3.6.4 Health Care Assessments and Health 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 Child in Care 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 Children in Care 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 that 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 well being.

2. Principles

• Children in Care 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 CYPMHS;
• 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 DHSC Statutory Guidance on Promoting the Health and Well-being of Children in Care (March 2015);
• When a child becomes Looked After, or moves into another ICB area, any treatment or service should be continued uninterrupted;
• A Child in Care requiring health services should be able to access these without delay any wait should 'be no longer than a child in a local area with an equivalent need';
• A Child in Care 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 the 'originating ICB' 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 Assessments

The purpose of Health Assessments is to promote children's physical and mental health, developmental health, emotional well-being and to inform the child's Health Plan. This holistic approach should be appropriate to the child's age and stage of development.

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 in Care:

• Working in partnership with parents and carers to contribute to the Health Plan;
• Ensure 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 3.4, Consent to Health Care Assessments);
• Ensure 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, to liaise 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);
• To support the Child in Care'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 in Care is undergoing health treatment, to monitor with the carers how this is being progressed and ensure that any treatment regime is being followed;
• To communicate 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 CYPMHS;
• 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 that 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 Initial Health Assessments

The Initial Health Assessments must be conducted by a registered medical practitioner. Subsequent review assessments (for children age 10 and above) may also be carried out by a registered nurse under the supervision of a registered medical practitioner, who should provide the social worker with a Health Summary and Health Plan.

Specially trained GP's under a local enhanced service agreement will be the first line delivery of this service and Community Nurses from the Vulnerable Children and Young People team can assist in this process as necessary.

The completed Health Assessment Summary and Health Plan are returned to the social worker via the Health Service Co-ordinator and identified Social Care business support.

The Social Worker will then arrange for a copy of the Health Assessment Summary and Health Plan to be sent to the child (depending on age), the parents and the staff/carers.

3.3 Frequency of Health Assessments

• The initial Health Assessment must be conducted in order that a Health Plan can be drawn up in time for the first Children in Care Review (unless one has been done within the previous 3 months), and any necessary follow up assessment must be arranged by the social worker;
• For children aged under five years, further Health Assessments should occur at least every six months;
• For children aged five and over further Health Assessments should occur at least annually.

In order to ensure the Initial Health Assessment takes place within the required timescale, 20 working days after becoming Looked After. The social worker must gain consent in the relevant sections of the Placement Plan and the CoramBAAF consent form. Ideally this should be prior to any planned placement or if unplanned within 72 hours of the placement.

The social worker must notify and send the completed CoramBAAF consent form to the designated Business Support Officer in their locality. This should be (no later than 3 working days) of entering care to enable the Health Service to arrange the Initial Health Assessment (IHA) within 20 days from entering care.

The identified social care business support in the relevant social work team sends the appropriate CoramBAAF consent and relevant age appropriate CoramBAAF form to the Health Care Co-ordinator within the relevant timescales.

The identified business support will then issue reminders to the relevant social worker as and when further HA's become due under the above timescales. It is then for the child's social worker to ensure that appropriate arrangements are made and in accordance with the statutory timescales.

Where a child is placed outside Lincolnshire, and it is not practicable because of the distance involved for the Health Assessment to take place in Lincolnshire, the Health Service Co-ordinator will contact the relevant local Heath Trust to make the necessary arrangements for Health Assessments.

In order for the Assessment to be conducted, the social worker must ensure that the Consents section of the child's Placement Plan has been completed and signed by the Parent or person with parental responsibility. In addition the CoramBAAF consent form (add reference) must be fully completed and sent to the Health Service Co-ordinator via the identified business support.

The social worker will inform the child, parents and staff/carer of the purpose of and arrangements for the Health Assessment, and accompany the child and parents (or arrange for staff/carers to accompany the child, as appropriate).

As part of the explanation, the social worker will ensure that the child, parent or carer receive the CoramBAAF Blue Health Book for Looked after Children.

The Health Care Co-ordinator will send information from the child health electronic system to the Health Assessor.

3.4 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 (DHSC) Reference guide to consent for examination or treatment.

4. Health Plans

The Initial Health Assessment should result in a Health Plan by the time of the first review of the child's Care Plan, four weeks after becoming looked after. The medical practitioner completing the IHA will summarise the child's current health status and make health recommendations which will be incorporated into the child's Care Plan. The Health Plan will be reviewed at each Health Assessment or sooner if required. The child's social worker is responsible for updating the care plan for a Child in Care Children based on the information in the Health Assessment. Arrangements and responsibilities for meeting any health needs will also be recorded in the child's Placement Plan as appropriate.

The Care Plan/for each Child in Care must incorporate how the health care needs of the child will be addressed.

As necessary the Care Plan and Placement Plan should address the following matters:

1. Whether there are any specific health care needs including needs raised from Disabilities - and how they will be met;
2. Whether it is agreed that medication can be used to provide relief for headaches, menstrual or other pain; also whether there are any restrictions on the use of non-prescribed medicines, Household Remedies or use of first aid;
3. The involvement of the child's parents or significant others in health issues during the placement;
4. Any specific medical or other health interventions which may be required, including whether it is necessary for any Intimate Procedures and how they will be undertaken;
5. The extent to which the child is able to retain or administer medication, or requires support to do so;
6. Whether it is necessary for any immunisations to be carried out;
7. Any specific treatment, strategies or remedial programmes required;
8. Any necessary preventive measures to be adopted;
9. Whether the child is allowed to smoke and any measures agreed to reduce the behaviour;
10. 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;
11. Whether the placement will contribute to any other health-related assessments;
12. Whether the placement will contribute to any health monitoring.

See also Sexual Health and Relationships Guidance in relation to the provision of advice to Child in Care on sexual health, sexual relationships and contraception.

Information should also be given about any allergies. See also Health and Safety Procedure.

4.1 Strength and Difficulty Questionnaires

Understanding a Child in Care'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.

The SDQ Questionnaire can be located on GEORGE Core Forms R – Z, 'Scales and Questionnaires – Strengths and Difficulties'.

(See also 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 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

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)