LAC Health Care 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 which 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;
• 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 Children and Young People's Mental Health Services (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 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 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 (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 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: 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 3.5, Consent to Health Care Assessments);
• Ensuring that any actions identified in the Health Plan (recommendations) 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, liaising 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 (recommendations) 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 ensure 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 Children and Young People's Mental Health Services (CYPMHS);
• Ensuring the child has a copy of their health assessment.

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 which 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 Looked After Child must have a Health Assessments at specified intervals as set out below:

• Fostering best practice all assessments should be completed within no later than 20 working days of a child becoming looked after in time for child's first Looked After Review);
• 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.

In the event that a child moves from a placement to another, it is not necessary to plan another assessment. In these circumstances, the allocated social worker should provide the foster carer/residential staff with a updated copy of the child's Health Plan. If the foster carer has a date for the health assessment in the future the new foster carer should be informed of the date.

3.3 Who carries out Health Assessments?

The first Health Care Assessments must be conducted by the a registered medical practitioner in accordance with the Children Act 1989, but a registered GP may complete these if child is placed outside of the borough they usually reside. Subsequent assessments will be carried out by an appropriately qualified registered nurse/midwife who will provide the allocated social worker with a written report (see Section 3.4, Arranging Health Care Assessments).

3.4 Arranging Health Care Assessments

On day 1 of the child or young person being accommodated the social worker should provide the LAC Nurse/administrator with the following information via email:

• Name, DOB, Gender, Next of Kin names and addresses, in or out of borough, GP (if known), Name and Address of Foster Carer and Contact numbers, What order the child is on, If an interpreter is required;
• Brief reason for reason why child has come into care.

On receipt of this information the LAC Nurse Admin will complete the IHA Form (Part A) and send by secure email along with information of the reason why child has become LAC to the Community Paediatrician's Admin for appointment to be booked.

In order for the Health Assessment to be carried out, the allocated social worker must ensure that the parent(s) have given consent and that the LAC paperwork confirming this consent has been signed by those with Parental Responsibility.

The health professional conducting the assessment will complete a relevant CoramBAAF Form and a Health Plan(recommendations), which should be passed to the allocated social worker - who should give copies to foster carers/residential staff, birth parents and young person if appropriate.

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.

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 Procedure).

For further information on consent, see Department of Health and Social Care Reference Guide to Consent for Examination or Treatment.

4. Health Plans and Recommendations

Each Looked After Child's Care Plan should incorporate the recommendations from the Health Assessment within 20 days and to be incorporated in the first Looked After Review, with arrangements as necessary outlined in the child's Placement Plan/Placement Information Record.

These recommendations should form part of the plan and be reviewed after each subsequent Health Assessment and at the child's Looked After Review or as circumstances change for the child so it is an accurate record of their health needs, as a looked after child.

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

4.1 Strength and Difficulty Questionnaires

Evidence suggests that Children in Care are nearly 5 times more likely to have mental health issues than children who are not in care. In order to address this, the government requires local authorities to report annually on the emotional health and wellbeing of Children in Care and provides guidance on how their emotional health needs can be better identified in order to improve the timeliness and relevance of referrals to Children and Young People's Mental Health Services (CYPMHS) and other services.

The screening tool used to do this is the 'Strengths and Difficulties Questionnaire'. The questionnaire has five sections that cover details of emotional difficulties, conduct problems, hyperactivity or inattention, friendships and peer groups and pro-social behaviour.

Who should carry out the questionnaire?

The questionnaire should be completed for all looked after children aged between 4 and 16 years (inclusive). The questionnaire will be sent out to all those being asked to complete it by the social work team 6 weeks prior to the Review Health Assessment, in order that it is completed, returned, scored and forwarded to the LAC Health Team in time to form part of the assessment.

For the Carers form, the main carer must complete the questionnaire - for most children this will be their foster carer.

• For children and young people in residential care or semi independent accommodation the questionnaire must be completed by their key worker or equivalent (as agreed with the child's social worker);
• If the child or young person has changed placements during the previous year the child's social worker should determine who is best placed to complete the questionnaire.

For the Teachers form the form should be completed by the Designated Teacher for Looked After Children, in conjunction with the child's Class Teacher, Personal Tutor or Year Head.

For the Young Person's form the questionnaire should be completed by the young person with support from their social worker if desired.

Completing the questionnaire

The Business Support Officer in the Social Work Team will initiate the process by sending the questionnaire to all relevant people. The questionnaire should be accompanied by a letter explaining what is required and the timescale for completion.

The questionnaire provides a number of statements and a judgement must be made by the person completing the form by ticking one of the three/four boxes. If the person completing the form feels unable to decide on a judgement then they should consult with the child's Social Worker.

The process should be carried out with the child's full knowledge. The child's Social Worker should meet with the child to discuss the process and agree who will be involved. If the child does not agree with the questionnaire being completed then this should be evidenced on the form as the reason for a nil return.

Actions following completion of the questionnaire

Once the questionnaire has been completed it should be returned to the child's Social Worker. Following this a number of actions should be completed:

• The Social Worker will score the answers given on each of the questionnaires submitted;
• The carers score should be collected by the Social Work Team Business Support Officer as this will be used to support the annual statutory return to the DfE;
• Once the scoring exercise is completed the outcome information should be shared with the LAC Health Team and the Independent Reviewing Officer;
• The LAC Health Team will include the scores into the Review Health Assessment form and the use the information provided to focus on emotional health in the RHA as appropriate;
• The Independent Reviewing Officer will use the score to ensure that the emotional wellbeing of the child/young person is considered as part of the LAC Review process;
• The Social Worker will review the scores, and if a Total Difficulties average score across all formats places it in the High of Very High category (i.e.17 or more) a consultation appointment with the Children and Young People's Mental Health Services (CYPMHS) CSC Team should be arranged. To support the consultation a chronology and contextual information should also be made available. If the score for any of the variants of the questionnaire places it in the Slightly Raised category the Social Worker should consider whether a Children and Young People's Mental Health Services (CYPMHS) consultation appointment should be requested;
• Any actions taken should be recorded on the children's social care record and used to review and update the care plan.

CAPTION: four band categorisation table

	Newer Four-band Categorisation (2014)
	Close to Average	Slightly Raised	High	Very High
Carer Total Difficulties Score	0-13	14-16	17-19	20-40
Teacher Total Difficulties Score	0-11	12-15	16-18	19-40
Young Person Total Difficulties Score	0-14	15-17	18-19	20-40

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).

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 (as amended) make it a requirement that the responsible authority consults with the area of placement and that the 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. 

5. Initial Health Care Assessments for Looked After Children (Flowchart)

Click here to view Initial Health Care Assessments for Looked After Children (Flowchart).

See also Appendix 1: LAC Flowchart: Merton Initial Health Assessments.

6. Social Worker Guidance for Initial and Review Health Care Assessments from LAC Nurse

Initial Health Assessments

When a child or young person is admitted to care, either with an order, or with Section 20 arrangements in place:

• The social worker responsible for taking the child in to care should email the LAC Nurse and administrator informing them of the reason for coming into care, Name, DOB, Gender, Next of Kin names and addresses, in or out of borough, GP (if known), Name and Address of Foster Carer and Contact numbers, What order the child is on, If an interpreter is required;
• Brief reason for reason why child has come into care.

Administrators in the team will generate a trigger informing the relevant people that the child has become 'Looked After' at this point the IHA Form should be generated with as much information on as possible about the child hopefully including the child current GP details. This form is subsequently emailed to the Specialist Nurse for Looked After Children's administrator. The IHA form, CoramBAAF Consent to Share Information, PH forms, and Signed Placement Agreement should be sent to the Community paediatric Dept by the LAC Nurse administrator.

Administrators from the relevant team should collate consent and information as follows within 7 working days of the child becoming 'looked after':

1. Placement Agreement & Essential Information 1 (Social Workers generate and should hand completed and signed forms both back to LAC Nurse or team administrator);
2. CoramBAAF IHA Form (Generated by Admin, checked for information pulling through and given to social workers to obtain signatures from person with PR on consent section, if child over 14 years child should sign consent also). Return to admin;
3. CoramBAAF Consent to share information Form (Generated by Admin and given to Social Worker to obtain signatures from parents. Ideally this form would include a parent's signature (or other person having 'Parental Responsibility) for MB part of the process. Child can sign if they are competent of giving their own consent. Should be returned to Admin);
4. CoramBAAF PH Forms x 2 (Generated by Admin, given to Social Worker for Parents to complete their own health information. This should be returned to Admin);
5. MB Forms - required for children under 14 years. (Generated by originating team admin and then passed to LAC Team Admin for sending to hospital child was born along with standard letter and signed CoramBAAF Consent to share Information Form).

Alternatively, if the child is on an ICO and social workers have made at least 2 attempts to obtain parental consent, but parents are not engaging, a letter can be signed by the relevant Head of Service giving consent to carry out the Initial Health Assessment.

Signed CoramBAAF Consent, Signed IHA, Completed Essential Information 1, Signed Placement Agreement Forms and Completed PH Forms should then be scanned onto SMART to enable the LAC Nurse to email information to Community Paediatric Dept.

The Foster Carer will then be contacted by the administrator for Community Paediatrics to arrange a mutually agreeable appointment. Community paeds will then inform the LAC Nurse admin of the date who will inform the social worker. Wherever possible, social workers should invite the birth parents if they feel there are no risks.

All children and young people regardless of age should be accompanied to their health assessment by their carer and/or social worker.

The Initial Health Assessment should take place 20 working days after the child/young person is admitted to care.

Following this assessment, sections A and C are scanned onto SMART and the health plan (recommendations) should be used to inform the Care Plan of health needs. The date of the IHA added to the social care information system and the LAC Spreadsheet.

Review Health Assessments

Designated Nurse for Looked after Children is responsible for deciding who is best placed to carry out the Review Health Assessment. In the majority of cases where the child is in a stable placement and attending a school in borough the assessment will be completed by the school nurse/health visitor. If the child is in college or placed out of borough then the LAC nurse will complete the assessment. The Designated Doctor will sometimes see children with the plan for adoption or if concerns were identified in the previous health assessment.

Review health assessment forms are generated centrally by the LAC administrators and the Specialist Nurse for Looked After Children. Social Workers are notified once they are completed. Annex forms and 'update medical information' forms are sent to carers for completion by the LAC administrators.

RHA forms are emailed to the Community Paediatric administrator at least 2 month in advance of the required date. RHA forms are emailed to the appropriate School Nurses or Health Visitors preferably 2 months prior to the required date. If an out of borough assessment is required either the Specialist Nurse for LAC will carry this out or the LAC Nurse for the appropriate area can be approached and a health assessment requested in conjunction with approval from the ICB for funding. Requests can be sent via 'Special Delivery post' to the appropriate person or via an NHS.net secure email account, this is all done by the Specialist Nurse for Looked After Children or her administrator.

Details of when the last health assessment took place are recorded on the social care information system and a spreadsheet kept by the LAC Nurse and LAC administrators.

Children under the age of five years must have a health assessment every 6 months. For children placed in Merton, Community Paediatricians or Health Visitors will normally carry out this assessment depending on the future permanence plan and if they have any medical concerns. Children placed out of Merton will also be seen usually by the Health Visitor or if need be their GP.

Children over the age of 5 years must have an annual health assessment. For children living in Merton and attending local schools, this will normally be carried out by the school nurse. For young people aged 16-18 years that are not at a school with a 6th Form facility they will be seen by the Specialist Nurse For LAC. Children living out of the area will usually be seen by the Specialist Nurse for LAC or at times if thought more appropriate will be seen by the local LAC Nurse or School Nurse. At times especially with Children with Disabilities the local GP will be asked to see.

Parts A and C of the RHA will be scanned onto SMART, and the date of the assessment added to the social care information system. Original paper copies of the whole assessment are kept on file by the LAC Nurse.

Appendix 1: LAC Flowchart: Merton Initial Health Assessments

Click here to view Appendix 1: LAC Flowchart: Merton Initial Health Assessments.