Developing Healthy Lifestyles

Executive Summary

Information in this executive summary was correct as at 24/08/2017

According to the King’s Fund ‘evidence from many countries confirms that there is a strong correlation between educational attainment, life expectancy and self-reported health, within and across generations. School is also an important setting for forming or changing health behaviours. But interventions need to be well targeted, and achieving improvements in behaviour among more deprived pupils may be more difficult and more costly (Matrix Evidence/NICE 2008).

  • Four more years of schooling reduces mortality rates by 16 per cent – equivalent to the life-expectancy gap between men and women – and reduces risks of heart disease and diabetes (Lleras-Muney and Cutler 2006).
  • Those with less education report being in poorer health; they are more likely to smoke, more likely to be obese and suffer alcohol harm (Department of Health 2008).
  • England has some of the widest education-related inequalities in self-assessed health in Europe, particularly for women; out of 19 countries, only Slovakia and the Czech Republic fare worse (Mackenbach et al 2007) .
  • Better education for parents improves health outcomes for their offspring. The introduction of reforms to increase school leaving age for girls in the 1970s led to a reduction in overweight boys (Nakamura 2012).
  • Only half of 7 year olds are getting the recommended levels of physical activity with girls doing less well than boys (Griffiths et al 2013); schools have an important part to play.’

Nationally there are renewed energies for the healthy school concept. The funding for a National Healthy Schools Rating Scheme is now being led jointly by the DH and the DoE and there will be funding for national resources to support the scheme. This is not a replacement for existing schemes, it will support those schemes that are running locally and allow some online support for those schools that do not have a scheme in their locality. The exact details for this are not confirmed at this stage.

Introduction

The National Institute for Health and Care Excellence (NICE) advises that primary schools and secondary schools should be supported to adopt a comprehensive, ‘whole school’ approach to promoting the social and emotional wellbeing of children and young people. Such an approach moves beyond learning and teaching to pervade all aspects of the life of a school, and has been found to be effective in bringing about and sustaining health benefits.

Personal, Social, Health and Economic Education (PSHE), is part of a Whole School Approach to Health and Wellbeing. PSHE is currently a non-statutory subject on the school curriculum. However, the Children and Social Work Act received Royal Assent on 27 April 2017. The Act requires the Secretary of State for Education to introduce ‘relationships education’ for all primary-aged pupils, which will focus on building healthy relationships and staying safe. For secondary-aged pupils, ‘relationships and sex education’ (RSE) will be introduced, currently only a requirement on local authority maintained schools. The new legislation applies to all maintained, academies and independent schools. Schools will be required to teach this content from September 2019.

Schools that focus on developing pupils’ social skills and emotional health can provide long-term paybacks to society through the creation of well-adjusted adults. For instance, school-wide anti-bullying programmes can return almost £15 for every £1 invested in the longer term through higher earnings, productivity and public sector revenue (Knapp et al 2011); interventions to tackle emotional-based learning problems in schools have paid for themselves within the first year through reductions in social service, NHS and criminal justice system costs, and have recouped £50 for every £1 spent over five years (Knapp et al 2011).

Who’s at risk and why?

Health Related Behaviour Questionnaire

The Health-Related Behaviour Survey is developed by the Schools Health Education Unit and has been carried out in Surrey in 2015 and 2017 with young people of primary and secondary school age. Nationally over 1 million school children have taken part and over 4000 schools and colleges have participated, we are able to compare Surrey data and results with these national results, as well as individual schools being able to access their own data.
294 schools out of a total of 392 schools were contacted across Surrey, questionnaires were completed on paper or on line. Of the 294 eligible schools, 41 completed the process which is 14% coverage across Surrey, which makes the results statistically significant. Of these
26 primary and junior schools completed which is 12%, 14 secondary schools completed which is 24% and 1 special school completed.

Gypsy, Roman, Traveller (GRT) comparisons in primary schools:

  • 16% say they worry about body changes quite a lot or a lot compared to 13% overall.
  • 8% report having tried smoking once or twice compared to less than 1% overall.
  • 24% report ever feeling afraid of going to school because of bullying compared to 37% of all primary school children, at least sometimes.
  • 8% of GRT children report having had an alcoholic drink (more than just a sip) in the last 7 days compared with 2% overall.

Gypsy, Roman, Traveller (GRT) comparisons in secondary schools:

  • 18% worry about becoming a parent before being ready quite a lot or a lot, compared to 6% overall
  • 14% say they smoke occasionally or regularly compared to 4% overall
  • 29% report having been bullied at or near school in the last 12 months, compared with 20% overall
  • 39% say they have drunk alcohol in the last 7 days compared to 12% overall

NB: Number of children identifying as GRT is low and so care should be taken drawing any conclusions from the data

Young carers and comparisons with other children in Surrey primary schools:

  • 2% report having tried smoking once or twice compared to less than 1% overall.
  • 22% say they worry about body changes quite a lot or a lot compared to 13% overall.
  • 50% report ever feeling afraid of going to school because of bullying compared to 37% of all primary school children, at least sometimes.
  • 5% of young carers report having had an alcoholic drink (more than just a sip) in the last 7 days compared with 2% overall.

Young carers and comparisons with other children in Surrey secondary schools:

  • 13% worry about becoming a parent before being ready quite a lot or a lot, compared to 6% overall
  • 6% say they smoke occasionally or regularly compared to 4% overall
  • 38% report ever feeling afraid of going to school because of bullying, at least sometimes. This compares to 24% overall
  • 13% say they have drunk alcohol in the last 7 days compared to 12% overall

Smoking amongst children and young people

Uptake of smoking

There are several risk factors associated with increased likelihood of smoking initiation among young people, including exposure to parent, carer, sibling and peer smoking, lower socio economic status, higher levels of truancy and substance misuse . The younger the age of uptake of smoking, the greater the harm is likely to be. Early uptake is associated with subsequent heavier smoking, higher levels of dependency, a lower chance of quitting, and higher mortalityi.

Looked after children

Looked after children are far more likely to smoke than children of the same age who are not in the care system. A study in 2003 found that as many as two thirds of children in residential care smoke . Looked after children are at high risk of long-term disadvantage, marginalisation and poor health and life outcomes. Smoking is a key factor driving this risk, undermining health, wellbeing and financial security. It is therefore vital to reduce the risk of smoking uptake among looked after children, especially through placement in smoke free homes, while also ensuring that looked after children who do smoke have every opportunity to quit.

Healthy Weight

Child obesity is a major public health issue. Excess weight in children increases the risk of them becoming obese as adults and they are more likely to develop long term conditions such as type 2 diabetes, coronary heart disease and cancer. It can also worsen child hood disease such as asthma, and can lead to increased risk of mental health problems, bullying and stigma.

Obesity is a complex problem with many drivers, including our behaviour, environment, genetics and culture. However, at its root, obesity is caused by an energy imbalance: taking in more energy through food than we use through activity.

Because children’s BMI changes considerably between birth and adulthood, fixed thresholds such as those used for adults are not applied to children as they would provide misleading findings. Instead; BMI is classified using thresholds that vary to take into account the child’s age and sex. In England we use the UK90 Growth Charts; which use centiles as the measurement where by underweight is classified at the 2nd centile, overweight the 85th centile and very overweight above 95th centile.

The burden is falling hardest on those children from low-income backgrounds. Obesity rates are highest for children from the most deprived areas and this is getting worse. Children aged 5 and from the poorest income groups are twice as likely to be obese compared to their most well off counterparts and by age 11 they are three times as likely.

Each year, as part of the National Child Measurement Programme (NCMP) children in Reception and Year 6 are weighed. A national NCMP report comparing changes in children’s Body Mass Index between 2006/7 and 2013/14 showed a significant upward trend across both age groups, particularly in Year 6 boys and Year 6 Pakistani and Bangladeshi girls but also reported a widening inequality gap for those living in deprivation.

The prevalence across Surrey, of children aged 5 – 6 years that are either overweight or obese is 16.6%. This indicates a downward trend from 17.9% in 2014/15 and 18.1% in 2013/14. However prevalence in Spelthorne continues to remain at around 20%, while in Surrey Heath levels have increased from 17.5% in 2014/15 to 18.4% in 2015/16.

The prevalence of excess weight in Year 6 pupils (ages 10 – 11 years) for Surrey as a whole remains level at 26.5%, however Spelthorne, Runnymede and Woking have significantly higher rates at 32%, 30.5% and 30.4%. There is a slow downward trend for Spelthorne and Runnymede, however Woking levels have increased by 3.6% over the past three years.

We know that being overweight or obese is strongly associated with lower socio-economic status. The map below shows combined data from 2012 to 2015 and shows those areas with higher proportions of Year 6 children who are overweight or obese. These areas do align with areas in Surrey known to be more deprived.

Unintentional injuries

In England, unintentional injury is a leading health burden and cause of death and illness among children and young people with more being admitted to hospital each year for that reason than for any other. Unintentional injuries and accidents are the leading cause of mortality among secondary school children (10–19 years), with the risk increasing as children get older. The causes of injury are diverse and risks vary with age and social status. The main causes of hospital admissions due to unintentional injury in children and young people are road traffic injury (pedestrian injury in particular), falls, poisoning, drowning and burns. Younger children are most at risk of injuries in the home, while older children are most risk of road traffic injuries.

Sexual Health

Sexually Transmitted Infections

In 2015 the most commonly diagnosed STI was chlamydia with 200,288 diagnoses, over 129,000 chlamydia diagnoses were made in England among young people aged 15 to 24 years (64%). (9)

In 2015, among heterosexuals diagnosed, 15 to 24-year-olds accounted for 62% of those with chlamydia, 52% with gonorrhoea, 51% with genital warts, and 41% with genital herpes. (9)

Under 18 conceptions

Office for National Statistics (2014) states that the under 18 conception rate for 2014 is the lowest since 1969 at 22.9 conceptions per thousand women aged 15 to 17 (10). The estimated number of conceptions to women aged under 18 fell to 22,653 in 2014, compared with 24,306 in 2013, a decrease of 6.8%.

It is widely understood that teenage pregnancy and early parenthood can be associated with poor educational achievement, poor physical and mental health, social isolation, poverty and related factors.

There is also a growing recognition that socio-economic disadvantage can be both a cause and a consequence of teenage motherhood. Teenage pregnancy rates are a well-established and evidence based indicator of deprivation and inequality with 50% of all teenage conceptions occurring in the top 20% most deprived wards in England. Poor self-esteem, lack of aspiration and alcohol misuse increase the likelihood of a teenage pregnancy.

Young Parents

Public Health England (2016) in their Framework for Young People (11) state “like all parents, teenage mothers and young fathers want to do the best for their children and some manage very well; but for many their health, education and economic outcomes remain disproportionately poor which affects the life chances for them and the next generation of children.” The babies of young parents can face more health problems such as premature birth or low birth weight and higher rates of infant mortality. Teenage mothers themselves may also have experience health problems. For example, postnatal depression is three times more likely in teenage mothers; smoking in pregnancy is twice as common and teenage mothers are one third less likely to breast feed. 2 in 3 teenage mothers experience relationship breakdown in pregnancy or the 3 years after birth. There is little data on teenage fathers but health, economic and employment outcomes seem to be similar to those of young mothers; men who were young fathers are twice as likely to be unemployed at 30.

Termination of Pregnancy

According to the Department of Health (2015) Abortion Statistics, England and Wales (12) the total number of terminations remains fairly constant at 185,824, 0.7% higher than in 2014 (184,571) and 0.3% less than in 2005 (186,416).

Around half of all under 18 conceptions in England lead to a termination. The rate for England and Wales equates to 9.9 per 1,000 women compared with 11.1 in 2014 and 17.8 in 2005. In young women under 16 the rate is 2.0 per 1,000.

Repeat terminations

38% of terminations in 2015 were to women who had already had one or more terminations. This varies according to age group and 10 % of terminations were to women aged under 18.

Substance misuse

Young people are more likely to take drugs then adults; data from the CSEW 2014 -15 showed 19% of 16-19 year olds and 20% of 20-24 years have taken drugs. Whilst few young people will develop a substance misuse or alcohol dependency, however, even for those who do not use frequently the risks associated with alcohol and substance misuse in CYP include damage to the developing brain, interference in the normal challenges of development, exacerbation of other life and developmental problems. Nationally the majority of young people accessing specialist drug and alcohol interventions have problems with alcohol (37%) and cannabis (53%) . Those who are likely to develop a dependency are likely to be vulnerable and experiencing a range of health and social problems, therefore the needs of CYP differ from adults who can access core treatment services. These vulnerabilities might include:

  • Looked-after child
  • Parent who is misusing drugs and / or alcohol
  • At risk or involved in of child exploitation
  • Living in poverty
  • Have a diagnosed mental health problem
  • Affected by domestic abuse

Drug use among young people is associated with other risky behaviour. Young people were more likely to have taken drugs in the last year if they were smokers or had drunk alcohol. 11 to 15 year olds who had been excluded from school or who had played truant were also more likely to take drugs.

The level of need in the population

PSHE review

In 2014 Babcock 4S completed a review of PSHE provision in Surrey secondary schools. The evaluation of Secondary PSHE provision in Surrey highlighted that there is good practice in place in many schools across the county. Overwhelmingly teachers strive to provide a high standard of provision of PSHE as they recognise the role it plays in supporting the mental health, wellbeing and the resilience of young people. There are, however, barriers to effective provision which can be overcome, either fully or partially, by effective pooling of expertise, the provision of high quality PSHE education consultancy, training and resources, the alignment of local priorities and strategies and an increased priority given to the subject area – in short – increasingly efficient and effective partnership working.

Surrey Heartlands STP 2017

The Surrey Heartlands Sustainability and Transformation Plan 2017 found that citizens felt that their community would benefit most from healthy lifestyles being taught and encouraged in schools (66%) and information on where to get help, health advice and support, rather than just a GP surgery (56%).

Health Related Behaviour Questionnaire

Summary of some of the primary school findings:

  • 22% of pupils responded that they 5 portions of fruit and veg on the day before the survey, while 22% said the same of sweets, chocolate, choc bars
  • 1% of pupils responded that their school knows they are a ‘young carer’
  • 83% of pupils responded that they feel happy talking to other pupils at school
  • 68% of Surrey Yr6 felt their school took bullying seriously compared to 78% of yr6s from the SHEU sample
  • 85% of pupils responded that they cleaned their teeth at least twice on the day before the survey
  • 29% of Year 6+ pupils responded that they have seen images or videos online that were for adults-only
  • 25% of pupils responded that they would like to lose weight.

Summary of some of the secondary school findings:

  • Of the 37 pupils who smoke regularly, 43% said they would like to give up
  • 85% of pupils responded that they have never heard of GUM clinics (73% CASH clinics), while 2% said that they know what they are, but not where or how to access them
  • 73% of pupils responded that they know an adult they trust who they can talk to if they are worried about something, while 8% said they don’t know anyone
  • 84% of pupils responded that they visited the dentist in the last 6 months
  • 9% of girls responded that they usually/always cut and hurt themselves when they have a problem that worries them or makes them unhappy
  • 58% of pupils responded that they are asked for their opinions about what they learn in school; 40% said their opinions make a difference and 52% would like to be consulted more
  • 25% of pupils responded that they at least ‘sometimes’ feel afraid of going to school because of bullying

Statistical Neighbours Comparisons:

Cambridgeshire, Hertfordshire, North Yorkshire are statistical neighbours’ of Surrey.

The broad picture seen in the comparisons is that Surrey is not markedly different from these other authorities.

Young people in Surrey, when compared with their peers in comparable local authorities, may be:

  • Less likely to think about their health when choosing food (secondary)
  • More likely to be happy with their weight as it is (secondary)
  • Primary pupils are more likely to travel to school by car while secondary pupils are less likely to do so
  • Less likely to think they know a drug user
  • Less likely to know where they can get condoms free of charge (secondary)

Smoking amongst children and young people

Prevalence

It is estimated that each year around 207,000 children in the UK start smoking. Among adult smokers, about two-thirds report that they took up smoking before the age of 18 and over 80% before the age of 20 . Among children who try smoking it is estimated that between one third and one half are likely to become regular smokers within two to three yearsiv.

In Surrey, the smoking prevalence modelled estimates at age 15 amongst regular smokers (at least one cigarette every week) is 7.9% (England 8.7%). Amongst 11 to 15 year olds in Surrey it is 2.8% and amongst 16 to 17 year olds, it is 13.6% .

E-cigarettes and Vaping

Surveys have shown that although children’s awareness of and experimentation with electronic cigarettes is increasing, regular use remains rare and is most common among those who currently smoke or have previously smoked. This indicates that it is unlikely that electronic cigarettes are currently acting as a gateway to regular smoking . According to the ‘What About YOUth survey’, 12.5% of 15 year olds have used or tried e-cigarettes in Surrey (England 18.4%).

Secondhand smoke

According to the 2015 Health Related Behaviour Survey, 6% of primary school pupils responded that someone smokes indoors at home in rooms that they use and 9% of responded that someone smokes in a car when they are in it too . For secondary school pupils, 9% responded that someone smokes indoors at home in rooms that they use and 13% responded that someone smokes in a car when they are in it toov.

Immunisation

Immunisation is acknowledged by the World Health Organisation (WHO) as one of the most successful and cost effective public health interventions. Active vaccination programs have helped to reduce, or in some cases virtually eliminate, the threat of some of the most dangerous childhood diseases.

The European Region of the WHO has set a 95% uptake rate for childhood immunisations. Currently Surrey falls short of this target and the national (England) benchmark in relation to cover rates for most childhood immunisations. For example, in 2015/16, average uptake of the Measles, Mumps and Rubella vaccination in Surrey was 82.5% for the first dose and 73.8% for the second dose, compared with an average of 91.7% and 88% in England.

School based immunisation programmes

HPV

The human papillomavirus (HPV) national childhood vaccination programme was introduced in 2008 for secondary school Year 8 girls (12 to 13 years of age) as a three-dose schedule given within a six-month period. From 2014 the schedule has changed to two doses, given at least six months apart. In Surrey, there is one community provider of the HPV vaccination programme. Percentage uptake of the HPV vaccine for dose one is 85.7% for 2015/16. As per Green Book guidance, HPV doses can be given 6-24 months apart allowing some flexibility in delivery of the programme by community providers. As such data for the second dose during the period 2015/16 is currently unavailable.

Men ACWY and Td/IPV vaccination programme

Since 2009 there has been a year on year increase in the number of cases of meningococcal W (MenW) disease. Older teenagers and young adults are more at risk of getting meningitis and septicaemia from MenW. A catch-up programme offering a MenACWY vaccination to all 14 to 18 year olds and new university entrants started from August 2015. Men ACWY protects against four groups of meningococcal bacteria that commonly cause disease, meningococcal (Men) A, C, W and Y. Uptake of the MenACWY programme via the school based delivery model for the academic year 2015/16 is shown in the table below.

LA Area Provider MenACWY Uptake Year 10 MenACWY Uptake Year 11 Td/IPV
Surrey FCHC 88.1 77.5 79.1
CSH 88.1 77.5 79.1
Virgin Care 82.3 79.8 80.0

The MenACWY vaccine is also provided through primary care via a locally enhanced service to older children and young people. The eligible cohorts for the MenACWY vaccination programme in primary care for 2015/2016 are:

  • From August 2015: the Year 13s (DOB 01/09/1996-31/08/1997)- 17 and 18 year olds regardless of whether these children are in education or not – call and recall model applied. (To prompt the timely delivery of childhood immunisation, systematic call and recall systems must be operated. Call/recall is a systematic method of inviting eligible populations for immunisations as per the Green Book, and are managed in partnership between Child Health Information Systems and individual GP practices. Where initial invitations are not taken up, further attempts must be made to re-invite patients for immunisations as per local arrangements)
  • First time university entrants between 19 to 25 years of age: this cohort will be notified by University and Colleges Admissions Services (UCAS) to access their GP practice for the MenACWY vaccine – hence they will self-present to their practices.

However, data highlights that uptake of the vaccine for these age groups is low, with CCGs only achieving uptake of between 25% and 42%. Children in year 10 are also offered the tetanus and polio booster alongside the MenACWY booster, with children who miss this being offered the vaccination in a community setting.

Childhood flu

From October 2016, children in years one, two and three have been invited to take part in the national childhood flu vaccination programme. Children may become unwell with the flu virus but can also spread the virus to many vulnerable people. A 40% minimum uptake of the childhood flu programme is expected in order to be effective in both protecting children, and in order to prevent the onward transmission of the virus. In 2015, over 60% of the eligible children in Surrey schools were vaccinated.

Sexual Health

Sexually Transmitted Infections

Chlamydia remains the most commonly diagnosed STI for young people aged 15-24 years old. The detection rate in Surrey is 1182.2 per 100,000 population.

Under 18 conceptions

  • In line with national data trends that show a continuing decrease in the rates of conception in under 18 year olds, Surrey’s average has been falling consistently since 2011
  • Rates are currently at their lowest of 14.2 per 1,000 population, compared to a South East region average of 18.8 and England average of 22.8 per 1,000
  • Runnymede and Spelthorne continue to have the highest rates in Surrey at 19.7 and 20.3 per 1,000 population respectively.

Termination of pregnancy

  • Surrey has significantly higher than the national average rate of Termination of Pregnancy (ToP) in under 18s, 64.8%
  • Rates for under 18s ToP ranges greatly from 48% in Runnymede to 80.6% in Reigate and Banstead
  • The South East region average is 53.2%, England average is 51.1%.

Repeat Terminations

  • Surrey has high rates of repeat terminations (woman has had one or more terminations). On average 38.1% of ToP in Surrey in 2015 (for all ages) were repeat ToP
  • 27.9% of terminations to women aged under 25 were repeat ToP. The highest was 32.1% in Surrey Downs CCG.

Unintentional Injuries

In Surrey, unintentional injuries account for approximately 13% of all emergency admissions and 4.5% of all hospital admissions. Unintentional injuries and accidents are the leading cause of mortality among secondary school children (10-19 years), with the risk increasing as children get older.

National figures from 2014/15 note that unintentional injuries led to around 106,043 admissions to hospital among children and adolescents aged 0–14 (9). Around 295,000 under-16s attend A&E with head injuries each year in England. Most head injuries are minor; but 1 in 10 is classed as moderate to severe. In England during 2010/11, around 36,500 children under 14 were admitted to hospital with head injuries. Falls and road traffic incidents are the most common causes of head injury, with falls most predominant in the under-2s (10). In England during 2010/11, around 400 children aged 0–14 were admitted to hospital with bath water scalds. Furthermore, in 2010-11, almost 1,200 children under the age of 16 were admitted to hospital in England and Wales with hot drink scalds (10).

There is one Public Health Outcomes Framework (PHOF) indicator relating to unintentional injuries for children and young people (2.07 Hospital admissions caused by unintentional and deliberate injuries in children and young people aged 0-4, 0-14 and 15-24 years). Limitations to this data are as follows:

  • It does not distinguish between deliberate and unintentional injuries
  • The data refers to the crude rate of hospital admissions caused by unintentional and deliberate injuries in children per 10,000 resident population. Please note that this kind of rate is not age-standardised and therefore does not adjust for possible confounding effects, such as the age structure of a population. However, evidence suggests that unintentional injuries in the under 18’s are 18 times higher than in the number of hospital admissions due to deliberate injuries
  • This data is limited to hospital admissions due to injury, it is therefore not possible to establish the cause or where the injury took place.
    Note that we are currently awaiting updated Hospital Episode Statistics focusing on emergency hospital admissions for injuries in children and young people. This will allow for in depth analysis of cause. The chapter will be updated accordingly when this data is available.

0-14 years

In 2015/16 for the age group 0 – 14 years, Guildford had the highest rate of hospital admissions, 114 per 10,000 population, followed by Mole Valley (112 per 10000) and Surrey Heath (109 per 10000); all of which are higher than the rates for Surrey (96 per 10,000), England (104 per 10,000) and the South East (99 per 10,000). Data for Surrey Heath suggests a general upward trend from 2011/12 (68.5 per 10,000). Investigation is required to understand this fully and a coordinated approach will be required in order to halt this increase.

15-24 years

In 2015-16, Mole Valley, Reigate and Banstead, Surrey Heath, Tandridge and Waverley have higher rates of hospital admissions per 10,000 population in the 15-24 age group than in Surrey as a whole, England and the South East. Mole Valley saw a significant year on year increase from 130.3 per 10,000 in 2013-2014 to 187.33 per 10,000 in 2014-15. It should be noted that 16 to 24 year olds constitute a fifth of all car occupant casualties (all severities).

Substance misuse

There has been an overall decrease in drug use reported by 11 to 15 year olds since 2001 which has been reflected in a reduction in the number of young people in specialist services. For example, in 2012, 17% of 11 to 15 year olds had tried drugs at least once in their lifetime, compared with 29% in 2001.

Consistent with the national trend, the number of individuals under 24 years who accessed substance misuse services in Surrey dropped from 366 in 2012 to 294 in 2015/16. Locally this may be due to the focused prevention and brief Intervention work undertaken by the Youth Support Service to reduce the number of CYP requiring specialist substance misuse support.

There were also decreases in the proportion of 11 to 15 year olds who had taken drugs in the last year from 20% in 2001 to 12% in 2012 and the last month from 12% to 6%.

The majority (94%) of young people in Surrey’s services began using their main problem substance under the age of 15, this is similar to the national picture. In 2015/6 Surrey has a lower number of under 15’s (29%) then the national average (41%) and had nearly double the number (29%) of 18-24 year olds compared to the national average (15%).

Among young people using services in Surrey; 7% are ‘looked after children’, 6% have been affected by domestic abuse, 21% were not in education, employment or training and 10% were identified as having a mental health problem. Young people’s specialist substance misuse treatment services in Surrey have reported an increase in the number of young people reporting the use of New Psychoactive Substances, however, this is thought to be declining since the introduction of the Psychoactive Substance Act 2016. 85% of young people who engaged with the CYP drug and alcohol Service completely reduced or ceased drug use in 2013/14.

Services in relation to need.

Current Provision

1. PSHE and Healthy Schools

PSHE is delivered in Surrey schools with support from Babcock 4S. The component of the Babcock contract that support PSHE delivery is jointly funded by public health and education and falls under the banner of Healthy Schools Programme.

The Healthy School Programme is evidence based and supports delivery of PSHE through training, resources and guidance for all schools. The aim of the Healthy Schools Programme is to support children and young people in developing healthy behaviours. Healthy Schools provides a framework for schools to co-ordinate, develop and improve all areas of PSHE, including relationships and sex education (RSE), drug, alcohol and tobacco guidance and emotional health and wellbeing (which includes e-safety, anti-bullying, school ethos and pastoral support).

In Surrey as of January 2017 the following number of schools had achieved the Healthy Schools Award.

  • Bronze Award – 95
  • Silver Award – 27
  • Gold Award – 7

Specific areas of Healthy Schools development that contribute to healthy relationships and on-line safety include:

  • PSHE Guidance 2016
  • Drug Education (inc alcohol, tobacco and other substances) Guidelines 2016
  • Relationships and Sex Education Guidelines 2016
  • PSHE Framework for secondary Schools

This work along with other partners also supports the new Prevent strategy.

The guidance documents were supported with training days which were well attended by maintained schools in Surrey.

2. Online Safety

Online Safety is now part of the curriculum and it is also statutory and it is taught in all schools as it now is part of Keeping Children Safe in Education 2016. Children are taught about keeping themselves safe whilst online, by not giving out personal information that may identify them. They are also taught to report any suspicious behaviour e.g. if they see something that upsets them, start chatting to someone they don’t know or become the victims of cyberbullying. Children are taught to be resilient when online and to lock down their accounts by having the highest possible privacy settings and only chatting and communicating with people they know. There are a vast amount of quality information and videos around from e.g. the UK Safer Internet Centre which is a collaboration of Childnet, the Internet Watch Foundation and the South West Grid for Learning. There are also information available from the Child Exploitation and Online Protection Centre (CEOP) for children, staff and parents.

Schools have a duty to protect their children when online and are now required to have monitoring and filtering software installed on their IT networks to alert them if a child or member of staff tries to access anything that is banned, deemed inappropriate or is contrary to the law. There is a definite lack of consistent practice when it comes to monitoring and filtering as some schools buy their Broadband from SCC (Unicorn) which has a programme “Smoothwall” added to the offer but a lot of schools buy their broadband from another Internet Service Provider and are expected to ensure that they are adequately covered. Some smaller schools use independent IT technicians to service their requirements which are in some cases not fit for purpose.

Online Safety is also associated with Radicalisation and Extremism as a number of young people who become radicalised are targeted firstly by use of social media.

The Education Safeguarding Team (EST) are the front runners when it comes to Online Safety within Surrey County Council. Although the Surrey Safeguarding Children Board has an Online Safety Sub Group, this is chaired by the EST and they are responsible for writing and delivering training. The current training is around Online Safety with an emphasis on Online Grooming and has been delivered for the past 3 years to a multi-agency audience when the course is held. It is also combined with Child Sexual Exploitation.

3. Emotional Mental Health and Wellbeing

There are a number of support services for professionals and children and young people within schools:

  • TaMHS (targeted mental health in schools) approach’ addresses and promotes positive mental health in Surrey and enables schools to access free assistance. 60 % of all schools have accessed the training
  • The CAMHS service offers a wide range of tools and opportunities to access emotional mental health and wellbeing support including; on-line self-help materials, individual counselling and parental support packages
  • Training for school nurses and wider support for professionals working in schools to identify and support children with an emotional mental health and wellbeing need is offered through Emotional Wellbeing Service, through the community health provider
  • A piece of work is being completed on 18th April which is looking to understand the offer being made to schools across all sectors in relation to training about emotional wellbeing and mental health with a view to ensuring the quality of the offer, reducing overlaps and filling gaps
  • Community Youth Work Service and YSS offer the LINX programme to schools. 3 have currently taken this up. It is a group work programme for young people who have witnessed or experienced domestic abuse
  • The Emotional Literacy Support Assistants (ELSA) programme is run by Educational Psychologists, it has been running in Surrey for four years, with a total of 344 ELSAs already trained. ELSAs are based and work in schools with individual children or small groups, they support children and young people to recognise, understand and manage their emotions with the aim of building emotional resilience. ELSAs complete a five day training programme delivered by Educational Psychologists who also provide half termly supervision.

4. School Nurse Service

The school nursing service offers dedicated help-lines and web-based ‘chat-health’ technology to ensure children and young people can access support and advice. They support the delivery of PSHE and contribute to the RSE agenda through delivery of sessions within schools and identification of at risk children. There is approximately 1 school nurse per every two secondary schools and their primary clusters.

5. Health Related Behaviour Questionnaire

The questionnaire is offered to all schools in Surrey and asks primary and secondary school pupils about their health behaviours (RSE, PSHE, bullying, healthy weight, on-line behaviours, mental wellbeing). It is currently the only direct survey of the health and wellbeing needs of children and young people across schools in Surrey. The data provides useful information as to the prevalence of behaviours and the information is analysed and provided to schools to assist them in the delivery of PSHE (/dataset/young-people-in-surrey-schools-the-health-related-behaviour-survey-2015-findings).

6. Fire and Rescue Service

Surrey Fire and Rescue Service provide fire safety sessions in schools for children and young people who have a high risk of unintentional injury including Pupil Referral Units and Special Educational Needs Schools. They deliver a youth engagement scheme to support young people’s development and provide a diversionary activity to prevent fires. A citizenship scheme funded by Boroughs and Districts and the Police Youth Team raises the profile of fire safety.

7. Smoking prevention

Smoking prevention is not achieved by youth targeted interventions alone. NICE guidance for smoking prevention suggests that school based interventions, mass media interventions and enforcement to restrict illegal access to tobacco among young people are effective . The impact of these interventions are considered more effective when delivered as a package of multi component interventions in family and community settings, particularly where there is an increased emphasis on reducing adult smoking through cessation .

8. Healthy weight

Surrey County Council currently commission “HENRY” – Healthy Eating and Nutrition for the Really Young and “Alive n Kicking” the Tier 2 Child Weight Management Programme. These interventions prioritise areas where child obesity has a high prevalence.

A Healthy Weight Strategy for Children, Young People and Families and Action Plan is in development, taking a whole system approach. Lead by a Healthy Weight Alliance the action plan will create a platform for a co-ordinated approach for work already being delivered across the county together with new or improved actions.

9. Immunisation

Currently across Surrey, routine vaccinations are primarily delivered via general practice, and routine school-aged vaccinations are delivered by specialist community immunisation provider teams using a school-based model. In addition, providers offer vaccination clinics inviting those children who have missed the school based programme to maximise uptake and ensure a 100% offer to all children inclusive of those attending independent schools, special needs schools and the home schooled cohort.

There is a wealth of evidence to suggest that a range of multidisciplinary and flexible approaches are effective in improving uptake of immunisations. In September 2009, the National Institute for Health and Clinical Excellence (NICE) (5) published public health guidance which focused on increasing immunisation uptake among children and young people aged under 19 years in groups and settings where immunisation coverage is low.

10. Unintentional Injuries

The priority for improving health literacy and reducing unintentional injuries in children has three elements. For example, the Healthy Children’s Centre Programme Indicators state that each children centre will:

  • Identify resources and have a hot drinks policy which endorses thermal injury prevention and is reinforced in the centre’s food policy
  • Support National Child Safety and Family Safety Weeks, display resources which raise awareness, provide guidance for parents and families and support national and local campaigns, and
  • Support parents and families to find a balance between encouraging play and physical activity and minimising risk of injury.

Local service specifications for health visiting and school nursing include delivering the Healthy Child Programme (0 to 19 years), which provides a framework in which advice and support is provided to families, and in which key messages on preventing harm from injuries can be given. For children up to 2/2.5 years, universal reviews present structured opportunities to reinforce safety issues.

Relevant activities currently undertaken by health visitors and school nurses are summarised below:

  • When a child attends A&E services a report is sent to their GP and health visitor. The health visitor is then responsible for following up with appropriate guidance and support. However, it should be noted that they would only work with individual families on unintentional injuries when there is another reason to visit
  • Where considered appropriate; school nurses are informed by the safeguarding team when a child attends A&E and appropriate guidance is provided.

11. Specialist Sexual Health Services for Young People

Surrey has a number of free to user services that are commissioned specifically for young people under 25 years old.

  • Chlamydia and Gonorrhoea testing
  • Condom distribution scheme
  • Emergency contraception

These are delivered in a variety of settings from schools and colleges, outreach and youth centres, sexual health clinics, and in pharmacies under Public Health Agreements.

12. Substance misuse

Education and Prevention: Public Health commission the development and production of a PSHE (Personal, Social, Health and Economic) – Drug & Alcohol Education Toolkit for Key Stage 4 (14 to 16 years old). The toolkit and other support documents can be found here.
CYP Specialist Treatment Service: specialist treatment service offering a range of support for young people, aged 11 to 21, who have problems with drugs or alcohol. Housing Support: residential support for young people (aged 17-30) identified through substance misuse services to move onto independent living.

Unmet needs and service gaps

Nationally there are renewed energies for the healthy school concept. The funding for a National Healthy Schools Rating Scheme is now being led jointly by the DH and the DoE and there will be funding for national resources to support the scheme. This is not a replacement for existing schemes, it will support those schemes that are running locally and allow some online support for those schools that do not have a scheme in their locality. The exact details for this are not confirmed at this stage.

Locally colleagues from different directorates across SCC are starting to bring together the different strands of work that could be encompassed under the banner of ‘Whole School Approach to Health and Wellbeing’. This will enable us to look at the total resource available and align priorities for delivery. For instance within early help, fire and rescue, education and SEND agendas, as outlined in the Children and Young People’s Partnership Plan. This will include continuing to action the recommendations from the PSHE review (2014).

This collective approach will also help us to have a joint understanding of need across Surrey schools. Public Health has been working with CSF to create a dashboard of schools to understand the level of need in individual schools. This will assist different services in targeting support to schools with their Early Help offer, PSHE provision and subsequent partnership working.

With specific reference to on-line safety we need to learn from innovation taking place in London through the London Grid for Learning. It has also been identified that one of the biggest gaps locally is that SCC does not have a dedicated Online Safety Officer compared to other local authorities. The Online Safety Officer would be a great asset to SCC and of great benefit to the children we protect.

Working together across directorates and organisations is unlikely to add any additional money to be spent on supporting schools with PSHE. However it will help us in modelling how we can work with all schools in Surrey. There is currently no offer to Independent Schools.

Through this developmental work we will need to continue to ensure that the new statutory requirements around RSE within the PSHE framework are supported so that schools can meet national requirements.

What works

The King’s Fund recommend local authorities:

  • Support schools to develop children’s life skills such as problem-solving, and to build self-esteem and resilience to peer and media pressure, this can reduce smoking initiation by 12 per cent (McLellan and Perera 2013)
  • Encourage schools to incorporate more physical activity into the curriculum. Some programmes have succeeded in increasing children’s moderate and vigorous activity levels threefold, and reducing hours spent watching TV at home
  • Help schools promote healthy diets, focusing on 6–12 year olds. Overall impacts in terms of reducing weight gains may be relatively small, but can lead to significant longer-term impacts, halving adult obesity rates (National Institute for Health and Care Excellence 2013a). Interventions can be just as effective with poorer children and can increase fruit and vegetable consumption – doubling the odds of fruit and vegetable consumption at lunch (Waters et al 2011) – and reduce total energy intake
  • Develop targeted wellness services towards clusters of children identified as being at high risk of multiple poor behaviours, rather than providing single issue services only. Schools should be encouraged to foster a strong sense of culture and belonging, and connectedness with teachers. ‘Whole school’ approaches to improving health behaviours are likely to be more effective (Jackson et al 2012; Bond et al 2004)
  • Support the use of resources such as the Department for Education’s Healthy Schools Toolkit (2013)
  • Supporting and challenging schools to focus on achieving good social and emotional health outcomes, and enabling children to make healthy rather than unhealthy lifestyle choices, provides substantial paybacks to individuals, society and local authorities. The overall health benefits of a good education have been estimated to provide returns of up to £7.20 for every £1 invested (Lleras-Muney and Cutler 2006)
  • Schools that focus on developing pupils’ social skills and emotional health can provide long-term paybacks to society through the creation of well-adjusted adults. For instance, school-wide anti-bullying programmes can return almost £15 for every £1 invested in the longer term through higher earnings, productivity and public sector revenue (Knapp et al 2011); interventions to tackle emotional-based learning problems in schools have paid for themselves within the first year through reductions in social service, NHS and criminal justice system costs, and have recouped £50 for every £1 spent over five years (Knapp et al 2011)
  • Behaviour change interventions in schools have also proven to be very cost-effective when considering longer-term paybacks. For example, smoking prevention programmes have recouped as much as £15 for every £1 spent (Stephens et al 2000) and for every £1 spent on contraception to prevent teenage pregnancy, £11 is saved through fewer costs from terminations, antenatal and maternity care (Teenage Pregnancy Associates 2011).

Unintentional Injuries

Unintentional injury contributes significant costs to local authorities and to society as a whole. Injury reductions can be achieved at low cost if local authorities strengthen the offer provided around unintentional injuries via existing programmes and by working in partnership. Available evidence suggests a number of recommendations to reduce the prevalence of unintentional injuries in children and young people, which have been summarised as follows:

  • Environment: Improvement in planning and design results in safer homes and leisure areas
  • Education: Increasing the awareness of risk of accidents in a variety of settings and providing information on ways of minimising these risks
  • Empowerment: Accident prevention initiatives, which have been influenced by the community, are more likely to reflect local need and therefore encourage greater commitment
  • Enforcement: Child safety legislation; local councils assess hazards to privately rented homes.

Road traffic incidents

There is a large body of evidence on what works to reduce unintentional injuries on the road (1, 16, 17, 18). A summary of the recommendations is outlined below.

A whole systems multi-disciplinary approach is needed to make road traffic systems less hazardous that include:

  • Good road design and management
  • Improved vehicle standards
  • Speed control
  • Use of seatbelts
  • Enforcement of alcohol limits
  • Local Transport Plans should include measures for reducing injuries and improving health through active measures such as walking and cycling reduce noise and air pollution from road traffic
  • The use of 20 miles per hour (mph) limits to reduce cycling and pedestrian casualties, especially to impact on inequalities in road casualty figures. This approach can protect the most vulnerable, and socially disadvantaged road users whilst encouraging people to walk or cycle
  • Consider opportunities to develop engineering measures to provide safer routes commonly used by children and young people, including to school and other destinations (such as parks, colleges and recreational sites)
  • Include school governors and head teachers in discussions about changes relating to school travel.

Recommendations for Commissioning

  1. Healthy schools is continued to be commissioned as a priority
  2. Funding will also be needed for 2019 to carry out the Health Related Behaviour Questionnaire, this should also be a priority, to ensure that the views and needs of children and young people are at the heart of commissioning processes
  3. Ensure development and Implementation of Healthy Weight Action Plan
  4. Embed a whole systems approach to improving uptake of immunisations – for example, health visitors, school nurses, teachers, children’s centre staff, prisons services, voluntary sector etc could play a pivotal role in explaining the importance of vaccinations to parents and young people, challenging myths, signposting effectively, and where appropriate, offering opportunistic vaccination
  5. Engage health in unintentional injury prevention e.g. primary and secondary care (including GP practices and A&E), antenatal clinics, Clinical Commissioning Groups (CCGs), school nursing, health visitors, and other community providers
  6. Develop key messages for frontline staff in order to develop skills in relation to unintentional injury prevention, such as for those working in educational settings
  7. Ensure schools have access to appropriate resources for PSHE and RSE
  8. Encourage schools to include work on homophobic bullying and positive relationships within their PSHE work
  9. Ensure sexual health is included in school nurse remit in the recommission of community services
  10. Provide Surrey Universities with links to accurate and current sexual health information and services via the Healthy Surrey website
  11. Look at the opportunities for University-based, dedicated sexual health services as part of future service commissioning.

Key contacts

  • Nicola Mundy Public Health Lead Children and Young People

Chapter References

  1. The Determinants of Mortality, David M. Cutler, Angus S. Deaton, Adriana Lleras-Muney. NBER Working Paper No. 11963. Issued in January 2006
  2. Mackenbach J. P., Meerding W. J., Kunst A. E. (2007). Economic Implications of Socio-Economic Inequalities in Health in the European Union. Luxembourg: European Commission.
  3. Intergenerational effect of schooling and childhood overweight Ryota Nakamura January 18, 2012
  4. How active are our children? Findings from the Millennium Cohort Study, BMJ, Lucy J Griffiths, Mario Cortina-Borja, Francesco Sera, Theodora Pouliou, Marco Geraci, Carly Rich, Tim J Cole, Catherine Law, Heather Joshi, Andrew R Ness, Susan A Jebb, Carol Dezateux
  5. Knapp M., McDaid D., Parsonage M., editors. Mental Health Promotion and Mental Illness Prevention: The Economic Case. London: Department of Health; 2011.
  6. Health & Social Care Information Centre Smoking, Drinking and Drug Use Among Young People in England – 2014. http://www.hscic.gov.uk/catalogue/PUB17879/smok-drin-drug-youn-peop-eng-2014-rep.pdf
  7. ASH Briefing: Health Inequalities and smoking. Available at: http://ash.org.uk/information-and-resources/briefings/ash-briefing-health-inequalities-and-smoking/
  8. ASH: Young People and Smoking Factsheet (2015). http://ash.org.uk/category/information-and-resources/fact-sheets/
  9. PHE Tobacco Control Profiles 2016. http://www.tobaccoprofiles.info/
  10. ASH Briefing: Use of electronic cigarettes among children in Great Britain (2016) http://ash.org.uk/category/information-and-resources/fact-sheets/
  11. The Health Related Behaviour Survey 2015
  12. The National Institute for Health and Care Excellence. Smoking prevention in schools [PH23].
    https://www.nice.org.uk/guidance/PH23
  13. The National Institute for Health and Care Excellence. Smoking: preventing uptake in children and young people [PH14]. https://www.nice.org.uk/guidance/PH14
  14. Public Health Research Consortium. A Review of Young People and Smoking in England. http://phrc.lshtm.ac.uk/papers/PHRC_A7-08_Final_Report.pdf