Introduction
The statutory removal of children experiencing neglect and/or abuse and placement into out-of-home care (OOHC) is common to many child protection systems. Such care can be with extended family (kinship care) or with trained care providers (foster care) or in residential units. International studies show that children entering OOHC (also known as ‘looked after children’) have higher rates of physical,1–5 mental6–10 and developmental4 9 11 health needs than the general population. Australian studies replicate these findings, in metropolitan and regional settings, and for Indigenous and non-Indigenous children in care.12–16 This is unsurprising, as reasons for removal from birth family are risk factors known to adversely affect development, health and well-being. Poor health negatively impacts on well-being, in childhood and long term, directly and indirectly: poor health in childhood negatively impacts on school performance, and poor educational outcomes lead to poorer health in adulthood.17 Early identification and management of health and developmental needs optimises long-term outcomes and minimises cost. This rationale underpins global expert bodies’ recommendations for early, routine health assessment of children on their entry to OOHC.18–20
If high health needs are routinely identified on entry to care, then high rates of health service use should follow. Some studies have shown such high rates (compared with children of similar socioeconomic background) for mental health service use,21–24 psychotropic drug use,25 well-child visits25 and hospitalisations.24 In Australia, Tarren-Sweeney found higher rates of mental health service use by children in OOHC in New South Wales even when compared with other children in OOHC, possibly due to a dedicated psychology service for children in OOHC in addition to universal school counselling services.26
However, there are concerns that both routine health checks and overall health service use is lower than it ought to be, given the level of need. Rates of timely initial health checks are often low: in Delaware, only 31% of children in care received a timely initial health check,25 and a Michigan study aiming to improve rates of timely health checks lifted rates from 27.6% pre-intervention to 52.2% post-intervention.27 In 2000, a UK study reported 65% of children having a timely health visit,28 and in Australia, an audit of case files in New South Wales showed that 22.1% had recorded an initial health assessment within 60 days.29 Melbye et al reported that most children in care received no dental care during a 12-month period,30 and those in kinship care were less likely than those in foster care to have received dental care. This care-type difference was also shown in Florida for likelihood of receiving mental health services.31
The myriad reasons for lower-than-expected routine health assessment and health service use have long been discussed. Over 25 years ago, Combs-Orme et al applied a health service use theoretical model to children in foster care and found barriers to healthcare in all domains of the model: health policy, healthcare delivery system characteristics and population characteristics.32 The challenges described—timely access, funding, health information management and legal responsibility for healthcare sitting with statutory authorities rather than the carers—still hinder timely and comprehensive healthcare.29 33
Despite the challenges, routine assessment for identification of health needs continues to be recommended by peak bodies and policy-makers in the USA, the UK and New Zealand.18–20 34 It was recommended in Australia in 201135 although no data are available to assess progress. Within Australia, state governments are responsible for child protection services and some health services (including hospitals and community health services). Approaches to the provision of health services to children in OOHC vary. In Victoria, there is no state-wide service providing routine assessment nor any means of determining the needs and access to health service for these highly vulnerable children. Data linkage provides the only option for understanding recent practice and to evaluate the impact of previous policy and programme interventions.