Organisational models for securing access to health and dental care services for children in out-of-home care

A systematic review and assessment of medical, economic, social and ethical aspects

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SBU Assessment

Presents a comprehensive, systematic assessment of available scientific evidence for effects on health, social welfare or disability. Full assessments include economic, social and ethical impact analyses. Assessment teams include professional practitioners and academics. Before publication the report is reviewed by external experts, and scientific conclusions approved by the SBU Board of Directors.

Background and aim

Children who enter or reside in out-of-home care are in greater need of health and dental care services than other children.

This report is one in a series of reports where SBU has examined interventions for children in out-of-home care (foster or residential care). The aim is to evaluate organisational models for securing access to health and dental care for children in out-of-home care.

Conclusions

  • An investigation of current Swedish practice in local child welfare shows that less than half of the Swedish local authorities have systematic routines to ensure that children in out-of-home care receive assessment of their physical health, only ten percent provide an oral health assessment and no local author­ity has routines for assessing mental health.
  • We did not find any studies of adequate qual­ity, therefore it is not possible to determine the effects of organisational models for providing health and dental care to childrenin out-of-home care. Henceforth, when organisational models are introduced in practice, well-conducted follow-up studies investigating their effects should be performed. There is also a need for studies that assess the prevalence of physical, dental and mental health prob­lems and oral illness among children enter­ing or residing in out-of-home care.
  • From an ethical point of view, it is important that children in out-of-home care are provided appropriate health and dental care. The new requirements in the Swedish law (5 kap. 1 d § SoL) regarding mandatory health assessments for children entering out-of-home care should be followed-up and evaluated. There is also a need for estab­lishing organisational models in Swedish practice to ensure that the rights and needs of health and dental care for these individuals are met.
  • In an international perspective, promising or­gan­isational models that could secure that these individuals receive health and dental care do exist, but they have not been evaluated with sufficient scientific rigour. A cost calculation performed by SBU suggests that an organ­isational model could be implemented in the Swedish system at a low cost with potential benefits for children in out-of-home care.

What does this report add?

This report shows that children in out-of-home care in Sweden do not receive adequate health and dental care. Furthermore, the report stresses the need for scientific evaluations of organisational models that could secure the access to health and dent­al care for this vulnerable group. An organisa­tional model inspired by the English health care system is described as an example of how a Swedish organisational model could be designed.

Method

The report includes a systematic review of studies investigating the effects of organisational models aimed to secure access to health and dental care for children in out-of-home care.

In addi­tion, the report contains an investigation of cur­r­ent practice in Sweden of routines and structures through electronic surveys that were followed-up via phone interviews with representatives of local child welfare authorities. Ethical, social and legal questions were also analysed by reviewing relevant literature, governmental reports and legal documents. Finally, an economic evaluation was conducted investigating the resources needed for an organisational model that could secure that children in out-of-home care receive health and dental care.

Main results

Investigation of current practice

In the evaluation of Swedish practice, 106 local authorities received an electronic survey with questions regarding routines and methods used to secure that children entering or residing in out-of-home care are provided with health and dental check-ups. The survey was followed-up with phone interviews. Taken together, the results show that less than half of the Swedish local authorities have syste­matic routines to ensure that children entering out-of-home care receive assessment of their physical health, only 10% provide an oral health assessment and no local authority has routines for assessing mental health. Furthermore, very few councils secure that these children receive systematic follow-up health assessments while they reside in out-of-home care.

Systematic review

In the systematic review, we did not identify any studies with low or moderate risk of bias that had investigated the effects of an organisational model for securing that children in out-of-home care receive adequate health and dental care.

Ethical, social and legal aspects

Since 2017, local councils have a mandated duty to provide health assessments (physical, dental and men­tal health) for children entering out-of-home care to acquire health examinations. The new legislation should be followed-up and evaluated. Possible, stricter regulations for implementation of the law need to be introduced.

The costs for a possible organisational model

An organisational model (inspired by the legal frame­work and implementation in England) to identify physical, mental and dental health problems among children in out-of-home care could imply low costs. The initial cost to set up the model would amount to approximately 5.5 million Swedish kronor (SEK), while the yearly cost per child would be SEK 3 300. This model would most likely lead to an increase in the use of health and dental care services, and thereby probably improve the health of childrenin out-of-home care.

Discussion

Research, policy and practice

SBU proposes a nation-wide follow-up of how the new legislation has been implemented with a focus on whether systematic routines in local practice have been established or not. Furthermore, SBU proposes that the initial phase for establishing an organisational model that secures the access to health and dental care, which includes developing standardised check-lists for health examinations and forming a digital health card, should be led by one central na­­­tion­al body. In addition, action plans on a more local level also need to be developed. Although the model should come with low costs, most of the initial finan­cial burden will fall on local councils where the care workers and their supervisors, will need an introductory course in order to systematically implement new routines and protocols. Finally, after the sug­gested organisational model has been imple­mented, its use and effects should be followed-up and evaluated.

The full report in Swedish

The full report in Swedish Organisatoriska modeller för att barn och unga i familjehem eller på institution ska få hälso- och sjukvård och tandvård

Published: Report no: 289 Registration no: SBU 2017/95 https://www.sbu.se/289e

Project group

Experts

  • Anders Hjern, Stockholm University and Karolinska Institutet
  • Gunilla Klingberg, Malmö University
  • Titti Mattsson, Lund University
  • Tita Mensah, Malmö University
  • Bo Vinnerljung, Stockholm University and Karolinska Institutet

SBU

  • Sofia Tranæus, Project Manager
  • Kickan Håkanson, Project Administrator
  • Pia Johansson, Health Economist
  • Ann Kristine Jonsson, Information Specialist
  • Kerstin Mothander, Assistant
  • Pernilla Östlund, Assistant Project Administrator

Flow charts

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