Health Care Assessments and Plans

1. The Responsibilities of Local Authorities and Integrated Care Boards

The local authority, through its corporate parenting responsibilities, has a duty to promote the welfare of looked after children, including those who are eligible and those children placed in adoptive placements. This includes promoting the child's physical, emotional and mental health; every Looked After Child needs to have a health assessment so that a Health 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 Integrated Care Board (ICB) and NHS England have a duty to cooperate with requests from the local authority to undertake health assessments and provide any necessary support services to Looked After Children without any undue delay and irrespective of whether the placement of the child is an emergency, short term or in another ICB. This also includes services to a child or young person experiencing mental illness.

The Local Authority should always advise the ICB when a child is initially accommodated. Where there is a change in placement which will require the involvement of another ICB, the child's 'originating' ICB, outgoing (if different for the 'originating ICB) and new ICB should be informed.

Both Local Authority and relevant ICB(s) should develop effective communications and understandings between each other as part of being able to promote children's wellbeing.

2. Principles

• Looked After Children 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 DHSC 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 ICB area, any treatment or service should be continued uninterrupted;
• A Looked After Child 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 Looked After Child 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 ICB, e.g. where the child is placed in an out of Authority Placement (see Out of Area Placements Procedure), the 'originating ICB' 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 Looked After Children:

• Working in partnership with parents and carers to contribute to the Health Plan;
• Ensuring that consents and permissions with regard to delegated authorities are obtained to avoid any delay. Note: however, should the child require emergency treatment or surgery, then every effort should be made to contact those with parental responsibility to both communicate this and seek for them share in providing medical consent where appropriate. Nevertheless, this must never delay any necessary medical procedure (see Section 3.5, Consent to Health Care Assessments);
• Ensuring that any actions identified in the Health 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 Plan being actioned, the impact for the child with regard to their learning should be highlighted to the relevant health practitioners);
• Supporting the Looked After 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 Looked After Child 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 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 Looked After Child 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 five years, further Health Care Assessments should occur at least once every six months;
• For children aged over five 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 Section 3.4, 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 Looked After Children.

Before a Health 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 Assessment to be conducted, the social worker must ensure that the parent(s) have given consent - this will usually be recorded on the Placement Information Record/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 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 Placement Plan (see Delegation of Authority to Foster Carers and Residential Workers).

For further information on consent, see Department of Health and Social Care Reference Guide to Consent for Examination or Treatment.

4. Health Plans

Each Looked After Child's Care Plan must incorporate a Health Plan in time for the first Looked After Review, with arrangements as necessary incorporated into the child's placement plan/placement information record.

This plan must be reviewed after each subsequent Health Care Assessment and at the child's Looked After Review or as circumstances change.

The Care and Placement Plan and Health Care Plan should contain the following:

• All known allergies and associated risks including spotting the signs and symptoms of an allergic reaction and anaphylaxis for the child/young person;
• Preventative measures should be detailed in the Plan - for example following good hygiene routines in terms of utensils and crockery, hand washing, avoiding cross contamination in the kitchen area, checking labels for allergens and any agreed allergen avoidance in the placement;
• Actions to take when a young person has an allergic reaction. The plan should describe exactly what to do and who needs to be contacted in the event of an emergency. For example, when to use an Epi Pen and calling for an ambulance;
• Staff/foster carers should be aware of the Plan and should have been trained to administer an Epi Pen by a suitable qualified health professional;
• The child/young person should be educated around their allergies and what to do in an emergency - a young person may be able to self-administer their own EpiPen or take antihistamines. If this is the case this should be recorded;
• Medication should be easily accessible so staff/foster carers and/or the child/young person can access their medication in an emergency situation;
• A record should be kept of each episode and any medication given should be recorded.

For further information see the NHS website or see Allergy UK Website.

4.1 Strength and Difficulty Questionnaires

Understanding a Looked After 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 Plan.

(See Appendix B of the 'DfE promoting the health and well-being of looked-after children', Strengths and Difficulties Questionnaire.)

4.2 Out of Area 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 ICB, the current ICB (if different) and the proposed area's ICB should be fully advised of any placement changes and to ensure that any health needs or Health 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.