identified as requiring targeted intervention, provide an assessment to identify health needs, strengths and vulnerability of parents, carers and young people.
Based on need, for example issues relating to stigma, housing, finance or mental health, provide personalised clinical interventions, including targeted advice and support to help individuals to overcome any barriers to accessing services.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
Collaborative approaches to preventing offending and re-offending by children (CAPRICORN)
No child left behind: a public health informed approach to improving outcomes for vulnerable children
HMPPS Support for professionals working with offenders
Barnardo’s, HMPPS National Information Centre on Children of Offenders (NICCO)
Inclusion health: applying All Our Health
Prisoners’ Families Helpline
Youth justice resource hub
Mental and emotional health and wellbeing
Safeguarding
Intensive parenting support including nurturing parenting
Provide information about local services, such as youth services, children’s centres or family hubs, where young people, parents and carers can seek additional support and advice.
HMPPS Support for professionals working with offenders
Barnardo’s, HMPPS National Information Centre on Children of Offenders (NICCO)
Prisoners’ Families Helpline
Youth justice resource hub
Mental and emotional health and wellbeing
Intensive parenting support including nurturing parenting
Where additional targeted or specialist services are required and follow local pathways to complete appropriate and timely referral.
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
Safeguarding (Universal)
Safeguarding (Targeted)
Use strength-based approaches to assess and support young people, and where appropriate their parents and carers, to avoid the potential for re-traumatisation by recognising when people may have experienced trauma or adverse childhood experiences.
Health visiting and school nursing delivery model
Universal
Community
Workless and low income households
Where families have been identified as needing targeted intervention due to being workless households or having low income, work in partnership with other agencies and parents and carers to carry out assessment to identify needs, strengths and vulnerabilities, and develop appropriate plans.
Offer targeted interventions in response to need, which may include joint visits or consultations with other professionals or advocacy. Use strengths-based approaches to empower young people, or where appropriate parents and carers to meet the needs of their young person, and access services appropriately.
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
GOV.UK Find your local council
Citizens Advice
UK Government Benefits and financial support for families
GOV.UK Disability living allowance for children
GOV.UK Financial help if you have children
GOV.UK Healthy Start
NHS.UK Healthy Start
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
Vulnerability in childhood: a public health informed approach
DLUHC, DfE Supporting families
Safeguarding
Education, employment and life opportunities
Work with partners to respond to identified needs requiring a multi-agency approach such as accident prevention, frequent attendance at A&E, housing needs or domestic abuse.
DLUCH, DfE Supporting families
Improving self-care and health literacy
Safeguarding
Where additional targeted or specialist services are required and follow local pathways to complete appropriate and timely referral.
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
Safeguarding (Universal)
Safeguarding (Targeted)
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Housing and living conditions including tenure
Where young people and families have been identified as needing targeted intervention due to unhealthy, overcrowded precarious housing, work in partnership with other agencies and young people, parents and carers to carry out assessment to identify needs, strengths and vulnerabilities, and develop appropriate plans.
Offer targeted interventions in response to need, which may include joint visits or consultations with other professionals or advocacy. Use strengths-based approaches to empower parents and carers to meet the needs of their young person, and access services appropriately.
Where additional targeted or specialist services are required, work in partnership to follow local pathways and to complete referral.
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
Reducing unintentional injuries among children and young people
Inclusion health: applying All Our Health
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
Vulnerability in childhood: a public health informed approach
DLUHC, DfE Supporting families
Safeguarding (Universal)
Safeguarding (Targeted)
Safeguarding (Community)
Healthy and inclusive neighbourhoods including housing and living conditions including tenure
Keeping safe and accident prevention
Inequalities and disparities
Where young people who are looked after are ready for independent living or semi-independent placements, contribute to the ‘Assessment of Need’ for the young person leaving care.
Offer targeted interventions in response to need, which may include joint visits or consultations with other professionals or advocacy. Use strengths-based approaches to empower the young person to prepare for independent living and access services appropriately.
Where additional targeted or specialist services are required, work in partnership to follow local pathways and to complete referral.
NICE Looked-after child and young people statement 8
DfE Looked-after children in independent or semi-independent placements
LGA Support for care leavers resource pack (PDF)
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
Safeguarding (Universal)
Safeguarding (Targeted)
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Metrics and outcomes indicators
Use evidence and data to monitor inequalities and disparities. Compare local data with similar areas, within a region and nationally, to identify opportunities for improvement. Use evidence and data to evaluate and demonstrate improvements in population health and other outcomes resulting from targeted intervention.
OHID Fingertips Child and maternal health
OHID Fingertips Public Health Outcomes Framework
OHID Fingertips Wider determinants of health
OHID Fingertips user guidance
Close pop-up
Vulnerability and early help
Where young people and families have been identified as vulnerable and require targeted interventions, for example families in poverty, poor housing, young people in care, in the youth justice system, not in education, employment or training (NEET), or at risk of hidden harms, work in partnership with other agencies and parents and carers to carry out assessment including family relationships and dynamics, and chronology of events to identify needs, strengths and vulnerabilities, and develop appropriate plans.
Offer personalised clinical interventions in response to need, which may include joint visits or consultations with other professionals. Use strengths-based approaches to empower young people, parents and carers to manage needs and access services appropriately.
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
Vulnerability in childhood: a public health informed approach
DLUHC, DfE Supporting families
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Community)
Use strength-based approaches to assess and support young people, and where appropriate their parents and carers, to avoid the potential for re-traumatisation by recognising when people may have experienced trauma or adverse childhood experiences.
Scottish Government Trauma-informed practice: toolkit
South Yorkshire Violence Reduction Unit Trauma-informed practice
Gloucestershire County Council Frameworks for being trauma-informed
Early Intervention Foundation Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care
Adverse Childhood Experience Support Hub Cymru and Wrexham University ‘Trauma-informed’: Identifying key language and terminology through a review of the literature
Working definition of trauma-informed practice
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Community)
Where a young person transfers in or out-of-area, ensure that the young person’s health records are transferred to the receiving service with particular reference to GPs, school nursing and children’s social care services. Local guidance and best practice should be adhered to, and include information regarding specialist services in the handover to ensure continuity of care.
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Community)
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Safeguarding (Universal)
Safeguarding (Community)
Missing young people
Where young people are identified as missing or their whereabouts cannot be established, for example runaways or misunderstanding between a young person and parent or carer, they may be at significant risk of harm.
Where young people go missing or frequently go missing from care or home, work in partnership with other agencies and young people, parents and carers to carry out assessment including family relationships and dynamics, and chronology of events to identify needs, strengths and vulnerabilities, and develop appropriate plans.
Offer personalised clinical interventions in response to need, which may include joint visits or consultations with other professionals. Use strengths-based approaches to empower young people, parents and carers to manage needs and access services appropriately.
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
Vulnerability in childhood: a public health informed approach
DLUHC, DfE Supporting families
DfE Working together to safeguard children
DHSC You're Welcome - Quality criteria for young people friendly health services
DfE Children who run away or go missing from home or care
Mental and emotional health and wellbeing
Safeguarding (Universal)
Safeguarding (Community)
Use strength-based approaches to assess and support young people, and where appropriate their parents and carers, to avoid the potential for re-traumatisation by recognising when people may have experienced trauma or adverse childhood experiences.
Scottish Government Trauma-informed practice: toolkit
South Yorkshire Violence Reduction Unit Trauma-informed practice
Gloucestershire County Council Frameworks for being trauma-informed
Early Intervention Foundation Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care
Adverse Childhood Experience Support Hub Cymru and Wrexham University ‘Trauma-informed’: Identifying key language and terminology through a review of the literature
Working definition of trauma-informed practice
Where additional targeted or specialist services are required, work in partnership to follow local pathways.
DfE Working together to safeguard children
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Community)
Where a young person transfers in or out-of-area, ensure that the young person’s health records are transferred to the receiving service with particular reference to GPs, school nursing and children’s social care services. Local guidance and best practice should be adhered to, and include information regarding specialist services in the handover to ensure continuity of care.
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Community)
Continue to provide young people, parents and carers with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Gangs and county lines
Where young people and families have been identified as vulnerable and at risk of violence and exploitation through gangs and county lines, including sexual exploitation and modern slavery, work in partnership with other agencies and young people, parents and carers to carry out assessment including family relationships and dynamics, and chronology of events to identify needs, strengths and vulnerabilities, and develop appropriate plans.
Offer personalised clinical interventions in response to need, which may include joint visits or consultations with other professionals. Use strengths-based approaches to empower young people, parents and carers to manage needs and access services appropriately.
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
No child left behind: a public health informed approach to improving outcomes for vulnerable children
DLUHC, DfE Supporting families
DfE Working together to safeguard children
DHSC You're Welcome - Quality criteria for young people friendly health services
School-aged years high impact area 1: Supporting resilience and wellbeing
E-Learning for Healthcare All Our Health: county lines exploitation
Collaborative approaches to preventing offending and re-offending by children (CAPRICORN)
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
Mental and emotional health and wellbeing
Alcohol, drugs and tobacco
Inequalities and disparities including workless and low income households
Safeguarding (Universal)
Safeguarding (Community)
Use strength-based approaches to assess and support young people, and where appropriate their parents and carers, to avoid the potential for re-traumatisation by recognising when people may have experienced trauma or adverse childhood experiences.
Scottish Government Trauma-informed practice: toolkit
South Yorkshire Violence Reduction Unit Trauma-informed practice
Gloucestershire County Council Frameworks for being trauma-informed
Early Intervention Foundation Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care
Adverse Childhood Experience Support Hub Cymru and Wrexham University ‘Trauma-informed’: Identifying key language and terminology through a review of the literature
Working definition of trauma-informed practice
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Community)
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Children in need
A child in need is defined under the Children Act 1989 and 2004 as a child who is unlikely to reach or maintain a satisfactory level of health or development, or their health or development will be significantly impaired without the provision of children's social care services, or the child is disabled.
Work in partnership with other agencies and young people, parents and carers to carry out holistic assessment including family relationships and dynamics, and chronology of events to identify needs, strengths and vulnerabilities, and develop appropriate care plans.
Offer personalised clinical interventions in response to need, which may include joint visits or consultations with other professionals in response to need. Use strengths-based approaches to empower young people, parents and carers to meet the needs of their young person, and access targeted services appropriately.
E-Learning for Healthcare Safeguarding children and young people programme
DfE Working together to safeguard children
Vulnerability in childhood: a public health informed approach
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
Children Act 1989
Children Act 2004
E-Learning for Healthcare Safeguarding children and young people programme
Safeguarding (Universal)
Safeguarding (Community)
Use strength-based approaches to assess and support young people, and where appropriate their parents and carers, to avoid the potential for re-traumatisation by recognising when people may have experienced trauma or adverse childhood experiences.
Scottish Government Trauma Informed-practice: toolkit
South Yorkshire Violence Reduction Unit Trauma-informed practice
Gloucestershire County Council Frameworks for being trauma-informed
Early Intervention Foundation Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care
Adverse Childhood Experience Support Hub Cymru and Wrexham University ‘Trauma-informed’: Identifying key language and terminology through a review of the literature
Working definition of trauma-informed practice
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Where a young person transfers in or out-of-area, ensure that the young person’s health records are transferred to the receiving service, with particular reference to GP, school nursing and children’s social care services. Local guidance and best practice should be adhered to, and include information regarding specialist services in the handover to ensure continuity of care.
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Community)
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Where safeguarding concerns escalate, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
E-Learning for Healthcare Safeguarding children and young people programme
Safeguarding (Universal)
Safeguarding (Community)
Children with child protection plans
A young person has a child protection plan if they are assessed as being at risk of significant harm at an initial child protection conference.
Work in partnership with other agencies and young people, parents and carers to review assessment including family relationships and dynamics, and chronology of events to identify needs, strengths and vulnerabilities, and develop appropriate care plans.
Offer personalised clinical interventions in response to need, which may include joint visits or consultations with other professionals in response to need. Use strengths-based approaches to empower young people, parents and carers to manage needs and access targeted services appropriately.
DfE, DHSC Promoting the health and wellbeing of looked-after children
DfE Working together to safeguard children
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
Safeguarding
E-Learning for Healthcare Safeguarding children and young people programme
Use strength-based approaches to assess and support young people, and where appropriate their parents and carers, to avoid the potential for re-traumatisation by recognising when people may have experienced trauma or adverse childhood experiences.
Scottish Government Trauma-informed practice: toolkit
South Yorkshire Violence Reduction Unit Trauma-informed practice
Gloucestershire County Council Frameworks for being trauma-informed
Early Intervention Foundation Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care
Adverse Childhood Experience Support Hub Cymru and Wrexham University ‘Trauma-informed’: Identifying key language and terminology through a review of the literature
Working definition of trauma-informed practice
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Where a young person transfers in or out-of-area, ensure that the young person’s health records are transferred to the receiving service with particular reference to GP, school nursing and children’s social care services. Local guidance and best practice should be adhered to, and include information regarding specialist services in the handover to ensure continuity of care.
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Community)
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Looked-after children
Follow statutory guidance including health assessments that consider family relationships and dynamics, and chronology of events to inform the health plan and ensure looked-after children have access to any physical, developmental, emotional or mental health care they may need, including support for foster carers regarding health issues, emotional support for young people not living with their parents, and planning for care leavers.
Offer personalised clinical interventions in response to need, which may include joint visits or consultations with other professionals in response to need. Use strengths-based approaches to empower young people, parents and carers to manage needs and access targeted services appropriately.
For example, looked-after children can be at a higher risk of missed immunisations offered in the national routine immunisation programme. For missed immunisations, refer to the guide for uncertain or incomplete vaccinations.
DfE, DHSC Promoting the health and wellbeing of looked-after children
DfE Working together to safeguard children
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
GOV.UK Children and young people leaving care
Vulnerabilities and identification of additional needs including young parents
Children’s Commissioner Help at hand
Immunisation
Vaccination of individuals with uncertain or incomplete immunisation status
Safeguarding
E-Learning for Healthcare Safeguarding children and young people programme
Work with foster carers and social workers to ensure full delivery of the local young people public health offer.
Health visiting and school nursing delivery model
Universal
Targeted
Specialist
Community
Where young people who are looked after are ready for independent living or semi-independent placements, contribute to the ‘Assessment of Need’ for the young person leaving care.
Offer targeted interventions in response to need, which may include joint visits or consultations with other professionals or advocacy. Use strengths-based approaches to empower the young person to prepare for independent living and access services appropriately.
Where additional targeted or specialist services are required, work in partnership to follow local pathways and to complete referral.
NICE Looked-after child and young people statement 8
DfE Looked-after children in independent or semi-independent placements
LGA Support for care leavers resource pack (PDF)
Use strength-based approaches to assess and support young people, and where appropriate their parents and carers, to avoid the potential for re-traumatisation by recognising when people may have experienced trauma or adverse childhood experiences.
Scottish Government Trauma-informed practice: toolkit
South Yorkshire Violence Reduction Unit Trauma-informed practice
Gloucestershire County Council Frameworks for being trauma-informed
Early Intervention Foundation Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care
Adverse Childhood Experience Support Hub Cymru and Wrexham University ‘Trauma-informed’: Identifying key language and terminology through a review of the literature
Working definition of trauma-informed practice
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Where a young person transfers in or out-of-area or has a change of placement, ensure that the young person’s health records are transferred to the receiving service with particular reference to GP, school nursing and children’s social care services. Local guidance and best practice should be adhered to, and include information regarding specialist services in the handover to ensure continuity of care.
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Community)
Continue to provide young people, parents and carers with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Domestic violence and abuse
Where domestic violence or abuse is suspected, discuss concerns safely, when the young person, parent or carer is away from the abuser and there is no risk of being overheard. This will usually be when a client is alone except where they wish to have a friend or family member present for support.
No child left behind: a public health informed approach to improving outcomes for vulnerable children
DfE Working together to safeguard children
Barnardo’s Families affected by domestic abuse
NICE Domestic violence and abuse
NHS.UK Domestic violence and abuse
DLUCH, DfE Supporting families
Home office Domestic abuse how to get help
NHS.UK Sexual health
NICE Domestic violence and abuse: multi-agency working
Safeguarding
Where domestic violence and abuse (including intimate partner violence and abuse or controlling relationships between parents or young people) is identified, follow statutory guidance and local safeguarding procedures.
Consider the young person experiencing or witnessing domestic violence and abuse as a victim here and what further safeguarding action will need to be taken.
Undertake holistic assessment according to local guidance to identify needs, strengths and vulnerabilities including family relationships and dynamics, and chronology of events.
NICE Domestic violence and abuse
NHS.UK Domestic violence and abuse
Home office Domestic abuse how to get help
NHS.UK Sexual health
NICE Domestic violence and abuse: multi-agency working
Bystander interventions to prevent intimate partner and sexual violence: summary
Mental and emotional health and wellbeing
Drugs, alcohol and tobacco
Safeguarding
NSPCC Learning Early help (or early intervention)
Home Office and Ministry of Justice Domestic Abuse Bill
Where young people, parents and carers have been identified as requiring targeted intervention, based on need provide personalised clinical interventions.
Where additional targeted or specialist services are required, work in partnership to follow local pathways to complete appropriate and timely referral.
NICE Domestic violence and abuse
NHS.UK Domestic violence and abuse
Home office Domestic abuse how to get help
NHS.UK Sexual health
NICE Domestic violence and abuse: multi-agency working
Bystander interventions to prevent intimate partner and sexual violence: summary
Mental and emotional health and wellbeing
Drugs, alcohol and tobacco
Safeguarding
NSPCC Learning Early help (or early intervention)
Home Office and Ministry of Justice Domestic Abuse Bill
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Safeguarding (Universal)
Safeguarding (Community)
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Universal
Community
Metrics and outcomes indicators
Use evidence and data to monitor the health and wellbeing of vulnerable young people and those with safeguarding needs. Compare local data with similar areas, within a region and nationally, to identify opportunities for improvement. Use evidence and data to evaluate and demonstrate improvements in population health and other outcomes resulting from targeted intervention.
OHID Fingertips Child and maternal health vulnerable children and young people
OHID Fingertips Improving health outcomes for vulnerable children and young people reports
OHID Fingertips Public Health Outcomes Framework
OHID Fingertips Wider determinants of health
OHID Fingertips user guidance
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Special educational needs and disabilities (SEND)
Where appropriate, contribute to education, health and care (EHC) plan needs assessments for the local authority to decide whether it is necessary for it to make provision in accordance with an EHC plan. Ensure these are completed to the national standards and within the statutory timeframe.
Where young people have been identified as in need of an education, health and care plan (EHCP) assessment, for example young people with neurodisability, work in partnership with young people, parents and carers, schools and education settings including SEN coordinators (SENCOs), and other agencies to identify the young person’s needs, strengths and vulnerabilities. Offer personalised clinical interventions in response to the identified EHCP. Use strengths-based approaches to empower young people, parents and carers to manage need and access services appropriately and prepare for transition to further education, apprenticeship, work or higher education.
Use strengths-based approaches to empower young people, and where appropriate their parents and carers, to manage need and access services appropriately and prepare for transition to further education, apprenticeship, work or higher education.
Work in partnership to contribute to the annual health assessment.
DfE, DHSC Promoting the health and wellbeing of looked-after children
DfE, DHSC SEND code of practice: 0 to 25 years
GOV.UK Children with special educational needs and disabilities (SEND)
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School-aged years high impact area 5: Supporting additional and complex health needs
School aged years high impact area 6: Supporting self-care and improving health literacy
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
Vulnerability in childhood: a public health informed approach
Safeguarding
Use strength-based approaches to assess and support young people, and where appropriate their parents and carers, to avoid the potential for re-traumatisation by recognising when people may have experienced trauma or adverse childhood experiences.
Scottish Government Trauma-informed practice: toolkit
South Yorkshire Violence Reduction Unit Trauma-informed practice
Gloucestershire County Council Frameworks for being trauma-informed
Early Intervention Foundation Trauma-informed care: Understanding the use of trauma-informed approaches within children’s social care
Adverse Childhood Experience Support Hub Cymru and Wrexham University ‘Trauma-informed’: Identifying key language and terminology through a review of the literature
Working definition of trauma-informed practice
Where additional targeted or specialist services are required, work in partnership to follow local pathways.
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Community)
Where a young person transfers in or out-of-area, ensure that the young person’s health records are transferred to the receiving service with particular reference to GPs, school nursing and children’s social care services. Local guidance and best practice should be adhered to, and include information regarding specialist services in the handover to ensure continuity of care.
Guidance to support commissioning of the healthy child programme 0 to 19 Commissioning guide 2: model specification
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Community)
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
NHS.UK How to care for children with complex needs
E-Learning for Healthcare: Early developmental support programme
Health visiting and school nursing delivery model
Universal
Community
Where young people have a long-term condition, complex need or disability, work in partnership to contribute to the development of a timely personalised plan for the transition from children’s to adult’s services and to prepare for transition to further education, apprenticeship, work or higher education.
School-aged years high impact area 5: supporting additional and complex health needs
NICE Transition from children’s to adults’ services for young people using health or social care services
RCPCH Transition to adult services
RCN Children and young people: transition to adult services
NHS.UK Moving from children's social care to adult's social care
Mencap Transition into adult services
Mind Moving from child to adult mental health services
Where agreed with young people, during the transition from children’s to adult’s services, advocate for young people with additional needs, including physical and mental health needs or learning disabilities to ensure that the young person’s voice is heard they are involved in decision-making, understand consent and that their needs are met.
School-aged years high impact area 5: supporting additional and complex health needs
NICE Transition from children’s to adults’ services for young people using health or social care services
RCPCH Transition to adult services
RCN Children and young people: transition to adult services
NHS.UK Moving from children's social care to adult's social care
Mencap Transition into adult services
Mind Moving from child to adult mental health services
Complex needs and disability
Work in partnership with other agencies and young people, parents and carers to review assessment identifying needs, strengths and vulnerabilities, and develop appropriate care plans to meet the needs of young people with complex needs, for example before hospital discharge or during transition to adult services and to further education opportunities.
Offer personalised clinical interventions in response to need, which may include joint visits or consultations with other professionals in response to need. Use strengths-based approaches to empower young people, parents and carers to manage need, engage in education and learning opportunities and access services appropriately.
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School-aged years high impact area 5: Supporting additional and complex health needs
School aged years high impact area 6: Supporting self-care and improving health literacy
NHS.UK How to care for children with complex needs
E-Learning for Healthcare: Early developmental support programme
Mencap Further education
Where young people with complex needs and disabilities have been identified as requiring targeted interventions for special educational needs or disabilities (SEND), support the multidisciplinary assessment and review process to identify health needs and vulnerability.
Based on need, work with young people, parents, carers and the multidisciplinary team including school nurses and education settings including SEN coordinators (SENCOs) to develop the education healthcare plan (EHCP).
Provide personalised clinical interventions in response to health needs, for example, targeted advice and support to help young people, families and carers to engage in education and learning opportunities, access the annual GP health check for people with a learning disability and specialist services appropriately and for managing medical conditions in education settings.
DfE, DHSC SEND code of practice: 0 to 25 years
GOV.UK Children with special educational needs and disabilities (SEND)
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School-aged years high impact area 5: Supporting additional and complex health needs
School aged years high impact area 6: Supporting self-care and improving health literacy
SCOPE Support groups for parents with disabled children
Annual health checks and people with learning disabilities
NHS England Annual health checks
NHS.UK Annual health checks
Specialist
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Targeted)
Safeguarding (Community)
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
NHS.UK How to care for children with complex needs
Health visiting and school nursing delivery model
Universal
Community
Where a young person is terminally ill, support them and their family.
Where agreed with the young person, advocate for them to ensure that their voice is heard, they are involved in decision-making, understand consent and that their needs are met.
Refer to specialist child palliative and end of life care where appropriate. Provide information about relevant support groups and programmes. Listen to parental concerns about caring for any other children and provide support, information and advice to help alleviate anxiety.
Palliative and end of life care
NICE End of life care for infants, children and young people with life-limiting conditions: planning and
management
GOV.UK Find a local support group for children, young people and families
Hospice UK
Child Bereavement UK
Long-term health and wellbeing needs
Work in partnership with other agencies and young people, parents and carers to review assessment identifying needs, strengths and vulnerabilities, and develop appropriate care plans to meet the needs of young people with long term health needs, for example young people who have epilepsy, diabetes or asthma.
Offer personalised clinical interventions in response to need, which may include joint visits or consultations with other professionals in response to need. Use strengths-based approaches to empower young people, parents and carers to manage needs and access targeted services appropriately.
NHS England House of care: a framework for long-term condition care
School-aged years high impact area 5: Supporting additional and complex health needs
School aged years high impact area 6: Supporting self-care and improving health literacy
NICE Epilepsy
BMJ Epilepsy: putting NICE guidelines into practice
NHS.UK Epilepsy
NHS England National bundle of care for children and young people with asthma
NHS.UK Asthma
NICE Asthma
RCPCH Allergy care pathway for asthma and/or rhinitis
Beat Asthma
Asthma UK
Healthier Together I’m worried about…
NHS.UK Diabetes
NICE Diabetes (type 1 and type 2) in children and young people: diagnosis and management
Diabetes UK
NHS.UK Sickle Cell Disease
Sickle Cell Society
NICE Sickle Cell Disease
NHS.UK Cystic Fibrosis
Cystic Fibrosis Trust
NHS England NHS Commissioning children and young people’s cancer
Young Lives vs Cancer
NHS.UK Congenital heart disease
NHS.UK Spina bifida
RCPCH State of child health long-term conditions
Ensure young people with diabetes are offered annual Diabetic Retinopathy Screening – DES (diabetic eye screening). Ensure that young migrants, refugees, asylum seekers and young people released from custody are aware of the screening programme and the benefits it can offer.
Provide evidence-based information, advice and guidance to support young people, and their parents and carers where appropriate, to make an informed decision about attending screening.
NHS.UK Diabetes
NICE Diabetes (type 1 and type 2) in children and young people: diagnosis and management
Diabetes UK
Screening
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Targeted)
Safeguarding (Community)
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
NHS England House of care: a framework for long-term condition care
Health visiting and school nursing delivery model
Universal
Community
Support young people and families with allergies and anaphylaxis, offering personalised clinical interventions in response to need, which may include joint visits or consultations with other professionals in response to need. Use strengths-based approaches to empower young people, parents and carers to manage needs and access targeted services appropriately.
School aged years high impact area 6: Supporting self-care and improving health literacy
NICE Allergies
RCPCH Allergy care pathways – education resources for healthcare professionals (2011)
NHS.UK Allergies
NHS England National bundle of care for children and young people with asthma
NHS.UK Asthma
NICE Asthma
RCPCH Allergy care pathway for asthma and/or rhinitis
Beat Asthma
Asthma UK
Speech, language and communication needs
Where young people have been identified as requiring targeted intervention for speech and language development, provide an assessment to identify health needs and vulnerability. This may include those with autism spectrum disorder; developmental coordination disorder (dyspraxia); social, emotional and mental health issues; hearing impairment; and motor disorders such as cerebral palsy and muscular dystrophy.
Based on need, provide personalised clinical interventions, for example information, advice and support for speech and language development. Follow local pathways and develop partnerships between health, education, and community services to support speech, language, and communication.
School-aged years high impact area 1: Supporting resilience and wellbeing
Solihull Approach Understanding your child
GOV.UK Working together to safeguard children
Downs Syndrome Association
RCSLT Creating better lives for people with communication and swallowing needs
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Continue to provide young people, and where appropriate their parents and carers, with the universal and community offer and work in partnership with other agencies while providing targeted support.
Health visiting and school nursing delivery model
Universal
Community
Metrics and outcomes indicators
Use evidence and data to monitor the health and wellbeing needs of young people with additional health and development needs including SEND. Compare local data with similar areas, within a region and nationally, to identify opportunities for improvement. Use evidence and data to evaluate and demonstrate improvements in population health and other outcomes resulting from targeted intervention.
OHID Fingertips Child and maternal health long-term conditions and complex needs
OHID Fingertips Child and maternal health vulnerable children and young people
OHID Fingertips Speech, language and communication reports
OHID Fingertips Public Health Outcomes Framework
OHID Fingertips user guidance
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Young parents
The outcomes for young parents and their children are disproportionately poorer, with higher rates of low birthweight, postnatal depression and negatively impact mental health for up to 3 years after birth.
Coordinated and sustained support for adolescent mothers and fathers can improve the life chances for them and the next generation of children.
Where young parents have been identified as requiring targeted intervention, provide an assessment to identify health needs, strengths and vulnerability.
Based on need, provide personalised clinical interventions, for example build a trusted relationship with young parents to enhance their skills, confidence and aspirations, develop their support networks and avoid poorer outcomes.
Teenage mothers and young fathers: support framework
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
Family Nurse Partnership
Mental and emotional health and wellbeing
Drugs, alcohol and tobacco
Mental Health Foundation Young mums together
Young minds.org.uk
Solihull Approach Understanding your child
Maintaining healthy relationships including sexual health
Safeguarding (Universal)
Safeguarding (Targeted)
Safeguarding (Community)
Provide information about local services, such as youth services, children’s centres or family hubs, where young parents can seek additional support and advice.
Teenage mothers and young fathers: support framework
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 3: Supporting healthy lifestyles
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
Family Nurse Partnership
Mental and emotional health and wellbeing
Mental Health Foundation Young mums together
Young minds.org.uk
Solihull Approach Understanding your child
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
While young parents are receiving targeted support, continue to provide the universal and community offer and work in partnership with other agencies.
Health visiting and school nursing delivery model
Universal
Community
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Targeted)
Safeguarding (Community)
Nurturing parenting
Where parents and carers have been identified as requiring targeted intervention due to concerns about inconsistent parenting, for example where parents and carers have learning disabilities, or where there are issues relating young people’s feelings of insecurity, inconsistent boundaries, expectations and behaviours, provide an assessment to identify health needs, strengths and vulnerability within the family.
Based on need, provide personalised clinical interventions, for example targeted advice and support on building trust between young people and their parents or carers, developing consistent responses, or reducing parental conflict.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
Alcohol, drugs and tobacco
DWP Reducing parental conflict: tools for commissioners, managers and leaders
NSPCC How childhood trauma affects child brain development
Safeguarding (Universal)
Safeguarding (Targeted)
Safeguarding (Community)
Provide accessible information about local services, such as youth services, children’s centres and family hubs, where parents and carers can seek additional support and advice. Where required, give assistance with interpreting information and accessing other sources of support.
School-aged years high impact area 1: Supporting resilience and wellbeing
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
Solihull Approach Understanding your child
GOV.UK Understanding accessibility requirements for public sector bodies
NHS England Accessible information standard
Where additional targeted or specialist services are required, follow local pathways to complete appropriate and timely referral.
Where there are safeguarding concerns, follow statutory guidance and local safeguarding procedures.
DfE Working together to safeguard children
Safeguarding (Universal)
Safeguarding (Targeted)
Safeguarding (Community)
While parents and carers are receiving targeted support, continue to provide the universal and community offer and work in partnership with other agencies.
Health visiting and school nursing delivery model
Universal
Community
Young people who frequently miss health appointments, are not brought to appointments or attend health services inappropriately are at risk of poor outcomes. Follow up non-attendance of health appointments or frequent use of A&E and provide support, information and advice to young people and parents as appropriate, including supporting young people to be involved in decision-making about their health and health appointments.
Non-attendance at appointments can be a sign of neglect. Where there are safeguarding concerns, referrals to social care services should be made.
Safeguarding
School-aged years high impact area 2: Improving health behaviours and reducing risk
School-aged years high impact area 4: Reducing vulnerabilities and improving life chances
School aged years high impact area 6: Supporting self-care and improving health literacy
No child left behind: a public health informed approach to improving outcomes for vulnerable children
Metrics and outcomes indicators
Use evidence and data to monitor factors which may benefit from intensive parenting support. Compare local data with similar areas, within a region and nationally, to identify opportunities for improvement. Use evidence and data to evaluate and demonstrate improvements in population health and other outcomes resulting from targeted intervention.
OHID Fingertips Child and maternal health
OHID Fingertips Teenage pregnancy and young parents reports
OHID Fingertips Public Health Outcomes Framework
OHID Fingertips user guidance
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