SCOPE OF THIS CHAPTER
This procedure applies to all Children Looked After, it summarises the arrangements that should be made for the promotion, assessment and planning of health care for Children Looked After.
It should be read in conjunction with DfE and DoH Statutory Guidance on Promoting the Health and Well-being of Looked After Children.
See also: Nursing Care and Medication Policy for Children Looked After in Foster Care (see Local Resources and One Minute Guides) and Children's Attachment: Attachment in Children and Young People who are Adopted from Care, in Care or at High Risk of Going into Care, NICE Guidelines (NG26).
A new Section 3.5, Consent to Health Care Assessments was added in October 2018 to provide guidance on the circumstances when young people can consent to their own Health Care Assessments and treatment.
- The Responsibilities of Local Authorities and Clinical Commissioning Groups
- Health Care Assessments
- Health Action Plans
1. The Responsibilities of Local Authorities and Clinical Commissioning Groups
The local authority, through its Corporate Parenting responsibilities, has a duty to promote the welfare of Children Looked After, including those who are Eligible and those children placed in adoptive placements. This includes promoting the child's physical, emotional and mental health. Every Child Looked After needs to have a Health Care Assessment so that a Health Action Plan can be developed to reflect the child's health needs and be included as part of the child's overall Care Plan.
The relevant Clinical Commissioning Group (CCG) and NHS England have a duty to cooperate with requests from the local authority to undertake Health Care Assessments and provide any necessary support services to Children Looked After without any undue delay and irrespective of whether the placement of the child is an emergency, short term or in another CCG. This also includes services to a child or young person experiencing mental illness.
The local authority should always advise the CCG when a child is initially accommodated. Where there is a change in placement which will require the involvement of another CCG, the child's 'originating' CCG, outgoing (if different for the 'originating CCG) and new CCG should be informed.
Both local authorities and relevant CCG(s) should develop effective communications and understandings between each other as part of being able to promote children's wellbeing.
- Children Looked After should be able to participate in decisions about their healthcare and all relevant agencies should seek to promote a culture that promotes children being listened to and which takes account of their age;
- That others involved with the child, parents, other carers, schools, etc are enabled to understand the importance of taking into account the child's wishes and feelings about how to be healthy;
- There is recognition that there needs to be an effective balance between confidentiality and providing information about a child's health. This is a sensitive area, but 'fear about sharing information should not get in the way of promoting the health of looked After Children' (see Annex C: Principles of confidentiality and consent, DfE and DoH Statutory Guidance on Promoting the Health and Well-being of Looked After Children (March 2015);
- When a child becomes Looked After, or moves into another CCG area, any treatment or service should be continued uninterrupted;
- A Child Looked After requiring health services should be able to access these without delay and any wait should 'be no longer than a child in a local area with an equivalent need';
- A Child Looked After should always be registered with a GP and Dentist near to where they live in placement;
- A child's clinical and health record will be principally located with the GP. When the child comes into local authority care, or moves placement, the GP should fast-track the transfer of the records to a new GP;
- Where a child is placed within another CCG, e.g. where the child is placed in an out of Authority Placement (see Out of District Placements Procedure), the 'originating CCG' remains responsible for the health services that might be commissioned.
3. Health Care Assessments
3.1 Good Health Assessment and Planning
Role of Social Worker in Promoting the Child's Health
The social worker has an important role in promoting the health and welfare of Children Looked After:
- Working in partnership with parents and carers to contribute to the Health Action Plan;
- Ensuring that consents and permissions with regard to delegated authorities are obtained to avoid any delay. Note: Should the child require emergency treatment or surgery, then while every effort will be made to contact those with Parental Responsibility this must never delay any urgent medical procedure (see Section 3.5, Consent to Health Care);
- Ensuring that any actions identified in the Health Action Plan are progressed in a timely way by liaising with health relevant professionals;
- In recognising that a child's physical, emotional and mental health can impact upon their learning, where this is necessary, liaising with the Virtual School Head to ensure as far as possible this is minimised for the child. (Should there be any delay in the child's Health Action Plan being actioned, the impact for the child with regard to their learning should be highlighted to the relevant health practitioners);
- Supporting the child's carers in meeting the child's health needs in an holistic way; this includes sharing with them any health needs that have been identified and what additional support they should receive, as well as ensuring they have a copy of the Care Plan;
- Where a Child Looked After is undergoing health treatment, monitoring with the carers how this is being progressed and ensure that any treatment regime is being followed;
- Communicating with the carer's and child's health practitioners, including dentists, those issues which have been properly delegated to the carers;
- Social workers and health practitioners should ensure the carers have specific contact details and information on how to access relevant services, including CAMHS;
- Ensuring the child has a copy of their Health Action Plan.
It is important that at the point of accommodating a child, as much information as possible is understood about the child's health, especially where the child has health or behavioural needs which potentially pose a risk to themselves, their carers and others. Any such issues should be fully shared with the carers, together with an understanding as to what support they will receive as a result.
3.2 Frequency of Health Care Assessments
Each Child Looked After must have a Health Care Assessment at specified intervals as set out below.
- The first Assessment must be conducted before the first placement or, if not reasonably practicable, in time for the Health Care Plan before the child's first Looked After Review (unless one has been done within the previous 3 months);
- For children under 5 years, further Health Care Assessments should occur at least once every 6 months;
- For children aged over 5 years, further Health Care Assessments should occur at least annually.
If a child is transferred from one Looked After Placement to another, it is not necessary to plan an assessment within the first month. In these circumstances, the social worker should furnish the carer/residential staff with a copy of the child's Health Care Plan.
If no plan exists, the social worker should arrange an assessment so that a plan can be drawn up and available for the child's first Looked After Review which will take place within 20 working days.
3.3 Who carries out Health Assessments?
The first Health Care Assessments must be conducted by a registered medical practitioner. Subsequent assessments may be carried out by a registered nurse or registered midwife under the supervision of a registered medical practitioner, who should provide the Social Worker with a written report (See Arranging Health Care Assessments).
3.4 Arranging Health Care Assessments
The social worker should liaise with the carer/residential staff to arrange the first assessment with the child's GP or Designated Nurse for Children Looked After.
Before a Health Care Assessment takes place, social workers must complete Part A of the CoramBAAF 'Initial Health Assessment Form' to ensure it is available at the time of the appointment.
In order for the Health Care Assessment to be conducted, the social worker must ensure that the parent(s) have given consent - this will usually be recorded on the Placement Plan /Initial Health Assessment Form at the point of becoming Looked After.
The health professional conducting the assessment will complete a relevant CoramBAAF Form and a Health Action Plan, which should be passed to the child's social worker - who should give copies to carers/residential staff.
3.5 Consent to Health Care Assessments
A valid consent will be necessary for a Health Care Assessment. Who is able to give this consent will depend on the age and understanding of the child. In the case of a very young child, the local authority as corporate parent can give the consent. An older child with mental capacity may be able to give their own consent.
Young people aged 16 or 17
Young people aged 16 or 17 with mental capacity are presumed to be capable of giving (or withholding) consent to their own medical assessment/treatment, provided the consent is given voluntarily and they are appropriately informed regarding the particular intervention. If the young person is capable of giving valid consent, then it is not legally necessary to obtain consent from a person with Parental Responsibility.
Children under 16 – 'Gillick Competent'
A child of under 16 may be Gillick Competent to give (or withhold) consent to medical assessment and treatment, i.e. they have sufficient understanding to enable them to understand fully what is involved in a proposed medical intervention.
In some cases, for example because of a mental disorder, a child's mental state may fluctuate significantly, so that on some occasions the child appears Gillick Competent in respect of a particular decision and on other occasions does not.
If the child is Gillick Competent and is able to give voluntary consent after receiving appropriate information, that consent will be valid, and additional consent by a person with parental responsibility will not be required.
Children under 16 - Not 'Gillick' Competent
Where a child under the age of 16 lacks capacity to consent (i.e. is not Gillick Competent), consent can be given on their behalf by any one person with Parental Responsibility. Consent given by one person with Parental Responsibility is valid, even if another person with Parental Responsibility withholds consent. (However, legal advice may be necessary in such cases). Where the local authority, as corporate parent, is giving consent, the ability to give that consent may be delegated to a carer (foster carer or registered manager of the children's home where the child resides) as a part of 'day-to-day parenting', which will be documented in the child's Care Plan (see Delegation of Authority to Foster Carers and Residential Workers Procedure).
For further information on consent, see Department of Health and Social Care Reference Guide to Consent for Examination or Treatment.
4. Health Action Plans
Each child's Care Plan must incorporate a Health Action Plan in time for the first Looked After Review, with arrangements as necessary incorporated into the child's Placement Plan.
This plan must be reviewed after each subsequent Health Care Assessment and at the child's Looked After Review or as circumstances change.
4.1 Strength and Difficulty Questionnaires
Understanding a child's emotional, mental health and behavioural needs is as important as their physical health. All local authorities are required to use the Strength and Difficulty Questionnaires (SDQs) to assess the emotional needs of each child.
The SDQ Questionnaire, along with any other tool which may be used to assist, can be used to identify the needs and be part of the child's Health Action Plan.
4.2 Out of District Placements
Where an Out of Authority placement is sought, the responsible authority should make a judgment with regard to the child's health needs and the ability of the services in the proposed placement area to fully meet those needs. The placing authority should seek guidance from within its own partner agencies and the potential placement area to seek such information out.
The originating CCG, the current CCG (if different) and the proposed area's CCG should be fully advised of any placement changes and to ensure that any health needs or heath plan are not disrupted through delay as a result of the move.
Where these are Placements at a Distance the Care Planning, Placement and Case Review (England) Regulations 2010 (as amended) make it a requirement that the responsible authority consults with the area of placement and that the Director of the responsible authority must approve the placement.Where the child's health situation is more complex, it is likely that both Health and Children's Social Care services will need to be commissioned; this will need to be undertaken jointly within the originating agencies' respective fields of responsibility together with the Health and Children's Social Care services in the area where the child is placed.