Health 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 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

• 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 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 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 ICB area, any treatment or service should be continued uninterrupted;
• A Looked After Child requiring health services should be able to do so without delay or 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;
• 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. Good Health Assessments and Planning

The purpose of Health Assessments is to promote the current and future health of the child and not focus solely on the detection of ill-health, but include developmental health, emotional well being, health promotion and inform the child's Health Plan.

The child or young person should be at the centre of the process of health assessment, planning, intervention and review. They should be empowered to take appropriate responsibility for their own health and their views sought and taken into account at all stages.

3.1 Role of the 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;
• 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;
• 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 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, 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.

3.2 Frequency of Health Assessments

Each Looked After Child must have a holistic Health 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 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 Assessments should occur at least once every six months;
• For children aged over five years, further Health Assessments should occur at least annually;
• Newly arrived Unaccompanied Asylum Seeking Children may have additional and possibly unassessed/detected health needs. It is essential that the Initial Health Assessment (IHA) takes place as soon as possible and that as much relevant information as possible is shared by the social worker with the doctor undertaking the IHA. For these reasons, it has been agreed with the designated health team that IHA's for UASC should be fast tracked.

If a child is transferred from one Looked After Placement to another, it is not necessary to arrange an assessment within the first month. In these circumstances, the Social Worker should provide the carer/residential staff with a copy of the child's Health 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.

The health assessment must lead to a health plan. The health plan will be incorporated into the child's care plan and reviewed at each statutory review.

Any immediate health needs must be identified and addressed in discussion with the child, young person, parents and their carers and noted on the placement plan.

3.3 Who Carries Out Health Assessments?

The first Health Assessments must be conducted by a registered medical practitioner. For children placed within the borough, the assessment will be undertaken by the designated doctor for looked after children or a specialist paediatrician. For children placed out of borough, the assessment will usually be undertaken by the local GP or other appropriate out of borough health professional trained/qualified to undertake Health Assessments.

Subsequent assessments may be carried out by Solihull's designated nurse for looked after children unless placed more than 50 miles outside of borough, in which case the child's GP or other health professional will need to undertake the health assessment.

For young people who become Looked After due to remand status, the Comprehensive Health Assessment Tool may be used by the assessing health professional.

(Out of Borough claims/queries for payment should to be submitted to the Child Health Looked After Children Team administrator who will facilitate relevant quality assurance of out of borough health assessment prior to payment and send to the Health Commissioner for settlement).

3.4 Arranging Health Assessments

3.4.1 Consent

In order for the Health Assessment to be conducted, the social worker must ensure that they obtain consent. If the child is competent to give consent then the consent of the parent or social worker is not needed. If the child is not competent to give consent, then consent must be provided by the parent (if child is Section 20 accommodated) or social worker if the Local Authority share Parental Responsibility through a Care Order. Where authority on this has been delegated to the foster carer and is recorded in the placement plan, the foster carer can give consent for the health assessment.

Consent will be recorded on the IHA form submitted to the Designated Health professionals by the child's social worker.

Unaccompanied asylum seeking children have no-one in the UK able to exercise parental responsibility. Young people will generally be able to give consent to assessment, treatment and information sharing, but will need careful explanations in their preferred language. It is the social worker's responsibility to arrange an interpreter. In the case of younger UASC, who are judged not to be Gillick/Fraser competent, a standard letter on consent will be provided by the social worker.

3.5 Initial Health Assessments

The Social Worker should complete a Notification of Change form (NOC) within 24 hours of a child being accommodated and arrange for this to be sent to relevant professionals. This will include the designated health team. They will ill arrange the initial health assessment with the Community Paediatrician. If the child is placed more than 50 miles outside of Solihull, the designated health team will arrange for the health assessment to be conducted by a relevant health professional.

The designated health team will let the social worker, and the carer/carer/residential staff know to arrange an appointment within 28 days of the child becoming LAC.

Before a Health Assessment takes place, social workers must complete Part A of the 'Initial Health Assessment Form (IHA)' within 10 days of the child first coming into care and send it to the Designated Child Health Administrator.

3.6 Review Health Assessments

To trigger the next Review Health Assessment, the designated Child health administrator will email the relevant social work team administrator 8 weeks prior to review health assessment. Social Workers should complete Part A of the age appropriate Review Health Assessment (RHA) forms and obtain the relevant consent from the young person, parent, or social worker or foster carer (see Section 3.4.1, Consent).

The social worker should ensure that the child's latest Strength and Difficulties Score is included in the proforma. See SDQ Process.

The RHA forms must be sent to the Child Health administrator four to six weeks before the review health assessment is due to ensure an appointment can be arranged in time.

For children placed in the borough or within 50 miles of Solihull, the Designated Nurse for Looked After Children will undertake the review health assessment. For children more than 50 miles away, the designated health team will arrange for a suitable health professional to undertake the review ( e.g. local designated LAC nurse, etc.

The health professional conducting the assessment will complete a relevant IHA/RHA Form and a Health Plan, which should be passed to the Child Health Administrator who will enter the date of when the child attended the appointment on Care First under "Classification". - A summary and draft health plan will then be sent to the social worker, GP, health visitor if the child is under five, the child, and carer.

3.7 Health Assessments Declined or Did Not Attend

If a child declines a health assessment, the Child Health administrator will inform the Social Worker and request they contact the child to discuss the reasons for declining and offer alternative options e.g. informal health discussion/telephone call to YP from LAC Nurse. If the child then consents to a health assessment, the social worker will notify the LAC nurse who carries out the assessment.

Should the young person continue to refuse a health assessment the social worker should notify the LAC nurse and Health administrator who will record that the young person declined their health assessment on Classifications on Care First.

Further discussion should take place by the social worker with the young person and the designated nurse, doctor and relevant others about the best way forward to develop a health plan. The LAC nurse will write to the young person with contact details should they wish to seek support at a later date.

A further health assessment will be offered in 12 months time.

Should a young person not attend a health assessment the LAC nurse will notify the social worker and carer and identify issues that prevented attending. A second appointment letter will be sent. Should a child not attend their second appointment, the LAC nurse will contact the Social Worker who will contact the child/carer to discuss reasons for DNA and offer alternative options e.g. informal health discussion/telephone call to child from LAC Nurse. If the child continues to decline their health assessment, the health administrator will enter that the child declined to attend on Care First.

3.8 Disabled Children

As disabled children/young people and children/young people with complex health needs frequently have numerous health professionals involved in their care on a regular basis, they may already have a detailed health history when they become looked after.

An additional Looked After Children's Health Assessment should only be conducted with these children/young people if the designated Doctor/Nurse - (in consultation with those professionals already involved with the child/young people) judge this to be necessary. Where it is felt unwarranted to undertake a separate LAC health assessment, it is still essential that a detailed health plan is devised. It is best practice to complete a health assessment the same time as review by Paediatrician.

4. Annual Dental and Optician Appointments

As soon as the child has four teeth, the carers should take the child to the dentist. Prior to this and after 12 months, the health assessor should check the child's gums/conduct an oral examination. This constitutes a dental check.

The carer and social worker should ensure the child has their eyes checked. It is good practice for pre-school children to be taken to an optician for screening before starting school. Where a child has not had an eye-sight check, this should be identified for action in the child's health plan. In the event of a concern about hand/eye co-ordination or squint referral to ophthalmology should be arranged.

The social worker must record on Classifications on Care First the dates the child saw the dentist and optician.

5. Health Plans

Each Looked After Child's Care Plan must incorporate a Health Plan in time for the first Looked After Review and any subsequent reviews.

The health plan should set out short-term and long-term objectives and address provision of health advice, health promotion and well-being, as well as guidance and support on the management of specific health needs. It should clearly set out how the health needs identified in the assessment will be addressed.

Specifically it should identify:

• What the problem or issue is including health check-ups (e.g. immunisations not complete, sexual health advice needed), and the intended outcomes;
• How this is going to be met i.e. required actions, measurable objectives;
• The timescales for this;
• Who is responsible;
• Likely arrangements for Annual review.

The social worker develops the plan by considering the outline plan from the IHA or RHA, liaises with all relevant parties, including the child/young person and carers and develops or updates the health plan. The health plan then is incorporated into the the Child's Care Plan.

In preparation for the child's statutory review, the social worker liaises with others to consider progress in achieving objectives in the health plan, and any review health assessments. Recognising the child/young person's health information is sensitive and confidential, the social worker and IRO will discuss with the child/young person and social worker prior to the review how best to manage, share, and record the information included in their health plan.

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

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

5.1 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).

5.2 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 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.

6. Health Passports for Care Leavers

Preparing young people for adult life is of critical importance. Particular attention must be given to the young person's need for support in taking responsibility for his/her own health and accessing appropriate services, information and advice

Solihull has developed a 'Health Passport' to enable care leavers to have access to their health information as they make the move to independent living. The Health Passport is designed to give them relevant information, stored in one place, and to make registering with a GP or other health professional easier.

The passport is designed to be completed by the young person's last health assessment before turning 18 years of age. The information included in it is determined by what the young person wants. It includes space for their NHS number, birth information and several pages which can be completed with details of medical history, regular medication, contact details for GP, dentist and other health professionals Social workers should record on Care First that the young person has received their health passport and a copy stored t on the child's file should they need to access a copy in the future.

7. Health Assessment & Adult Medical Information for LAC Children when the Plan is Adoption

Where there is a recently completed IHA or RHA (i.e. within 4-6 months) and where there are no new health problems, then it will not be necessary to arrange a further health assessment. The existing IHA/RHA will suffice.

However, this will be at the discretion of the Medical Advisor and in certain circumstances, a further health assessment may be necessary

The usual forms used for the Health Assessment process is first followed:

• The Consent Form is signed by parent/s;
• Complete Form IHA-C or IHA-YP (dependent upon the child's age);
• 1st or 2nd Statutory Review is trigger to start and send off further forms;
• Form PH - separate one for each parent;
• Part A is completed by the Agency;
• Part B is completed by Birth Parent with Social Worker;
• Annex to Form C or D (dependant on the child's age);
• Keep a copy for the child's file;
• Send these forms to:
  
  PA to Dr MacEachern/Dr R Jainer,
  3 The Green,
  Stratford Road,
  Shirley,
  Solihull,
  B90 4LA
  Tel: 0121 746 4472.

Social Worker is responsible for also sending:

• Form M - Obstetric Report (complete Part A) and Form B - Neonatal report to the child's birth hospital;
• A copy of the consent form is to be attached to Forms IHA-C/IHA-YP, PH, M and B;
• For children born at Heartlands Hospital send these forms to:
  Linda Newey,
  Office Manager,
  Neonatal Unit,
  Heartlands Hospital,
  Bordesley Green Road,
  Bordesley Green,
  Birmingham,
  Tel: 0121 424 2719.
• Keep a copy for the child's file.

8. Special Guardianship - Child's Health & Adult Medical Reports

Following a special guardianship planning meeting, the allocated social worker should request medical report. They will need to send to the designated community paediatrician the following:

• The notification, including the date;
• The child's name;
• The child's legal status;
• If the child is the subject of care proceedings, the court timetable for filing of evidence;
• The name of the prospective special guardian(s);
• The names of birth parents;
• Confirmation that if consent forms are not immediately available, they will be forwarded as soon as possible;
• Confirmation that health history of each parent is not immediately available, it will be forwarded as soon as possible.

In respect of looked after children, the designated community paediatrician is responsible for routine health assessments and should have relevant information in respect of the child's health, health history and any current treatment.

In respect of children who are not looked after, the designated community paediatrician, in consultation with the social worker, will decide if it is necessary for the child to be seen or whether there is an appropriate health professional who knows the child and who can provide a report.

In either case, Forms M and B (obstetric and neonatal) are required for under 5's and should be sent off for completion as soon as possible (as per adoption procedures).

The prospective special guardian should be asked to take the CoramBAAF Adult Health Report Form AH along with a medical claim form (SS3) to their GP for completion.

In respect of the birth family, the health history of each parent should be provided on the form AH, including details of any serious physical and mental illness, any hereditary disease or disorder or disability, if this information is not already known to the designated community paediatrician.

The designated community paediatrician will send the summary to the social worker for filing with the rest of the court report.

9. Further Information

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) covering the identification, assessment and treatment of attachment difficulties in children and young people up to age 18 who are adopted from care, in special guardianship, looked after by local authorities in foster homes (including kinship foster care), residential settings and other accommodation, or on the edge of care.

British Medical Association Consent Toolkit

Practice Guidance: Supporting Young People with HIV Testing and Prevention