School-aged Years

Why the School-aged Years are an important period

The Chief Medical Officer and Professor Sir Michael Marmot⁵¹ have highlighted the importance of giving every child the best start and reducing health inequalities throughout life. They recognise the importance of building on the support in the early years and sustaining this across the life course for school-aged children and young people to improve outcomes and reduce inequalities through universal provision and targeted support. There will be challenges within a child’s or a young person’s life and times when they need additional support. Universal and targeted public health services provided by health visiting and school nursing teams are crucial to improving the health and wellbeing of all children and young people.

Over the past 10 years, there has been significant research emerging around young people’s brain development. Puberty is a time of a major ‘second wave’ of brain activity, as young people develop skills to make decisions, empathise and reason.⁵² At the same time, the body is developing its potential for fitness, physical strength and reproductive capacity.⁵³

What is the local picture?

The most recently compiled and published data is compared with other local authorities of similar deprivation, unless stated otherwise, as of July 2021⁵⁴

School-Aged Indicator	Previous Period [Comparator IMD 2019] (Date)	Most recent available period [Comparator IMD 2019 or England] (Date)
Reception children age 4-5 overweight and obese (%)
	21.7 [22.6, England] (2018/19)	21.2 [23.0, England] (2019/20)
Year 6 children overweight and obese (%)
	34.3 [34.3, England] (2018/19)	33.2 [35.2, England] (2019/20)
Year 9 Meningitis ACWY (%)
	93.10 (2018/19) Recovery over into academic year 2020/21	85.80 (2019/20) Recovery over into academic year 2020/21
Smoking prevalence at age 15 – current smokers (%)
	NA	9.6 [8.2, England] (2014/15)
First-time entrants to the youth justice system aged 10-17 (Rate per 100,000)
	255.3 [240.9, England] (2018)	157.2 [208.0, England] (2019)
Children with one or more decayed, missing or filled teeth (5 years, mean dmft per child)
	0.72 [0.78, England] (2016/17)	0.71 [0.80, England] (2018/19)
Hospital admissions: alcohol-specific conditions, under 18 (Rate per 100,000)
	22.1 [28.0] (2016/17-18/19)	19.5 [27.8] (2017/18-19/20)
Hospital admissions: substance misuse aged 15-24 (Rate per 100,000)
	71.2 [74.6] (2016/17-18/19)	62.9 [75.4] (2017/18-19/20)
Rate of hospital admissions caused by injuries in children (0-14 years) (Rate per 10,000)
	88.3 [91.4] (2018/19)	75.3 [84.9] (2019/20)
Rate of hospital admissions caused by injuries in children (15-24 years) (Rate per 10,000)
	119.8 [128.5] (2018/19)	105.8 [121.9] (2018/19)
Hospital admissions: mental health conditions (Under 18 years) (Rate per 100,000)
	73.2 [80.0] (2018/19)	87.2 [81.4] (2019/20)
Pupil absence (Persons 5-15 years); percentage of half-days missed %
	4.75 [NA] (2017/18)	4.64 [4.62] (2018/19)
Not in Education, Employment or Training (NEET); 16-17 year olds %
	4.7 [4.0] (2018)	5.7 [4.2] (2019)
Under 16s conception rate per 1,000 females aged 13-15
	1.8 [1.6] (2018)	2.3 [N/A] (2019)
Under 18s conceptions (Rate per 1,000)
	18.4 [13.8] (2018)	13.8 [N/A] (2019)
School pupils with social, emotional and mental health needs (%)
	2.08 [2.40] (2019)	2.22 [2.54] (2020)
Hospital admissions for asthma (under 19 years) (Rate per 100,000)
	168.2 [160.2] (2018/19)	153.2 [145.7] (2019/20)
GCSE: average attainment 8 score (mean score
	46.4 [48.3] (2018/19)	48.8 [51.6] (2019/20)
MMR vaccination coverage for two doses (5 years old) (%)
	90.7 [86.7] (2018/19)	89.7 [87.3] (2018/19)
Year 9 Diphtheria/Tetanus/Polio booster
	93.40 (2018/19) Recovery over into academic year 2020/21	86.20 (2018/19) Recovery over into academic year 2020/21
Hospital admissions as a result of self-harm in children aged 10-24 (Rate per 100,000)
	289.0 [407.1] (2018/19)	279.4 [395.5] (2018/19)

Milton Keynes’ overall score for deprivation (using the Index of Multiple Deprivation 2019) relative to all other local authorities in England, puts it in the 3rd least deprived decile. Throughout this report, Milton Keynes’ performance is compared to other areas of similar deprivation where possible. For comparison to other local authorities of similar deprivation (IMD 2015), please refer to the reference.⁵⁶

Table 3: The school-aged years as of July 2021 sources:
Public Health Outcomes Framework: CYP JSNA – Section 3 (IMD 2019). [online] Available at: https://fingertips.phe.org.uk/indicator-list/view/8WDJSm5kGD#page/0/gid/1/pat/10113/par/cat-113-8/ati/202/are/E06000042/iid/10301/age/193/sex/4/cid/1/tbm/1 [Accessed 13 January 2021].

Public Health Outcomes Framework: CYP JSNA – Section 3: (IMD 2015) [online] Available at: https://fingertips.phe.org.uk/indicator-list/view/8WDJSm5kGD#page/0/gid/1/pat/10105/ati/202/are/E06000042/iid/10301/age/193/sex/4/cat/-1/ctp/-1/
yrr/1/cid/1/tbm/1 [Accessed 1 April 2021].

In summary, compared to other local authorities in the same deprivation decile, the data for Milton Keynes highlights the following:

Compared to other local authorities in the same deprivation decile, we have a higher percentage of young people not in education, employment or training, lower attainment 8 scores for pupils aged 15-16 and a lower percentage of two doses for MMR by 5 years (below 90%).

We are improving against indicators for children being overweight, pupils with social, emotional and mental health needs and hospital admissions caused by injuries, self-harm and alcohol specific conditions.

Excess Weight

Children with excess weight (either overweight or obese) are more likely to become overweight and obese adults and have a higher risk of poor health, disability and premature mortality in adulthood. There is also a link between obesity and poor mental health in teenagers, with weight stigma increasing vulnerability to depression, low selfesteem, poor body image and maladaptive eating behaviours. Nationally, by age 11, almost a third of children are overweight or obese, and this proportion is predicted to rise if concerted action is not taken.⁵⁷

The National Child Measurement Programme (NCMP) records the height and weight of children in their first year at school, reception (Year R), aged 4-5 years and again in Year 6, aged 10-11 years. This is then translated into a BMI centile to identify children who are underweight, overweight and obese so that they can be offered support, as well as being used to monitor trends.58 Between April 2019 and March 2020, the rates of excess weight (overweight and obesity) in children who live in Milton Keynes were similar to the England average:⁵⁹

In Year R 21.2%* of children were overweight or obese (including severe obesity); this is better than the England average at 23.0%
In year 6, 33.2% of children were overweight or obese (including severe obesity); this is better than the England average at 35.2%.
There had been a decrease to all the indicators except year R for overweight children. There were no significant changes identified.

The Impact of obesity on a child’s health, now and in the future

Obesity has a profound effect on children’s physical and mental health. It can frame children’s life chances – not just their health, but also their employment, opportunities and lifetime earnings.

Once established, obesity is notoriously difficult to treat. Children with obesity are five times more likely to be obese as an adult⁶⁰ and are more likely to develop cardio-metabolic disease, some cancers and musculoskeletal conditions in adult life.⁶¹

The causes of obesity are complex and multi-faceted. They can be driven by biological factors such as genetics, social factors such as the built environment and transport systems; values, culture and norms around eating; leisure centres and green space; education and schools; and poverty. Finally, obesity is influenced by commercial factors such as the production, supply, marketing and sale of high calorie sugar and fat foods.

As well as helping children and young people maintain a healthy weight, there is increasing evidence of the mental health benefits of participating in regular physical activity for children and young people. including feeling good about themselves, better concentration in addition to physical health benefits

Health Inequalities

There is a strong association between deprivation and being overweight or obese as a child, with children is disadvantaged areas twice as likely to be obese as their peers living in more advantaged areas. Families living in deprived communities experience multiple interacting exposures to material, psychosocial and behavioural risks for childhood obesity across the life-course. Obesity prevalence is highest amongst some of the most deprived wards in Milton Keynes, including Woughton, Fishermead and Bletchley East. This is sowing the seeds of adult diseases and health inequalities in early childhood.

What are we aiming for?

Nationally the Government have committed to halving childhood obesity and to reduce the obesity inequalities by 2030.⁶² With the recent spotlight on obesity due to COVID-19, key actions include interventions to support a reduction in consumption of sugar, food labelling, calorie and sugar reduction, restrictions on advertising and food promotions as well as the ‘Better Health’ campaign to help people lose weight, get active and eat better after COVID-19 ‘wake-up call’.⁶³

Tackling excess weight requires a whole systems approach to change the environment in which we are born, live, learn, play, work and age. Working with multiple partners including health colleagues, local planning teams and education the council has already begun to follow a whole system approach to identify ways we can change the local obesogenic environment. The approach should be complemented by local weight management services. Commissioners and partners need to maximise attendance of these services to effectively support those living with overweight or obesity including families, pregnant women and school pupils.

School age vaccinations

From March 2020, the delivery of school aged vaccinations by the Community and School Aged Immunisations team was severely affected by school closures due to the Covid 19 pandemic. Social distancing, bubbles and school closures resulted in a more time consuming and complicated delivery of the programme. The academic year that has just ended (Summer 21) has been focused on restoration and recovery. Between April 2019 and March 2020, the uptake of Meningitis ACWY is 85.8% and Diphtheria/Tetanus/Polio 86.2% and the team continues to offer these vaccines both in school and community clinics.

Flu was the most challenging programme to deliver and it has a time limited delivery model and had to work around all the complexities of school closures, social distancing, bubbles, pupil absence and parental concern. Uptake in 4-10 year olds for 2020/21 was 52.8%, slightly below the East of England average.

Reducing health-related risk-taking behaviours

Health during adolescence is strongly linked to educational attainment and employment. Adolescence is
recognised as the most significant time for introducing behaviours that can have long-term negative health impacts, for example, smoking, and substance and alcohol misuse.

Whilst most research shows that risk-taking behaviours amongst young people are on the decline, there seems to be an upward trend of children and young people experiencing poor emotional health. There is also evidence of a link between risk-taking behaviours and poor mental health.

The Adverse Childhood Experiences (ACE) study in Hertfordshire, Luton and Northamptonshire64 detailed the harmful impacts of childhood adversity on local populations. Findings were consistent with those of ACE studies carried out elsewhere, showing that almost half of adult residents had experienced at least one ACE before the age of 18 years and almost one in ten experienced four or more. A list of adverse experiences is outlined earlier on P18.

As adults, these individuals are more likely to engage in harmful behaviours, and are at greater risk of exploitation, poor physical and mental health, chronic diseases, and premature mortality. Compared to people with no ACEs, people who have experienced four or more ACEs are:

2 times more likely to currently binge drink
2.2 times more likely to have visited A&E
3 times more likely to be a current smoker
4 times more likely to have had sex while under 16 years old or to have smoked cannabis
8 times more likely to have been a victim of violence

Smoking

Smoking continues to be a major cause of ill health, particularly heart and lung disease. Many people start smoking as adolescents and some will continue to smoke into adulthood. However, across England, the number of young people aged 11-15 who reported trying smoking has fallen and is now at the lowest levels since 2003.⁶⁵ Tobacco remains the main cause of preventable morbidity and premature death in England.66 Beyond the well recognised effects on health, tobacco also plays a role in perpetuating poverty, deprivation and health inequalities.

Drug and Alcohol Misuse

Drug and alcohol misuse can have significant harmful impacts on young people, beyond the immediate health impacts. This can affect educational outcomes, employment, housing relationships, and increase the likelihood of criminal behaviour. There is also evidence to suggest that young people who use recreational drugs and alcohol are at risk of poor mental health outcomes, including depression, disruptive behaviour disorders and suicide. Cannabis and alcohol are the most common substances used by young people.⁶⁷ Although there is evidence that young, people also use new psychoactive substances (NPS), also known as ‘legal highs’. Young people who misuse substances may be at a greater risk of both criminal and sexual exploitation and may be more likely to be involved in criminal and gang behaviour.

Nationally, the 2018 England survey⁶⁸ reported that 24% of pupils aged 11-15 years had taken drugs at least once; ranging from 9% of 11 year olds, to 38% of 15 year olds. Nine percent of pupils surveyed reported taking drugs in the month prior to the survey. Of those who had taken drugs in the past year, 33% reported taking cannabis only; however, 35% reported taking two or more types of drug.

The Young people’s substance misuse treatment statistics 2019 to 2020 national report⁶⁹ demonstrates that:

there were 3% fewer young people accessing drug and alcohol services between April 2019 – March 2020
compared to the previous year.
76% of those accessing treatment reported that they started using substances before the age of 15.
37% of those accessing treatment reported a mental health need; this was higher in girls compared to boys (49% compared to 30%).
22% of young people in the service were affected by others’ substance use, and 21% were affected by domestic violence.
Child sexual exploitation (CSE) was reported by 4% of those in treatment; this was more common in girls (10%) than boys (1%).
A local survey conducted in five Milton Keynes secondary schools, in 2013, found that 4% of pupils had taken some form of illegal drug in the month before the survey and 6% said they had taken illegal drugs at some point, most commonly cannabis

Locally, hospital admissions due to alcohol-specific conditions in under 18s or substance misuse in 15-24 year olds are relatively rare but are the ‘tip of the iceberg’, pointing to wider substance misuse and its impacts:

For under 18’s, the hospital admissions due to alcohol-related conditions is 19.5 per 100,000 and is significantly
lower than the local authorities in the same deprivation decile at 27.8 /100,000 (2017/18 – 2019-20).⁷⁰
For 15-24 year old, Hospital admissions due to substance misuse were 62.9/100,000 which is similar to local authorities in the same deprivation decile at 84.9/100,000 (2017/18-2019/20).⁷¹

Drug and Alcohol Services for Young People

Since April 2020, the Young People Drug and Alcohol Service in Milton Keynes has been providing support for children and young people under the age of 18 who are experiencing problematic drug and/or alcohol misuse or are affected by the use of others. By the end of Q2 2020-21, 65 young people were accessing treatment support from the service.

Sexual Health

As young people become sexually active, it is important that have easy access to contraception and sexual health services. Chlamydia is the most common, curable sexually transmitted infection in the UK. If left untreated it can cause infertility in both women and men. An effective screening programme for chlamydia aims to screen young people between the ages of 15 and 24 years, to achieve a detection rate of at least 2,300 per 100,000. This ensures that the programme is effectively targeting those young people at highest risk of infection.

Areas achieving this rate should aim to maintain or increase it. Such a level can only be achieved through the ongoing commissioning of high volume, good quality screening services across sexual health services and primary care.

In 2019 in Milton Keynes:

The Chlamydia detection rate was 2,385 per 100,000 for people aged 15-24, better than the deprivation decile average (1,736 per 100,000).
Milton Keynes has reached the recommended detection rate of 2,300 per 100,000
1,138 new STIs were diagnosed (excluding chlamydia) in under 25 year olds – a rate of 661 per 100,000, which is significantly better than the deprivation decile average

There is support for secondary schools around contraception and sexual health across Milton Keynes. Targeted outreach work is delivered to vulnerable young people including looked after children, young people from areas of high teenage pregnancy and young people not in employment, education or training.

Teenage Pregnancy

Teenage pregnancy is a complex issue, affected by personal, social, economic and environmental factors. Under-18 conception data includes all conceptions that result in either a live birth or abortion. Since 2009, there has been a 58% reduction in under 18 conceptions across England.

In Milton Keynes:

The 2019 conception rate amongst under 18s was 13.8 per 1,000 (actual number 65). This is a decrease of 25% from the 2018 rate of 18.4 per 1,000.
The overall trend shows a downward trend in rates in Milton Keynes since 2009.
Bletchley East and Woughton & Fishermead wards have significantly higher rates of teenage pregnancy than England for the three years 2016-2018.⁷²

The Integrated Contraception and Sexual Health service (iCaSH) provide an integrated contraceptive and sexual health service across MKC for all ages, including services specifically for young people.

LGBT+

As part of growing up, all young people will spend time exploring their identity and developing a sense of who they are. This will include thinking about who they are attracted to (their sexual orientation), how they feel about their gender (their gender identity), and the different ways they express their gender.⁷³
LGBT+ (lesbian, gay, bisexual, trans and those questioning their sexual or gender identity) children and young people realise they are lesbian, gay, bisexual or trans at different stages in their lives, but will often know at an early age.

Growing up, LGBT+ young people face specific challenges in addition to wider factors that lead young people in general to face additional difficulties. These include homophobic, biphobic and transphobic discrimination, and a lack of support and inclusion in education, training and work.⁷⁴ In addition, nearly half of LGBT+ young people are bullied at school, simply for being who they are.⁷⁵

Being LGBT+ can feel like an extra pressure for young people, particularly at school, depending on the extent to which staff, peers and the wider school community are supportive. Creating an inclusive environment is a key part of making sure that LGBT+ young people feel welcome and valued in any environment.⁷⁶ The principles around supporting LGBT+ young people are the same at any age. This includes helping young people to talk about how they feel, ensuring they are providing age-appropriate information to answer any questions they may have.

Personal, Social, Health Education

Today’s children and young people are growing up in an increasingly complex world and living their lives
seamlessly on and offline. This presents many positive and exciting opportunities, but also challenges and risks. In this environment, children and young people need to know how to be safe and healthy, and how to manage their academic, personal and social lives in a positive way. This is why high quality and effective Relationships Education has been made compulsory in all primary schools in England, and Relationships and Sex Education compulsory in all secondary schools, as well as making Health Education compulsory in all state-funded schools.

Mental health & wellbeing

Children suffering from mental ill health are at risk of poor physical health outcomes, poor educational attainment, and are at greater risk of unhealthy behaviours such as taking up smoking. There is relatively little data about prevalence rates for mental health disorders in pre-school age children but by the time they reach school age, 1 in 10 children need support or treatment for mental health problems. This means that in a class of 30 school children, three are likely to suffer from a mental health disorder such as depression, conduct disorders, anxiety, and hyperkinetic disorders (e.g. Attention Deficient Hyperactivity Disorder).

Young people have been uniquely impacted by the pandemic and lockdown, with NHS research suggesting 1 in 6 may now have a mental health problem, up from 1 in 9 in 2017.⁷⁷

A whole systems approach will be needed to address the challenge and provide care and support to local children and young people in the wake of the pandemic. Addressing the priorities therefore needs to be a collaborative programme across the commissioning and provider system, inclusive of local authorities, educational partners and the voluntary and community sector.

Improving Emotional Health and Wellbeing and Building Resilience

Positive emotional health and wellbeing amongst children and young people promote healthy behaviours, good attainment and helps prevent behavioural and mental health problems.⁷⁸ A majority of children and young people are part of happy and healthy families, and their parents/carers are the providers of their emotional support. Sometimes though, children and young people need support.⁷⁹

Families, schools, local health, and social care organisations have a vital role in helping children and young people to build resilience and supporting them through life’s adversities. We are aiming for children and young people to have good levels of resilience to enable healthy relationships and life choices.

Milton Keynes Health and Wellbeing Awards and the Healthy Young People’s Network encourage all organisations working with Children and Young People in Milton Keynes to work towards a ‘whole system’ approach, which prioritises the emotional health and wellbeing of children and young people.

The Impact of COVID-19 on School-Aged Children

On the 20th of March 2020, schools in England closed except for vulnerable pupils and children of key workers. National exams were also cancelled for 2020 and 2021. From March 2020, remote education was rolled out to support children and young people to continue their learning at home. Remote learning became statutory from mid October 2020 for any pupils unable to attend school or college due to the pandemic.

During the coronavirus pandemic, we have seen both increasing numbers and increasing acuity of children and young people suffering crisis, whether it is due to mental ill health, or related to learning difficulties and /or autism. This has included an unprecedented surge in the numbers of children and young people presenting with eating disorders.

There has been increasing pressure on CAMHS (Child and Adolescent Mental Health Service) Tier 4 beds, our local hospital paediatric beds and the CAMHS crisis teams. Young people are often admitted to a paediatric ward whilst awaiting admission to a Tier 4 unit. They also frequently present at A&E and are admitted to a paediatric ward in the event of a social crisis, family or placement breakdown. As well as being unsuitable environments for these young people, this also causes immense pressures on the acute paediatric staff. Due to the lack of Tier 4 beds, we have also recently seen children and young people admitted inappropriately to adult mental health beds.

GPs are also seeing an increased number of children and young people with mental health difficulties and have less capacity to support these young people. Schools are similarly challenged with decreased resilience in the teaching and support staff leading to increased stress in the pupil populations.

Following the first lockdown there was a surge in mental health referrals when children and young people went back to school. It is expected this surge will continue adding further pressure on services across the system that are already extremely stretched.

The national lockdowns through 2020 and 2021 have led to children and young people losing their usual routines including walking to schools, clubs, PE and school meals and some are spending more time doing sedentary activities including an increase in screen time, consuming more calories and eating more unhealthy food.

‘With the onset of the pandemic there was a significant reduction in face-to-face meetings, appointments and contact with professionals which has potentially led to fewer safeguarding concerns being raised. This is particularly of note with children and young people not being physically in educational settings as schools and colleges are the highest referees into safeguarding systems. There maybe a potential increase in child exploitation in all forms, in particular online exploitation due to increased regular use of technology.’ Professionals are very mindful of this and are building capacity to take account of the projected increase in demand on services as systems begin to return to normal.

Priority areas we should continue to build on:

Schools in Milton Keynes must continue be supported to achieve good health, wellbeing and resilience for all pupils, including the most vulnerable, through a whole-school approach that includes high-quality and effective Personal Social & Health Education, Relationships & Sex Education, Health Education and Physical Education.
Ensure parents, carers and families in Milton Keynes have access to services to help build emotional resilience in children and young people particularly at transition points to develop the healthy behaviours that will continue in adult life.
Ensure that the details of services in Milton Keynes that support children and young people, parents and carers are clear, accessible and effectively communicated to all.
Create environments that promote physical activity and healthier lifestyle choices and use the NCMP data as a measure to focus outcomes to tackle excess weight in children and young people across Milton Keynes.
Ensure excess weight is everybody’s business by working in partnership, and by developing a workforce, which is confident and competent in addressing excess weight.
Continue to use evidence from local validated surveys with young people to inform commissioning and provision of services, including the Milton Keynes Oxwell Survey
Ensure easy access and promotion of contraception and sexual health services.
Ensure effective implementation of Milton Keynes Inter-Agency safeguarding guidance and guidance that supports work with vulnerable families
Children and young people are supported to transition between into educational stages and into employment and training.
Strengthen non CAMHS offer, be clear about what’s available, increase capacity, and communicate clearly to primary care, schools and families.
Empower and educate communities to develop programmes to help tackle risk-taking behaviours.

Priority actions to deliver better outcomes

Encourage coproduction with young people (and their families and schools) across Milton Keynes in order to explore issues related to health and wellbeing and the impact that COVID on access to services and support.
Ensure services for young people are personalised and are able to provide choices for how they access support, including both face to face and virtual provision
Adapt the CAMHS pathways to focus on higher risk young people, provide more intensive community support and reduce waiting times.
Rapidly explore the potential for step up and step down beds/ intensive day care (potential solution for the increased number of CYP needing intensive support for eating disorders) inpatient provision and local bed management.

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JSNA Sections