3.7.1 Health Care Assessments and Health Care Plans |
SCOPE OF THIS CHAPTER
This procedure applies to all children in care. Note however, that as from 3 December 2012, all children remanded other than on bail will be Looked After Children. Different provisions will apply in relation to those children/young people - see Remands to Local Authority Accommodation or to Youth Detention Accommodation Procedure, Care Planning for Young People on Remand.
This Procedure summarises the arrangements that should be made for the promotion, assessment and planning of their health care.
This chapter should be read in conjunction with the Department of Health and Social Care Statutory Guidance on Promoting the Health and Wellbeing of Looked After Children
AMENDMENT
In October 2018, a new Section 3.5, Consent to Health Care Assessments was added.
Contents
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 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 Clinical Commissioning Group (CCG) 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 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 that 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 Authority and relevant CCG(s) should develop effective communications and understandings between each other as part of being able to promote children’s well being.
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;
- Foster carers and residential staff must be prepared and supported to promote the progress of children in relation to their health, emotional, social and psychological wellbeing;
- Children and young people should be supported to maintain good health and manage long term conditions;
- Health issues (including their mental and sexual health needs, as appropriate) should be identified by the multi-disciplinary team around the child or young person. The child and young person should also have access to local Health services when needed such as CAMHS;
- Carers should develop good working relationships with Health professionals and services to meet the needs of the child or young person;
- 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 Looked After Child requiring health services should be able to access 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 CCG, e.g. where the child is placed in an out of Authority Placement, (Out of Area Placements Procedure) the ‘originating CCG ’remains responsible for the health services that might be commissioned;
- Arrangements for managing medication must be safe and effective and promote independence whenever possible. There must be safe management of controlled drugs (such as morphine, pethidine, methadone and Ritalin). See CQC Information on Controlled Drugs.
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
Each Looked After Child must have a Health Care Assessment at specified intervals set out below.
- The first Assessment (must be conducted before the first placement or, if not reasonably practicable, 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 five and over, 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 is responsible for ensuring that health care assessments are undertaken. The first assessment should be with the child’s GP or Designated Nurse for Looked After Children.
In order for the health care assessment to be conducted, the social worker must ensure that the consents section of the child's Placement Information Record has been completed and signed by the parent.
Once notice of an appointment has been received, the social worker will inform the child, parents and staff/carer of the purpose of and arrangements for the health care assessment, and either accompany the child and parents or arrange for staff/carers to accompany the child, as appropriate.
Where the child refuses a health care assessment, this must be recorded. The child should be encouraged to take advantage of the opportunity of the health care assessment to discuss health issues.
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 Procedure).
For further information on consent, see Department of Health and Social Care Reference Guide to Consent for Examination or Treatment.3.6 Merging Health Care/Health Checks
Some looked after children receive a great deal of health intervention; it may therefore be appropriate to combine review health care assessments with other necessary health checks. For example, if a child has disabilities or a Statement of Special Educational Need (SEN) or when children are known to have complex medical needs and regularly attend hospital, the medical information already available should be accepted as being the child's health record. In these circumstances, the child's social worker in conjunction with his or her manager and the Designated Nurse for LAC can decide to record the dates of medical assessments as the dates of the child's health care assessments. The reasons for this must also be recorded.
3.7 Black and Minority Ethnic Children
Black and minority ethnic children can suffer considerable health disadvantage.
They can be vulnerable to certain hereditary illnesses (e.g. sickle cell anaemia), can be predisposed to certain forms of diabetes, and there is evidence of high levels of depression amongst certain ethnic groups. It is important that:
- An accurate family history is taken;
- The emotional and behavioural development of black and minority ethnic children is accurately and fully assessed;
- Prior discussion with the child takes place in order to enable choice (e.g. in the gender of the doctor that a child may see);
- Arrangements are made for children undergoing health assessments to use the language in which they feel most confident.
3.8 Children in Secure Settings and/or on Remand
The health needs of children in secure accommodation and/or on remand should not become secondary to issues of keeping them secure or on remand, nor should health expectations be any lower than for other groups of children.
3.9 Refugees
Unaccompanied refugee children are unlikely to have medical records from their country of origin, and any medical history they themselves give is likely to be incomplete. Their immunisation status may be unknown, and they may have had no previous health surveillance.
4. Health Care Plans
Each looked after child must have a Health Care Plan in time for the first Looked After Review, with arrangements as necessary incorporated into the child's Placement Information Record.
The Designated Nurse for LAC will draw up the child's Health Care Plan based on the information in the health care assessment, in conjunction with the child, staff/carer (as appropriate), GP and any other relevant professional. The plan will then be passed to the child's social worker who will update the child's electronic records and arrange for copies to be sent to the child (depending on age), the parents and the staff/carers.
Where the child expresses a wish not to disclose the contents of the Plan to his or her parents and this is accepted by the social worker (having regard to the child's age and understanding and after consultation with his or her manager), the parents will not receive a copy.
The child's social worker is responsible for implementing the Health Care Plan and will do this with the assistance of the health professionals identified in the plan. The specific responsibilities of the staff/carers will also be identified in the Plan.
The Health Care Plan will set out how the health care needs of the child will be addressed, including the following matters:
- Whether it is necessary for any immunisations to be carried out and if so, when;
- When it is necessary for a dental check to be carried out;
- When it is necessary for any hearing or vision checks to be carried out;
- Whether there are any specific health care needs - and how they will be met, including future hospital appointments, referrals to specialist services and/or any specific treatment, strategies or remedial programmes required;
- Whether there are any health or education issues to be addressed, for example, nutrition, sexual health and relationships, substance misuse, personal hygiene;
- Whether there are any illegal or other activities including self harming which it is known or suspected the child is engaged in which may be harmful to the child's health, and the interventions/strategies to be adopted in reducing or preventing the behaviour.
This Health Care Plan must be reviewed after each subsequent Health Care Assessment or as circumstances change.
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.
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 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 make it a requirement that the responsible authority consults with the area of placement and that 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.
Who Pays? provides information on which NHS Commissioner is responsible for making payment to a provider.
Further Information
Legislation, Statutory Guidance and Government Non-Statutory Guidance
DfE and DHSC Statutory Guidance on Promoting the Health and Well-being of Looked After Children
Good Practice Guidance
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