Keeping the Promise - health and wellbeing of care experienced children and young people: longitudinal quantitative evidence review

Conclusions

Health and wellbeing of care experienced children and young people

Across the available evidence, care experienced children and young people experience markedly poorer health and wellbeing outcomes than the general population. Elevated risks were observed for mortality, psychiatric admission, self-harm, substance use, and hospitalisations. Some evidence suggested that formal care placements may offer temporary improvements in access to healthcare for school aged children and adolescents, such as reduced hospitalisations during placement. However, these gains were not sustained, with risks remaining elevated both prior to entering and after leaving care. Some placement-level analyses indicate variation, with children in away-from-home care experiencing less favourable outcomes than those in kinship care or on adoption pathways. Specific physical health concerns – such as epilepsy, and poorer dental health, were evident. In addition, looked after children were more likely to have concerns identified during preschool health reviews, particularly in speech, language, and emotional/behavioural domains. Taken together, the evidence consistently highlights health inequalities linked to care experience.

Quality of the evidence base

Scotland benefits from CLAS – a high-quality, population-wide administrative dataset. CLAS allows for precise identification of care status and enables linkage to rich outcomes data. This dataset supports robust longitudinal analyses capable of generating generalisable findings. However, existing analyses predate the introduction of The Promise, limiting their ability to reflect the more current context. The Census provides potentially valuable health outcomes information for some care arrangement. Nonetheless, it lacks a direct measure of care experience, creating a risk of misclassification. This limitation also applies to household surveys which are further limited by few Scottish care experienced participants for meaningful analysis. A further limitation is their inherent reliance on household-based sampling. This approach excludes children living in residential settings, resulting in the omission of an important segment of the care experienced population. A further limitation relates to existing preschool data linkage. PHS’s ECD statistics provide valuable insight into developmental concerns during the preschool period. This data includes an indicator for looked after status, addressing a critical gap in the evidence base. Broadly, the existing evidence base is most useful for its methodological insights and historical benchmarking.

While this review focuses on health and wellbeing outcomes, it also recognises the need to strengthen data on wider determinants of wellbeing, such as housing, education, and other social factors. Data partners, including Scottish Government, PHS, Research Data Scotland, and ADR Scotland, can all play a part in this work, including initiatives to provide ongoing access to linked data for research purposes.

Priorities for policy development

It is critical to address the lack of comprehensive data and evidence on health and wellbeing outcomes for care experienced children and young people in Scotland. These evidence gaps limit policymakers' ability to make informed, evidence-based decisions. The evidence highlighted within the review indicated several priorities for policy and service development, including:

• Mental health, with care experienced children and young people facing disproportionately high risks of psychiatric hospital admission, self-harm and suicide.
• Early intervention for developmental and behavioural difficulties, where vulnerabilities are already evident during infancy and early childhood.
• Addressing unmet needs in physical health, including dental health, management of chronic conditions and injury prevention.
• Ensuring proactive and comprehensive health assessments at the point of entering care entry. Transitional support requires particular attention, as the period after leaving care is associated with heightened health risks.
• Sustained access to preventive services (e.g., immunisations), tailoring interventions to placement type, and embedding health and wellbeing support throughout the care journey.

Gaps in the evidence base

There is limited up-to-date evidence that captures health and wellbeing outcomes in the years following the implementation of The Promise. Existing sources either do not include direct measures of care status or contain insufficient Scottish sample sizes to enable robust analysis. While there is some evidence for mortality, mental health and some physical aspects of health (e.g. psychiatric admissions, self-harm, certain chronic conditions, and dental health), other important areas are under-explored. This includes access to and timeliness of mental health support (beyond hospital-based care), early intervention and preventive health care, sexual and reproductive health service access, as well as outcomes associated with subjective wellbeing.

The lack of existing linkage for children under five limits our understanding of early outcomes. Comparative analyses by placement type are often lacking, and there is little research exploring intersecting inequalities by disability, ethnicity, or sex. Addressing these gaps will require improving the consistency of care status recording across datasets, refreshing longitudinal follow-up and expanding this into adulthood, and strengthening data linkage across health and social care systems. This will be critical to providing a comprehensive evidence base to monitor progress towards 2030 and beyond.

Recent investment through the ESRC to transform data collections for child welfare research underscores the national priority of strengthening evidence on outcomes for care experienced children and young people. The study aims to develop innovative approaches to improve the quality, consistency, and linkage of administrative and survey data, enabling richer longitudinal insights into children’s lives. It will explore how existing datasets can be better integrated and identify opportunities to capture more comprehensive measures of wellbeing alongside service use. This aligns with some of the limitations identified in this review, such as fragmented data sources and gaps in longitudinal coverage. Our recommendations to enhance care status recording, expand linkage capacity, and capture broader wellbeing measures complement these objectives. This reflects a shared commitment to building a more robust, integrated data infrastructure. Leveraging such initiatives offers an opportunity to accelerate progress towards comprehensive monitoring of health and wellbeing outcomes in line with The Promise.

Recommendations

Extend exploratory analysis using the Census

Scotland’s Census communal establishments questionnaire could be explored as a potential proxy source for estimating the number and health outcomes of children looked after in residential care. This would follow a similar methodological approach to that used in the Scottish Government’s Kinship Care Statistics analysis. Specifically, data for residents aged under 18 recorded in potentially relevant communal establishment categories (e.g., ‘Children’s home’) could be extracted and analysed to produce health outcomes of children in residential care. However, any figures derived through this method should be treated with considerable caution. Communal establishment categories are broad and may include children and young people residing for reasons unrelated to being looked after by a local authority. For example, ‘Children’s home’ could encompass a range of residential settings. Other categories such as ‘Education’ may also include some looked-after residents alongside non-care experienced populations. Consequently, there is a risk of both over- and under-estimation. While this proxy approach cannot provide a definitive count of children looked after in residential care, it could offer useful contextual estimates for population-level analysis, particularly when disaggregated by characteristics such as age, sex, disability status, and health outcomes.

In addition, we recommend that outcomes derived for the residential care proxy group are compared with those for children in kinship care. The existing Kinship Care Statistics publication is limited to high-level disability proportions. There is value in extending this analysis to include more specific data from the Census, including disability breakdowns and self-reported health outcomes. This would enable meaningful, albeit caveated, comparisons between children in different care settings, providing further insight into placement-related differences in health outcomes.

Introduce a care experience indicator to future censuses

We recommend investigating the feasibility of introducing additional questions in future censuses to allow clearer identification of care experienced children and young people. This would help to strengthen the utility of the Census as a resource for monitoring outcomes and reduce the current reliance on proxy measures or indirect indicators of care experience.

Support PHS’s ongoing linkage project and invest in developing CLAS

We recommend that the most proportionate and sustainable approach to developing an evidence base on child health in Scotland lies in supporting and building on PHS’s ongoing data linkage work. This work is already underway, with plans to test initial health indicators over 2025/26.

Rather than seeking to replicate large-scale academic projects such as CHiCS, PHS’s initiative can be regarded as an important vehicle for evidence development in relation to The Promise. This requires a well-designed, adequately resourced, linkage programme that meets The Promise’s needs, and includes a dedicated programme of analysis to evaluate and monitor progress. Using the linked datasets as a platform for ongoing analysis can generate timely, policy-relevant insights into the health outcomes of care experienced children and young people.

Working with PHS may offer advantages over academic initiatives such as CHiCS. As a permanent public health body, PHS has the potential to provide continuity, sustainability, and reliable resourcing. This helps ensure that the work is embedded as a lasting piece of national infrastructure, rather than a time-limited research project. In addition, PHS already maintains established relationships with data controllers and service providers. This may help streamline the approvals and access processes that often slow down linkage projects. Importantly, evidence generated by PHS carries additional weight because it is produced at arm’s length from government, offering independent, robust monitoring that enhances credibility.

Together, these factors render the PHS linkage project as an effective route to addressing some of the current evidence gaps. It enables linkage of key administrative datasets and has the potential to establish a sustainable analytical programme to monitor and evaluate progress towards The Promise in a robust, independent, and timely way.

There is growing recognition that linking administrative data across public services is required for the public good. There are currently a range of opportunities to link CLAS data to other datasets to enable a more holistic view of the lives of care experienced young people. By developing the CLAS data set to enable better linkage of young children, and by working with those developed linked datasets, we believe that this would be the most proportionate and sustainable approach to developing an evidence base. Data partners across Scotland can be involved in ensuring this work is high quality, reduces current data gaps, and answers the most salient questions about the outcomes of care experienced children and young people in relation to health and beyond. This could, over time, include linking to survey data for sub-sets of the care experienced population to provide further insight.

Addressing gaps in this evidence base

While PHS’s data linkage and analysis programme represents a promising step towards strengthening the evidence base on child health data, it is important to acknowledge its current limitations. The initial phase of work is restricted to school-aged children. Additionally, the outcomes available for analysis are confined to those captured in health care datasets, which tend to focus on service use (e.g. prescriptions) or severe health events (e.g. hospital admissions). These indicators, while valuable, do not provide a holistic or person-centred view of health and wellbeing, and may miss important dimensions such as emotional wellbeing, developmental vulnerabilities, and children’s own voices. Moreover, the programme is only resourced for exploratory work within the current financial year. Without sustained investment, there is a risk that future monitoring and expansion of the outcome range will be delayed or discontinued, limiting the ability to track progress towards The Promise over time.

To address these limitations and strengthen the evidence base, we recommend the following actions be considered collectively across Scottish Government, PHS, and other partners:

• Expand linkage capacity to include pre-school children, by exploring alternative identifiers and working with early years services to improve data completeness. Additional identifiers added to the CLAS collections from 2023/24 onwards may remedy this issue in the future.
• Broaden the range of outcomes by incorporating additional health-related datasets that go beyond acute or service-oriented indicators (e.g., dental health records, maternal and perinatal health data, prescribing information, and community based mental health service use).
• Secure multi-year funding to ensure continuity of the programme and allow for iterative development.
• Embed a programme of regular reporting and stakeholder engagement, to ensure that findings are translated into actionable insights and aligned with the ambitions of The Promise.
• Enable access to linked data, and conduct analyses to build a stronger evidence base.

While this review focuses on health and wellbeing outcomes, we recognise the need to also strengthen the evidence on wider determinants such as housing and education. Our overall recommendation for health is therefore to prioritise and build on PHS’s data linkage work, while working collaboratively with partners to expand and improve the evidence base around The Promise more broadly.

By addressing these gaps collaboratively and proactively, Scotland can begin to build a more robust national infrastructure for monitoring the health and wellbeing of care experienced children and young people. While the current phase of PHS’s data linkage programme offers a promising foundation, its limitations underscore the need for continued development and investment. Strengthening this evidence base will support both accountability and continuous improvement across the care system.