SCOPE OF THIS CHAPTER
This procedure applies to all Looked After Children. 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 health care for Looked After Children.
This chapter should be read in conjunction with DfE and DHSC Promoting the health and well-being of looked-after children Statutory guidance for local authorities, clinical commissioning groups and NHS England.
Children's Act (1989 and 2004)
Requires local authorities; CCG and NHS England to cooperate to promote the health and welfare of looked after children (section 10). Stipulates that an IHA must be carried out by a registered medical practitioner, a RHA may be carried out by a registered nurse, health visitor or midwife.
Looked After Children: knowledge, skills and competence of healthcare staff (Intercollegiate Role Framework, 2015)
This sets out the specific knowledge, skills and competencies which health staff require in order to work with Looked After Children.
Special educational needs and disability code of practice: 0-25 years (Department of Education and Department of Health and Social Care)
This is a statutory code of practice which outlines the duties of local authorities, health bodies, schools and colleges to provide for those with a special educational need (SEN) under part 3 of the Children and Families Act 2014. Approximately 70% of looked after children have some form of special educational need.
NICE Guideline PH28: Looked after Children and Young People (2010 updated 2015)
This aims to enable children's health and social care services to meet their obligations to improve the health and well- being of looked after children. The recommendations cover local commissioning, multi-agency working, care planning, placements and timely access to appropriate health and mental health services.
NICE Quality Standard QS31. Looked after children & young people (2013)
This gives specific measurable statements around the health and wellbeing of looked after children and young people and care leavers for all services.
NICE Quality standard QS165
This quality standard covers the prevention or delay of harmful use of drugs by children, young people and adults most likely to start using drugs, or already experimenting or using drugs occasionally. This includes illegal psychoactive substances, solvents, volatile substances, image- and performance-enhancing drugs, prescription-only medicines and over-the-counter medicines. It describes high-quality care in priority areas for improvement.
Quality statement 1: Looked after Children and young people having their annual health plan review are assessed for vulnerability to drug misuse.
Quality statement 2: Care leavers having a health assessment as part of planning to leave care are assessed for vulnerability to drug misuse.
Who Pays? Determining Responsibility for payments to providers (NHS England, 2013)
Provides guidance on how to determine who pays for health services for looked after children who are placed out of area.
The Care Planning, Placement and Case Review (England) Regulations (2010)
This guidance sets out the functions and responsibilities of local authorities and partner agencies under Part 3 of the Children Act 1989 ('the 1989 Act'), which concerns the provision of local authority support for children and families. In particular, it describes how local authorities should carry out their responsibilities in relation to care planning, placement and case review for looked after children.
In January 2019, a new Section 3.5, Consent to LAC Health Assessments was added.
- The Responsibilities of Local Authorities and Clinical Commissioning Groups
- Looked After Children Statutory Health Assessments
- Health 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 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 must have an Initial health assessment completed by a registered medical practitioner within 28 days of becoming "Looked after" with a health plan to reflect the child's health needs this will form 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 statutory health assessments and provide 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 area.
The Local Authority must always advise the CCG when a child is initially accommodated. Where there is a change in placement which may require the involvement of another CCG, the child's 'originating' CCG, and new CCG must 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 wellbeing.
- 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 CCG area, any treatment or service should continue uninterrupted;
- A Looked After Child requiring health services should be able to access these services 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 as a permanent patient with a GP and Dentist near to where they live;
- A child's clinical 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 Area Placements Procedure), the 'originating CCG' remains responsible for the commissioning of health services.
3. Looked After Children Statutory Health 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:
- Work in partnership with parents and carers to contribute to the Health Plan;
- Ensure that the appropriate consent is gained from those with Parental responsibility, this maybe the local authority if the child is under a care order for LAC statutory health assessments, medical consent, immunisations and dental procedures when the child becomes LAC. Also permissions with regard to delegated authorities are also obtained to avoid delays. Note: 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 urgent medical treatment (see Section 3.5, Consent to LAC Health Assessments);
- Ensuring that all actions identified in the Health Plan are progressed within the given time frames by liaising with the relevant health 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 a 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 and the Health Action Plan;
- If a Looked After Child is undergoing treatment, the social worker will liaise with the carers on progress and ensure that any prescribed treatments are being followed;
- Communicate with the carer's and child's health practitioners, including dentists, issues which have been 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;
- Ensure 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 collected and 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/or 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 Statutory LAC Health Assessments
Each Looked After Child must have a Statutory LAC Health Assessment at specified intervals as set out in the Children Act (1989 and 2004).
- The Initial Health Assessment must be completed within 28 days of a child becoming LAC by a registered medical practitioner in time for the child's first LAC review (unless one has been done within the previous 3 months);
- For children under five years, further Review Health Assessments should occur at least once every six months;
- For children aged 5 to 18 years, Review Health Assessments should occur annually.
If a child is transferred from one Looked After Placement to another, it is not necessary for another health assessment to be completed. In these circumstances, the social worker should furnish the carer/residential staff with a copy of the child's Health Plan.
If no plan exists (due to a change of placement within the first month of becoming LAC), the social worker should contact the LAC health team to arrange an Initial health 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 of the child becoming LAC.
3.3 Who Carries out LAC Health Assessments?
The Initial Health 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 will provide the social worker with a written report (see Section 3.4, Arranging LAC Health Assessments).
3.4 Arranging LAC Health Assessments
The social worker must liaise with the carer/residential staff and the LAC health team or Designated Nurse for Looked After Children to arrange for the completion of the IHA.
Before a LAC Health Assessment can take place, social workers must complete the IHA referral template and send it to the LAC health team. This will include demographics, signed consent and background information for the child.
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 Health assessment Form (or other agreed template) which includes a Health Plan. The completed form will be passed to the child's social worker - who will give copies to carers/residential staff.
3.5 Consent to LAC Health Assessments
A valid consent will be necessary before a LAC Health Assessment can be undertaken.
For children who are accommodated under a voluntary agreement, entered into with their parents (Section 20), birth parents retain parental responsibility and their consent to the health assessment must be obtained prior to its completion.
Children who are the subject of a Care Order (Section 31) or interim Care Order (Section 38); Consent to health assessments may be given by the local authority. It is good practise, where appropriate, to involve the birth parents in the decisions.
An older child who is deem, by assessing clinician, to have the capacity to understand may be able to give their own consent to a LAC health assessment.
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.
4. Health Plans
Each Looked After Child's Care Plan must incorporate an up to date 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 Assessment and at the child's Looked After Review or as circumstances change to ensure health action have been completed.
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 carers 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.
A total difficulty score of 18 or higher will be notified by the LAC health team to the Attach team, child's social worker and child's IRO who will ensure the appropriate actions are taken to review the child's needs.
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 and ensure services are available.
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.