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 Children in Care, 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 Care 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 Care 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;
• 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 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 Child in Care 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 Children 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, (see Out of Area Placements Procedure) 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 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 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: Should the child require emergency treatment or surgery, then while every effort will be made to contact those with Parental Responsibility, the medical team will act in the child's best interest, avoiding any delay in treatment or surgery. In the event of planned treatment or surgery, consent will be sought from those with Parental Responsibility. (See Section 3.9, 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, 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'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;
• 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 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 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 Frequency of Health Care Assessments

The purpose of the Initial Health Care Assessment is to provide a baseline regarding children's physical and mental health at the point they are placed in local authority care and to inform the child's Health Plan.

The first health assessment must be undertaken before the first placement, or if not reasonably practicable, before the first Looked After Review unless one has been done within the previous 3 months.

It is the responsibility of the allocated social worker to make sure that Initial Health Care Assessments are carried out for every Child in Care and to ensure that the Consent Section of the child's Placement Plan has been completed and signed by the parent or Service Manager where a parent cannot be located or refuses to give consent. The Initial Health Care Assessment must be arranged by the child's social worker. When making these arrangements, please note the following:

• Each Child in Care should have a holistic health assessment on entering care within 28 days which results in a Health Plan being drawn up;
• Statutory timescales for Health Care Assessments must be followed; every 6 months for children under 5 years and every 12 months for children aged over 5 years;
• Initial Health Care Assessment  must be carried out by a registered medical practitioner and who will specify who will undertake the Review Health Care Assessment;
• The first assessment must be by a registered medical practitioner;
• The Review Health Care Assessment may be undertaken by registered nurse/midwife;
• The person undertaking the assessment will require all available information about child's health;
• The Health Care Assessment is a continuous process ensuring actions in Health Plan are being taken forward by the child's carer, social worker and relevant professionals from health;
• The assessment should be child centred and appropriate to the child's age and development.

See LAC Initial Health Assessment Process Maps for further details.

See LAC Review Health Assessment Process Maps for further details.

3.3 Refusal to have initial/Review Health Care Assessments

Where a child/young person refuses a Health Care Assessment, this must be recorded. The child/young should be encouraged to take advantage of the opportunity of the Health Care Assessment to discuss health issues.

3.4 Children in secure settings or on remand

The health needs of these children/young people in secure accommodation and/or on remand should not become secondary to any other issue, nor should health expectations be lower than for any other groups of children/ young people.

3.5 Care Leavers

Multi-agency approaches are particularly crucial for care leavers and health needs cannot be separated from their wider needs. There is an important health promotion and advisory role here, and, young people should be able to continue to obtain health advice and services. Leaving Care Services should ensure that health and access to positive activities are included as part of a young person's Pathway Planning process. Child and Adolescent Mental Health Services (CAMHS) transitions should be planned at least 6 months in advance of their 18th Birthday in line with the CAMHS review. Care leavers with complex needs, including those with disabilities may transfer direct to adult services - transitions should be seamless and supported.

3.6 Unaccompanied Asylum Seeking children and Refugees

Unaccompanied asylum seekers are unlikely to have medical records from their country of origin, and any medical history they give is likely to be incomplete. Those undertaking health assessments with this group of children/young people require access to good local interpreting services or link workers familiar with the child's culture and able to advocate on their behalf.

Also see Unaccompanied Migrant Children and Child Victims of Trafficking and Modern Slavery Procedures.

3.7 Children with Complex needs/Disabilities

If a child has disabilities or an Education, Health and Care Plan, or when a child is known to have complex 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 their 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.

3.8 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 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 Plan, which should be passed to the child's social worker - who should give copies to carers/residential staff.

3.9 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 Plans

Each Child in Care  must have a Health Plan completed in time for their first Looked After Review, with arrangements as necessary incorporated into the child's Placement Plan.

The child's Health Plan will be drawn up at the Initial Health Care Assessment, in conjunction with the child, staff/carer (as appropriate), social worker, GP and any other relevant professional. The plan will then be passed to the child's social worker who needs to ensure that a copy is placed on the child's social care file and ensure that copies to be sent to the child (depending on age), the parents and the staff/carers and GP.

Making sure every Child in Care has a Health Plan which forms part of their Care Plan is the responsibility of the child's allocated social worker. Key principles to be adhered to when preparing, drafting and reviewing Health Plans:

• Objectives, actions, timescales and responsibilities arising from Initial and Review Health Care Assessments as set out in the plan must be clear;
• The Health Plan should be integrated into overall Care Plan for the child/young person, ensuring actions are monitored;
• The G.P held record is the lead health record for the child/young person, copies of any health assessments/plans and the Care Plan should be part of this;
• The Health Plan is drawn up with a health care professional and with the child's parents or foster carers where possible;
• Fostering and Residential Services providers should work with foster/residential carers to provide information re child's health needs.

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

4.1 Content of Health Plan

As a minimum, this plan must contain:

• Details of the child's state of health, including physical, emotional and mental health;
• Details of the child's health history, including if possible their families health history;
• The effect of the child's health history on their development;
• Arrangements for the child's medical and dental care appropriate to their needs including:
  • Routine checks of the child's general state of health including dental history;
  • Treatment and monitoring for identified health, including physical, emotional and mental health, or dental care needs;
  • Preventative measures such as immunisations;
  • Screening for defects of vision or hearing; and
  • Advice and guidance on promoting health and effective personal care.
• Any planned change to the arrangements.

4.2 Confidentiality

The principles and legal requirements concerning confidentiality should be adhered to at all times.

Confidentiality, information sharing and consent are three key issues which arise in the provision of effective health care to Children in Care.

4.3 Strength and Difficulty Questionnaires

Understanding a the emotional, mental health and behavioural needs of a Child in Care 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 in Care.

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).

4.4 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 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 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 social care services in the area where the child is placed.

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