Health Assessments and Health Recommendation 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 Looked After, 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 Looked After needs to have a health assessment so that a Health Recommendation 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 Looked After 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 Looked After 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, Statutory Guidance on Promoting the Health and Well-being of Looked After Children Department for Education and Department of Health and Social Care);
• When a child becomes Looked After, or moves into another ICB area, any treatment or service should be continued uninterrupted;
• A Child Looked After 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 Child Looked After 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 and to inform the child's Health Recommendation Plan.

3.1 Good Health Assessment and Planning

Role of S/W in Promoting the Child's Health

The social worker has an important role in promoting the health and welfare of Children Looked After:

• Working in partnership with parents and carers to contribute to the Health Recommendation Plan;
• Ensure that consents and permissions with regard to delegated authorities are obtained to avoid any delay. Note: In the event of an emergency, 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 3.5, Consent to Health Care Assessments);
• Ensure that any actions identified in the Health Recommendation Plan are progressed in a timely way by liaising with health relevant professionals and others who have been identified to complete the action;
• In recognising that a child's physical, emotional and mental health can impact upon their learning, social workers should liaise with the Virtual School Head as necessary. Should there be any delay in the child's Health Recommendation 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 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 Looked After 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, where appropriate, has a copy of their Health Recommendation 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 Assessments

Each Child looked After must have a Health Assessment within 20 working days of becoming Looked After, then at specified intervals as set out below.

Initial Health Assessments must be conducted by appropriately qualified medical practitioner; who should provide the social worker with a Summary report and Health Recommendation Plan (HRP) (see Arranging Health Assessments).

• The Initial Health Assessment (see box below) must be conducted before the first placement or, within 20 working days of the child becoming Looked After to coincide with the child's first Looked After Review (unless one has been done within the previous 3 months);
• For children under 5 years, Review Health Assessments should occur at least once every 6 months;
• For children aged over 5 years, Review Health Assessments should occur at least annually.

When a child is transferred from one Looked After Placement to another, the social worker should provide the new carer/residential staff with a copy of the child's most recent Summary Report and Health Recommendation Plan.

3.3 Arranging Health Assessments

The first Health Care Assessment must be conducted by a registered medical practitioner. Subsequent assessments may be carried out by a registered nurse or registered midwife who should provide the social worker with a copy of the summary report and the Health Recommendation Plan.

The social worker should enter the child's details onto CASS as soon as the child becomes Looked After. This will trigger an electronic notification to the Children Looked After (CLA) health administrator, who will then send all appropriate paperwork to the social worker for completion.

Before a Health Assessment takes place, the social worker should electronically complete and return Part A of the CoramBAAF Initial Health Assessment form. The accompanying CoramBAAF Consent Form should be printed off and completed and signed by the birth parent(s) and returned by the social worker, by post or fax to the CLA health administrator at Brighouse Health Centre.

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 Plan/Initial Health Assessment Form at the point of becoming Looked After. The social worker should sign Part A to confirm that consent to undertake the Initial Health Assessment has been given.

On receipt of the completed CoramBAAF Initial Health Assessment and CoramBAAF Consent Form, the CLA health administrator will arrange the initial health assessment appointment. The CLA health administrator will invite the child's carer by letter to the initial health assessment. The social worker will be informed of the pending appointment.

The child's social worker should make every effort to attend the Initial Health Assessment, in order to share information with the Designated Doctor CLA. If the social worker is unable to attend in person, they should contact the Designated doctor prior to the assessment to discuss the child's pre care experience and social history.

The CLA health administrator will make all the necessary arrangements for the health assessment. In cases where issues arise the CLA health administrator will notify the social worker in order to effect resolution.

3.4 Preparing the child/young person for the Health Assessment

The social worker should spend time explaining the Health Assessment process to the child to reduce any anxieties they may have but also to stress the benefits of the Assessment.

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.

The CLA health team will only assess children who have a signed and completed CoramBAAF Part A form. This signed consent gives permission for the Designated Doctor to assess the child. In addition if appropriate, the child or young person attending for assessment will be asked to sign consent for the assessment. The Designated Doctor will apply Gillick competency principles to assess the child or young person's capacity to 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 Policy for Delegation of Authority to Foster Carers and Residential Workers).

For further information on consent, see Department of Health and Social Care Reference Guide to Consent for Examination or Treatment. The Child Looked After Health Team can also be contacted for advice.

3.6 Recording and Monitoring of the Health Assessment

The Summary Report and HRP, when complete, will be shared via SystmOne with the child's GP, Health Visitor or School Nurse.

They will be shared via CASS with the child's social worker and Independent Reviewing Officer. Copies of the documents will be posted out to the foster carer or residential carer.

It is at the SW's discretion as to whether a copy is given to the birth parent.

It will be the responsibility of the allocated social worker and Independent Reviewing Officer to monitor the HRP through the CLA Review process.

The HRP should be placed on the child's case file (CASS) by the CLA Health Team administrator.

It is the responsibility of the allocated social worker and Independent Reviewing Officer to monitor the HRP through the CLA Review process.

The HRP should be placed on the child's case file (CASS).

It is the responsibility of the allocated social worker to ensure that the Child's Electronic Record has been updated to record that the Health Assessment has taken place.

4. Health Recommendation Plans

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

A copy of the Child's Care Plan/Health Recommendation Plan should be given to the child's carers or home's manager, if placed in residential care.

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

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

4.1 Strength and Difficulty Questionnaires

Understanding a Child Looked After'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 Recommendation Plan.

See also: Annex B of the 'DfE promoting the health and well-being of looked-after children', Strengths and Difficulties Questionnaire) and Strengths and Difficulties Questionnaires (SDQs) Guidance.

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 Health Recommendation 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.

5. Children Placed in Residential Care or Foster Care

If children are placed in residential care or foster care, the designated keyworker or carer is responsible for supporting the allocated social worker to promote the health, wellbeing and educational needs of the child, liaising with key professionals, including the CLA Health Team, the child's GP and dental practitioner.

The carer/keyworker must also ensure that up to date information is kept on the child in relation to their health needs, development, illnesses, operations, immunisations, allergies, medications, administered, dates of appointments with GP's and specialists.

The carer/keyworker must also ensure the child is registered with a GP, dentist and any other health care professionals deemed appropriate.