Introduction

The Marmot Review, Fair Society, Healthy Lives, identified giving every child the best start as the highest priority in reducing the health inequalities gap that exists between different groups of people. Action to reduce health inequalities needs to start before birth and be followed through the life of the child to improve adult health outcomes.

This is the first year that Merton joint strategic needs assessment (JSNA) has included a separate section on the needs of children and young people and maternal health. The aim is that this will provide a clear focus on children and young people and make it easier to access information on their needs.

This section sets out the high level needs of children, young people and maternal health. It outlines services to meet those needs, highlights evidence of good practice and sets out implications and recommendations. The aim is to improve outcomes for children and young people in Merton by informing and influencing commissioning and service delivery.

This section covers:

  • Maternal health
  • Child health and early years 0-5
  • Vulnerable children and young people
  • Access to health services  

In addition, information on lifestyles and health improvement is set out in Lifestyle Risk Factors information on wider determinants of health, including access to education, is set out in Social Determinants; and information on the voice of young people in Merton is set out in Merton Voice.

It is recognised that this is a developing section of the JSNA and in future years we aim to strengthen aspects of this section. In a number of areas data is still only available at PCT level (Sutton and Merton). Over time this will change as health data is recorded at CCG level (Merton).

Strategic priorities for children and young people

Strategic priorities for children and young people are set out in the Health and Wellbeing Strategy and the Children and Young People Plan:

Merton Health and Wellbeing Strategy has identified ‘Giving every child a healthy start’ as a key priority. The strategy includes a commitment to further strengthen partnership approaches to prevention strategies for children and young people, across universal services and settings. This will ensure the earliest identification of health and wellbeing issues to better target services to those families that are in the greatest need of support, particularly for residents living in the east of the borough.

The Merton Children and Young People's Plan 2016-19 sets out the Children’s Trust Board’s commitments to improving outcomes, life chances and choices for children and young people. The Children’s Trust Board provides a focus for integrated planning and delivery of children’s services, particularly focusing on key groups of children vulnerable to poor health outcomes.

 

Further resources

The Annual Report of the Chief Medical Officer 2012, Our Children Deserve Better – Prevention Pays, sets out evidence about challenges and priorities to improve the health and wellbeing of children and young people:

Further sources, including a child health profile for Merton is available at the Public Health England Child and Maternal Health Observatory (ChiMat):  

Summary and Overview of Recommendations  

The Marmot Review, Fair Society, Healthy Lives, identified giving every child the best start as the highest priority in reducing the inequalities gap that exists between different groups of people. Action to reduce health inequalities needs to start before birth and be followed through the life of the child to improve adult health outcomes.

Key findings

Demographic trends

Merton: The Place and the People sets out demographic changes in Merton. Key findings for children and young people include:

  • There has been a 40% net increase in births from 2,535 in 2002 to 3,537 births in 2011.
  • By 2021 there will be an expected 20% increase in children born each year with future special needs (from 230 to 276).
  • There are 47,500 children and young people aged under 20 years old, which is nearly 24% of the population in Merton.
  • The number of children and young people aged 0-19 years is forecast to increase by around 3,200 (3%) by 2017. In particular, there is forecast to be an increase of 2,300 (20.3%) in the number of children aged 5 to 9 years.
  • There are 15,000 (7.5%) 0-4 year olds, which is expected to rise by 780 by 2017.
  • There are 32,500 (16.2%) children and young people aged 5-19 years, which is expected to rise by 2,400 by 2017.
  • It is forecast that the proportion of BAME people in the 0-19 age group will increase from 44% in 2011 to 47% in 2017.

Where Merton is doing well

Maternal health

  • The infant mortality is similar to London and England, at a rate of 4 infant deaths per 1,000, compared with 4.4 regionally and nationally.
  • Fewer babies are born with a low birth weight compared with London.
  • Breastfeeding initiation and breastfeeding rates at 6-8 weeks are higher compared with England.
  • Smoking in pregnancy is lower compared with England.

Early years

  • The proportion of children achieving a good level of development (GLD) at age 5 is above the national average, at 68% for Merton compared with 66% for England (2014/15).
  • The proportion of children eligible for Free School Meals (FSM) achieving the GLD has increased by 11 percentage points to 55% in 2014/15.  

Children

  • There are fewer children living in poverty (18.3% or about 7,000 children) compared with England (21%).
  • Hospital admission rates for injury are lower compared with London and England.
  • Hospital admissions as a result of self-harm are lower than for London and England.
  • Educational attainment in 2014/15 shows 60% of pupils achieved five GCSEs at A*-C grades, including English and maths which is above the national average of 54% but is just below the London average of 61%.
  • The rate of progress in performance in Merton schools is greater than the majority of other local authorities.

Young people

  • Teenage pregnancy rates have reduced significantly over the past 13 years, down from 51 per 1,000 in 1989 to 27.6 per 1,000 in 2011.
  • There has been a year-on-year reduction in first-time entrants to the youth justice system over the past four years, and a reduction in the number of violence against the person crimes.

Where Merton has some challenges

Maternal health

  • There is variation in low birth weight by area and ethnicity, with higher rates in more deprived wards and among BAME ethnic groups.
  • There is variation in breastfeeding by area and ethnicity, with lower rates in more deprived areas and among white British ethnic groups.
  • There are higher rates of delivery by caesarean section –27 % compared with 24% for England.

Early years

  • Childhood immunisation coverage is below London and England levels and the World Health Organization’s target of 95%, and there is variation in the level of immunisation coverage by GP practice.
  • Emergency attendances for children aged 0-4 years are higher compared with England and there is variation by GP practice.

Children

  • There is an increase of nearly 14% in levels of excess weight (overweight and obesity) in children between the ages of 5 and 11 years, from just over a fifth of Reception level children to just over a third of Year 6 level children.
  • There is variation in obesity rates by gender, ethnicity and area, with higher levels of obesity associated with deprivation.
  • Nearly 30% of 5 year olds are estimated to have decayed, missing or filled teeth, an increase of 6.4% between 2008 and 2012, and there has been a reduction in the proportion of decayed teeth filled by dentists. Nearly 38% of children in Sutton and Merton do not access an NHS dentist.
  • There is a gap between the number of children and young people accessing Tier 3 Child and Adolescent Health Services and the estimated numbers with a mental health problem indicating a need for Tier 3 services.
  • There has been an increase in the number of children with statements of SEN with ASD over the past three years.
  • Nationally and in Merton there has been an increase in children in care and on a child protection plan.
  • There has been an increase in the number of looked-after children (LAC).

Young people

  • There is variation in teenage pregnancy rates by area, with higher rates concentrated in more deprived wards.
  • Hospital admissions for alcohol-specific conditions in children and young people aged under 18 are the ninth highest in London (although still lower compared with England).

Summary of recommendations for commissioners

Impact of demographic change

The current picture of rising births and of potentially less outward migration has implications for projecting future need and demand for services. Commissioners need to consider the implications for:

  • Increasing need for maternity services – planning for additional capacity is needed linked to a regional strategy for maternity services.
  • Impact on primary care and community services – planning for additional capacity to deliver the Healthy Child Programme, including health visiting and school nursing services.
  • Increased incidence of long-term conditions in children and young people, such as asthma and diabetes.
  • Impact on children social care, child protection and education services – planning for additional capacity.
  • If the proportion of low and very low birth weight babies stays the same (approximately 7% of all births) there will be a rise in children born with future special needs – which will impact on planning for additional capacity for paediatric and neonatal services; SEN; and continuing care/short breaks.

Impact of deprivation

Deprivation is linked to poor health. Higher numbers of children are being born in the more deprived areas of the borough. Commissioners need to consider:

  • The impact of the recession and welfare reform on longer-term child health, including long- term care and mental health.
  • The significant link between deprivation, poverty and mental wellbeing in young people. More robust information is needed on the mental health and wellbeing of children and young people.
  • The geographical inequalities that exist in health and lifestyles in maternal health, and children and young people, including breastfeeding rates, teenage pregnancy rates, levels of overweight and obesity, and oral health, which need to be addressed.
  • The clear link between teenage pregnancy, offending behaviour, truancy and alcohol and drug misuse. Commissioners need to review the opportunities to look more holistically in tackling these issues.

Service development

The JSNA has identified a number of priorities and areas for development, many of which build on current commissioning and service development activity:

Maternal health

  • Maintain a focus on action to ensure that infant mortality and low birth weight remain low in Merton, including:
  • reducing child and family poverty and housing needs
  • reducing maternal obesity and improving nutrition, particularly in more disadvantaged areas
  • improving the accessibility of antenatal care and support during the first year of life, targeting areas of higher needs.
  • Review the rate of caesarean deliveries, both elective and emergency, and identify how this can be reduced.
  • Develop and deliver a breastfeeding action plan that targets lower levels of breastfeeding in the more deprived areas of the borough, based on best evidence of effective practice.
  • Ensure providers achieve Level 3 UNICEF Baby Friendly initiative.
  • Ensure the effective delivery of the Family Nurse Partnership, targeting mothers aged under 20 years.
  • Ensure that the South West London maternity dashboard is monitored to provide standardised data from providers. Ensure that there is robust analysis of data for the Merton population to inform commissioning.
  • Going forward, ensure that the new national Maternity and Children’s Data Set (MCDS), which over time will result in comprehensive data (HSCIS-MCDS), informs local commissioning.

Early years

  • Monitor progress on childhood immunisation coverage towards local and WHO targets; ensure that improvements to childhood immunisation data systems are monitored and sustained.
  • Deliver childhood immunisation action plans, including improving call-recall systems and increasing access to and awareness of immunisation for parents.
  • Develop an outcomes model of commissioning for early years, based on evidence of best practice and underpinned by strong data systems.
  • Develop early years prevention and early intervention pathways, with clear referral routes for all partners.
  • Parental mental health has been identified as a significant factor in parenting; there is a need to increase parent support, ensure there is staff training and awareness and develop clear pathways into mental health services.
  • Implement a data sharing agreement across early years in order to strengthen the ability to provide earlier intervention for families identified as having additional needs.
  • Establish a vision, model and transition plan for health visiting as commissioning responsibility for the service moves to the local authority in 2015.

Vulnerable children and young people

  • Understand and address the impact of increasing numbers of low birth weight babies on the demand for health and social care services.
  • Ensure children with long-term conditions are supported to access the full curriculum in schools and have a smooth transition to adult services.
  • In light of the increasing numbers of children diagnosed and increasing waiting times for assessment, develop an autism pathway for children and young people linked to the Autism Strategy.
  • In order to gain a better understanding of the need for services and inform future commissioning strategy, undertake a needs assessment of the mental health and wellbeing of children and young people.
  • Review the impact of implications of the Children and Families Bill 2013 on all services, including schools, health and therapy services, special educational needs and disabilities, and social care.
  • Ensure pathways and links across services are in place to ensure effective access and intervention for children and young people on the threshold of care and looked after children.
  • Consider the impact on services of increasing numbers of LAC requiring timely health assessments.
  • Substance misuse is a major factor in youth offending and there is a need to better market existing pathways into substance misuse services.

Access to health services

In light of existing and future financial constraints, and at a time when the birth rate is increasing, there is a need to:  

  • ensure that in the majority of cases children with both acute and long-term conditions are supported in the community as much as possible
  • ensure the local pathway of unplanned care is underpinned by a consistent model of care for all organisations.
  • review data on hospital attendances for children aged 0-17 years, including a focus on the 0-4 age group, and further develop local initiatives to reduce A&E attendances.