This case study shows how Hounslow Council used the children and young people scrutiny review process to tackle teenage pregnancy locally and also scrutinise partners involved in meeting the local strategic partnership (LSP) target on teenage pregnancy. The review brought about renewed corporate drive at senior level to reach this stretching target by 2010. It also resulted in a teenage pregnancy (TP) action plan with a detailed programme of measures for 2006-08.

A series of recommendations for action by the council and its partners was agreed based on conversations with witnesses, the evidence gathered and best practice in other local authorities. These included looking at:

• structures – the make-up of the TP partnership board; location of the TP coordinator’s post
• processes – monitoring spending of the TP grant
• better data collection
• better signposting of services for young people
• practitioners
• a higher corporate profile for children’s safeguarding information – across the whole spectrum of safeguarding including substance abuse, mental health and sexual health.

The issue

National

In 1999, the Social Exclusion Unit published its teenage pregnancy (TP) report which highlighted concerns about the poverty trap and poor outcomes for teenage parents and their children. The government’s Every Child Matters agenda also sets out a number of reasons why reducing teenage pregnancy is important. The evidence shows that children born to teenagers are much more likely to have a variety of negative outcomes in later life, for example:

• Teenage mothers are less likely to finish their education and more likely to bring up their child alone and in poverty. Their children have a higher risk of poverty, low educational attainment, poor housing and health, and lower rates of economic activity in adult life.
• Teenage mothers are more likely to smoke during pregnancy and less likely to breastfeed. Infant mortality rates are higher and low birth weight babies are more common.
• Teenage mothers have three times the rate of post-natal depression of older mothers and a higher risk of poor mental health for three years after the birth. Half of all teenage conceptions end with an abortion with all the damage and trauma to the mother and others that this can cause.
• Rates of teenage pregnancy are highest among deprived communities.

In addition, government estimates suggest that every £1 spent on preventative measures saves at least £4 required to deal with the impact and issues relating to a teenage pregnancy over a period of five years.

Hounslow

Hounslow’s teenage conception rate in 1998 was 49.6 per 1,000 under-18-year-olds. The borough needed to reduce this by half to 24.8 per 1,000 to meet the government’s national target. Some councils made significant progress towards this target, including Hammersmith and Fulham, Kensington and Chelsea and two of Hounslow’s closest statistical neighbours.

The conception statistics – onthe Every Chlid Matters website

However, in 2004, Hounslow’s conception rate had increased to 52.2 per 1,000 15 to 17-year-olds (203 conceptions). This meant Hounslow’s rate was the ninth highest of the 32 London boroughs and 19th highest of the 148 upper-tier authorities in England. The council had ‘red’ status on the so-called ‘traffic light’ monitoring system by the then Department for Education and Skills (DfES). In real terms it meant that, of the 203 conceptions, there were 104 abortions and 99 births.(Ward data suggested that the problem was concentrated at the western end of the borough).

The Hounslow Strategic Partnership and Children’s Partnership Board had set milestones for achieving the 50 per cent reduction by 2010 in their local area agreement (LAA) 2006-09. However, they had only achieved half the target reduction for 2005 and progress had not been consistent. The scrutiny review found that there had been a lack of leadership on this issue. Money earmarked for reducing teenage pregnancy had not been spent and work between agencies had not been well coordinated.

In addition, it is the director of children’s services in each council who is accountable for the improvement (or not) of teenage pregnancy rates, even though they do not directly manage all the relevant services. At the time of the scrutiny review, the TP coordinator was located in community services.

Hounslow’s LAA included references to national indicators:

• NI 112 Under 18 conception rate PSA 14
• NI 117 16 to 18-year-olds who are not in education, training or employment (NEET)
• NI 123 16+ current smoking rate prevalence.

What they did

Fresh energy came from the new management team within children’s services and lifelong learning and a DfES-led event with other councils in London in January 2007. Hounslow had to attend – having got a ‘red traffic light’ rating for the 2004 figures – and completed a self-assessment ahead of this meeting with a review of action to date and a set of actions for the next six to 12 months.

The children and young people’s strategic partnership (CYPSP) agreed terms of reference that guided the scrutiny review panel’s work:

• to examine the causes for the rise in teenage pregnancy levels and understand the data and in-borough variations
• to understand the choices and circumstances that can lead to becoming a teenage parent
• to examine the extent to which young people are shaping the delivery of services to reduce teenage conception
• to learn about good practice models in other boroughs in the UK regarding staffing structures and policy implementation
• to look at current policies, staffing structures and funding across the council and local NHS regarding reducing teenage conceptions.

The panel explored and challenged a number of assumptions and preconceptions about teenage pregnancy. Mainly because of population changes since the 2001 Census, it used primary care trust (PCT) data, which suggested that teenage mothers were much more likely to be white and with lower educational achievement when compared with borough population average figures.

Review panel’s series of recommendations

The Teenage Pregnancy Partnership Board (TPPB) needed to improve the recording and sharing of statistics and all relevant information between all partners in Hounslow – particularly to target key risk and vulnerable groups. The TP grant had been underspent every year, suggesting poor monitoring and missed opportunities. It recommended regular monitoring by the TPPB.

The review panel met teenage mothers at young mothers’ hostels and at the young mothers’ group at West Middlesex University Hospital and found little evidence to back up the popular belief that becoming pregnant was a calculated move to get on the fast-track for the housing register or to live on benefits. All the mothers interviewed said that their pregnancy was not planned and hospital statistics suggested almost two-thirds were taking no contraceptive measures.

Statistics showed that 41 per cent of teenage mothers were smokers, compared with about 30 per cent in the borough’s female 16-24 population as a whole.

The review panel adopted the recommendation of the Deep Dive study (2006) published by the DfES, ‘Teenage Pregnancy Next Steps: guidance for local authorities and primary care trusts on effective delivery of local strategies’, that the council and PCT should:

• note the poor outcomes experienced by young mothers and their children
• ensure that senior managers through to frontline professionals understand that reducing teenage pregnancy is a priority
• recognise that actions to reduce teenage pregnancy represent an important ‘invest to save’ measure.

The Deep Dive study compared three councils that were performing well against three that were not. Seven key best practice factors emerged, many of which became part of the borough’s TP Forward Action Plan 2006-08, which the TPPB approved and was brought to the CYPSP in October 2006. Based on the evidence the review gathered, these seven points shaped the panel’s observations and recommendations.

1. Active engagement of all the key partners in health, education, social services and youth support services

In line with the London regional teenage pregnancy (LRTP) coordinator, the panel recommended:

• “TPPB should be a high-level strategic steering group, chaired by a council or PCT representative who is senior (at least assistant director level) and with organisational and personal influence to ensure that work is sustained.” This was the only way that aims would become organisational commitments and unlock funding streams and overcome high-level obstacles.
• The CYPSP should get an annual update (six-monthly update in the first year) on progress on teenage pregnancy and the panel should review the TPPB’s performance and effectiveness.
• Acknowledging the important management role that schools can play, the panel recommended that the TPPB should include at least one secondary and one primary headteacher representative – possibly from different ends of the borough.

Acknowledging lead officers’ heavy workloads, the review panel recommended administrative resources to support the various leads of the working groups. The LRTP coordinator favoured the TP coordinator post being located where it could exert strategic influence, so the panel recommended that it be moved from public health to the children’s services and lifelong learning directorate.

2. Strong senior champion for tackling teenage pregnancy

According to the LRTP coordinator, the local TP champion(s) could be drawn from either the elected membership or officers, or both – they needed to be accountable, driven and have clout and control over budgets. The review welcomed the director of children’s services and lifelong learning as Hounslow’s local champion.

3. Well-publicised, young people-centred contraceptive and sexual health advice service

Every effort should be made to have drop-in centres in all schools wanting to have one. Pilot drop-ins had been set up and initial reports suggested that young men were making very good use of them.

In addition, there were several recommendations about revising and publicising children’s signposting information.

4. Priority on PHSE and comprehensive programmes of sexual and relationships education (SRE) in schools

Some panel members observed a Year 9 PHSE SRE lesson. They found variations in the extent to which secondary schools consulted their pupils about the content of SRE and there were also many variations in the way SRE was delivered. Some had specialist PSHE teachers, but not all of these had attended training. Others had form tutors who regularly attended training teach SRE, but sometimes only a third of secondary schools attended borough PSHE coordinator meetings.

In Tower Hamlets and Slough, the preference was for form tutors to do SRE teaching, rather than specialists. That way the whole issue was mainstreamed into the life of the school community. Form tutors are often best placed to pick up on safeguarding issues (from eating disorders to abuse and mental and sexual health) which can have a link with SRE. But the pupil survey showed that young people preferred high quality, experiential SRE teaching, adding weight to the argument for specialists. So the review recommended that secondary schools should:

• set up specialist PSHE teaching teams
• make sure all those teaching sex and relationships education had regular training
• consider inviting health professionals to be part of the SRE quality assurance process.

The review panel were impressed by Tower Hamlets Council’s two-year exercise to draw up SRE guidelines for schools. They had successfully engaged with all faith groups, and indeed all stakeholders, to produce guidelines on which everyone could agree.

The panel wanted the council to start and facilitate a borough-wide debate among all stakeholders (pupils, parents, governors, teachers, faith groups, council, voluntary sector and healthcare professionals) on SRE teaching and advice in primary and secondary schools, the college and youth clubs. They could do this by revisiting and renewing the council’s SRE policy. Some useful steps would include a policy for SRE for SEN pupils and for looked after children.

The SRE policy could also include:

• a list of ‘approved’ external organisations to deliver additional SRE in schools and youth clubs
• an updated list of recommended teaching materials and list of useful materials for parents
• revised and clearer templates for individual schools’ SRE policies (building on practice the panel observed in Ealing) and templates for letters to parents about SRE teaching
• a brief signposting document with all relevant contact points on children’s safeguarding issues, including on sex and relationships.

Drawing on lessons from Ealing, the panel suggested that a Hounslow school might work with the council to host an SRE teaching resource centre. They also encouraged schools to make use of the council’s offer of a systematic review of schools’ SRE policies as well as their PSHE curriculum. When this had been done in Slough gaps were often identified, as well as help to improve coordination of SRE teaching in the PSHE and science curricula.

5. Targeted interventions with young people at greatest risk of teenage pregnancy, in particular with looked after children

Looked after children are a key risk group, but no local figures were available. The panel wanted to explore Ealing’s approach, developing a specific “personal relationships and sexual health policy for looked after children and care leavers”.

Young mothers need help and support after the birth of their first child. When the review team met some of them it was clear they were not getting the advice and support they needed – sometimes getting incorrect advice from JobCentre Plus workers and conflicting messages. The panel recommended a review of coordination between agencies of the information and advice they give parents after the birth of their first child to make sure they have full and easy access to the correct and consistent information.

It also recommended:

• The TPPB (or sub-group) should discuss the most effective and appropriate support for young men and fathers, perhaps building on Richmond’s experience.
• Hounslow should keep piloting and evaluating interventions for vulnerable teenagers based on analysis of need.
• No 16 or 17-year-old should be in unsupported temporary accommodation, as had previously been the case.
• Couples could be supported to stay together, wherever possible.
• The TP coordinator should work closely with the area committees – in particular in the West Area Committee, where teenage pregnancies were concentrated.
• As in Ealing, parents of SEN children might want help in discussing sex and relationships with their children and supporting them. This should be reflected in the SRE strategy.

6. SRE training for professionals in partner organisations working with the most vulnerable young people

This formed part of the action plan 2006-08. Multi-agency training could be a chance to promote better integration of working practices between agencies, including schools.

7. Well-resourced youth service with a clear focus on addressing key social issues affecting young people, such as sexual health and substance misuse

Given the success of the borough’s Detached and Outreach Teams (DOT) in reaching vulnerable young people, the review panel saw scope to engage a part-time health worker to work alongside the DOTs.

The impact

The review panel came to the view that the most important thing was choice for the young people concerned. It also made the point that efforts to reduce teenage pregnancy do not just benefit the few. Better SRE and better access to advice and support benefit all Hounslow’s children and young people.

Following the scrutiny review there was a borough-wide audit of how sexual health services were delivered both for adults and young people. This brought changes to the way services were delivered. Some were decommissioned where it was felt GPs could deliver them better; others were expanded – in particular the sexual health services for younger people in the areas of greatest need in the west and central parts of Hounslow. Anecdotal evidence is that even before the launch, take-up of this service was very good as the location was right. The launch itself in the west of the borough was very successful and well coordinated by youth services

The school-based drop-in has been expanded to two further schools and there is a new TP project development officer post. There is a new sessional worker to deliver SRE in schools and to model good SRE, and the new development officer will also deliver SRE. All requests from schools for SRE external input are now coordinated by the authority, which is leading to a more consistent message on SRE. Speakeasy training has begun and around 20 family support workers, youth workers and health professionals have been through the training.

One of the main hostels for young women is going to be refurbished so that living conditions are safer for young women and their babies.

Most importantly, there have been changes to leadership in this area. The TP coordinator post became the ‘children’s public health manager’ post located in children’s services and the post-holder changed. There is now much greater dynamism and coordination of activities, although the figures do not yet reflect that, partly because they take time to come through.

The latest figures are from 2007 and they showed an increase on 2006 from 44.4 per 1,000 in 2006 to 46.9 in 2007. In real terms there were nine more conceptions in 2007 than 2006. Members understand that it is too early to make a judgement on the effectiveness of measures that were put in place in 2007-09. They understand the difficulty of obtaining up-to-date figures and know that they have to take the long view on impact. In general terms, the level of debate between the politicians has been more mature and informed than it was prior to the scrutiny review. They are key stakeholders in debate in the public arena. It was useful to dispel some of the myths – particularly in the west of the borough – about the reasons a young woman might become pregnant.

Challenges, barriers and lessons

The scrutiny process was a good reminder of how important and powerful it is to speak with users. There are many myths about teenage mothers and so it was useful to bring politicians into direct contact with young parents. The review panel made arrangements sensitively, ensuring that the midwives who knew the young people were in attendance. Despite fears and misgivings from various quarters, the council just wanted members to be trusted to do what they do best and understand the human stories behind the figures and the stereotypes. This also seemed helpful in building cross-party consensus.

The review process drew in some of the teenage mothers’ own mothers, who had their own stories to tell. In Hounslow’s experience it has always been beneficial for members to see and hear these things for themselves. It can be time-consuming to set up in a way that is comfortable for everyone, but it has always proven beneficial.

In the follow-up work with the teenage parents (and their parents), members made further recommendations about the contract monitoring of the hostels. One of these is now being completely refurbished to make it safer for the young women and their babies.

SRE in schools has remained a difficult nut to crack. While there have been some definite improvements as a result of the review, such as a new SRE facilitator, SRE in schools is a big piece of work on its own, demanding a very long preparation time. It is about changing attitudes in schools and in the community in a highly sensitive area. The results of the consultation on whether PSHE should be compulsory are due to be published in Autumn 2009. There remain questions about the quality of delivery on the ground and scrutiny can still have a role in monitoring this.

Data and intelligence sharing

One of the greatest frustrations for members was the lack of good, up-to-date local data both from national and borough sources. Ward data from the Office for National Statistics comes out with a 24-month delay. Members identified a historic lack of coordination at the centre on this issue. Agencies are now talking more to each other and a concerted effort is being made to pull all the available data together.

The gaps were numerous and covered both data and intelligence about specific individuals – where they are, what their needs are, how they are being supported and which are the most vulnerable. Hounslow’s young parents are known to the various agencies, but there had not been the same joined-up approach as in some other boroughs.

• There was no effective data to identify which schools had the highest need.
• There had been a lack of data from hostels and information sharing with them and no coordination of statistics from the maternity unit at West Mid or other hospitals where Hounslow residents gave birth.
• There was no evidence of GPs being better involved in information exchange, no evidence of good information exchange with the temporary accommodation unit at the council, no numbers for pregnant looked after children and no useful statistics on ethnicity or drug use.
• Most of this information was already collected by the different organisations – or could be fairly easily if they were asked to, for example, if midwives were asked to record which schools young mothers attended. Across the TPPB, moves have been made to improve data capture and sharing and to establish protocols and SLAs, as well as proposals to explore the use of the existing Connexions database to manage the information. The increased used of the common assessment framework should also help.
• Since the scrutiny review, data sharing has improved between the council and the PCT, which is informing commissioning decisions.

Further information

Jonathan Hill Brown
Scrutiny Officer
London Borough of Hounslow
scrutiny@hounslow.gov.uk

Hounslow Council website.