Health Assessments, Health Plans and Strengths and Difficulties Questionnaires

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 wellbeing.

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;
• 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 DfE and DoH Statutory Guidance on Promoting the Health and Well-being of Looked After Children, Annex C: Principles of confidentiality and consent (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 access these 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 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.

3. Health Assessments

It is the responsibility of local authority to ensure that the Looked After Children Health Team are notified of children and young people entering into care, within 48 hours. Each child or young person should have a holistic assessment on entering care.

3.1 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:

• Working in partnership with parents and carers to contribute to the Health Plan;
• Ensuring 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;
• Ensuring that any actions identified in the Health Plan are progressed in a timely way by liaising with health relevant professionals;
• Recognising that a child's physical, emotional and mental health can impact upon their learning, the social worker should, where necessary, liaise with the Virtual School Head. (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 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, monitoring with the carers how this is being progressed and ensuring that any treatment regime is being followed;
• Communicating 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 Assessments

The First / Initial Health Assessment (IHA) should be undertaken by a registered medical practitioner and should result in a Health Plan by the time of the first review of the child's Care Plan, 4 weeks (20 Working Days) after they become Looked After.

Review Health Assessments (RHA) are completed on children under 5 years every 6 months, and for those over 5 years an RHA should be completed each year.

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.

3.3 Arranging Health Assessments

It is the responsibility of the social worker once the child has become Looked After to obtain consent for the Health Assessment, and return this to the Looked After Children (LAC) Health Team within 5 working days. Consent should be completed in all circumstances.

The LAC Health Team will arrange an appointment with a medical practitioner within 5 working days for the initial assessment. The LAC Health Team will inform the carers of the child and the child's social worker to inform the child and parents of the Health Assessment, and to accompany the child, parents and or carers at the assessment.

The LAC Health Team will arrange for RHA's to be undertaken by the child's lead health professional, or where there is need for medical / adoption review this will be arranged and undertaken by the team's medical advisors. Updated demographic and legal information for RHA's will be taken by the LAC health team form the New Key Information Record held on Liquidlogic.

A copy of the summary and Health Plan from the Health Assessment will be sent from the LAC health team to the child's social worker, carer, Independent Review Officer (IRO), general practitioner and community health professional.

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 Reference Guide to Consent for Examination or Treatment.

3.5 Decline of Health Assessment

Wherever possible a child should be encouraged to attend their appointment, and have the opportunity for their health to be assessed. Where an assessment is refused this should be documented along with the circumstances around this refusal, and the work undertaken to encourage cooperation in the process.

If an IHA is declined with a medical practitioner, young people may find it easier to engage with an experienced member of the LAC Nursing Team, this can be offered in a place suited to the young person and medical supervision can be given.

Where all reasonable attempts have been made to complete and IHA or RHA, and where there is consent to carry out a Health Assessment, the young person will be informed that an assessment will be completed using all other information sources.

3.6 Combining Health Care / Health Checks

A small number of Looked After Children require a significant amount of health intervention. Therefore where appropriate Health Assessments can be combined with other necessary health reviews. In such circumstances the child's social worker in conjunction with their manager and the Designated Doctor for LAC can make the decision to hold only one review / appointment. Such a decision must be recorded along with the reasons why the decision was taken.

3.7 Black and minority ethnic children

Black and minority ethnic children may suffer additional health disadvantage; this may be a result of previous discrimination.

It is important that:

• The emotional and behavioural development of black and minority ethnic children is accurately and fully assessed;
• Prior discussion with the child takes place in order to enable choice (e.g. in the gender of the doctor that a child may see);
• Arrangements are made for children undergoing Health Assessments to use the language in which they feel most confident;
• Cultural sensitivity is shown at all times.

3.8 Children in secure settings and/or on remand

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

Wherever a child is placed in secure care, the LAC Health Team will make contact with the health services providing care in the secure setting / remand, to provide a handover and a copy of the last Health Assessment.

3.9 Asylum Seekers / Refugees

Unaccompanied refugee children seeking asylum or with refugee status are unlikely to have medical records from their country of origin, and any medical history they themselves give is likely to be incomplete. There may have been no previous health surveillance and immunisation status may be unknown moreover schedules in their country of origin may differ from UK directives. General information / advice on immunisation is available from the Designated Doctor / Designated Nurse for LAC.

4. Health Plans

Making sure that every Looked After Child has a Health Plan which forms part of their Care Plan is the responsibility of the local authority that looks after the child. It is a statutory requirement that Integrated Care Boards cooperate with local authorities to ensure Health Plans are both in place and effective.

The IHA should result in a Health Plan by the time of the first review of the child's Care Plan, 4 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 this is required.

Where the child / young person or other individual expresses a wish not to disclose the contents of their plan to their parents, this will be discussed with the child's social worker and their manager (having regard for the child's age and level of understanding) and where appropriate the young person's request will be followed.

4.1 Content of the Health Plan

The content of the Health Plan will vary according to the age and development of the child. The content should always reflect the issues that are addressed at the Health Assessments, including physical and emotional health.

The following should be included as a minimum:

• The child's health history including as far as practicable, including their family's 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:
  1. Routine checks of the child's general state of health, including dental health;
  2. Treatment and monitoring for identified health (including physical and emotional health) or dental care needs;
  3. Preventative measures such as immunisation;
  4. Screening for defects of vision or hearing; and advice and guidance on promoting the health and effective personal care.

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

5. Strengths and Difficulties Questionnaire

Local authorities are required to ensure a short behavioural screening questionnaire (SDQ) is completed on all the children whom they Look After between the ages of 4 and 16 years. SDQ's are completed at the time of the Health Assessment.

Requests for SDQ completion are sent to children / young people over 11 years, in addition to the child's carer and teacher. SDQ's are completed at IHA and repeated annually.

SDQ 's are scored by the LAC health team using the online tool SDQ Score website and recorded onto Liquidlogic.

Appendices

Appendix 1: Practice Guidance: Supporting Young People with HIV Testing and Prevention

Appendix 2: Information pack for social care-combined