SCOPE OF THIS CHAPTER
This procedure applies to all Children in Care; It summarises the arrangements that should be made for the promotion, assessment and planning of health care for Children in Care.
This chapter should be read in conjunction with Promoting the health and well-being of looked-after children - Statutory Guidance for Local Authorities, Clinical Commissioning Groups and NHS England (March 2015) and Remands to Local Authority Accommodation or to Youth Detention Accommodation Procedure.
See also 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) and Aftercare under Section 117 of the Mental Health Act Procedure.
Who Pays? Determining which NHS commissioner is responsible for making payment to a provider
Derby City Council uses a Strengths Based Approach for all work with children and families.
- The Responsibilities of Local Authorities and Clinical Commissioning Groups
- Health Assessments
- Health Plans
- Appendix 1: Complex Cases Panel Referral Form
- Appendix 2: SDQ Pathway
1. The Responsibilities of Local Authorities and Clinical Commissioning Groups
Derby City Council, 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 Assessment so that a Health Plan can be developed to reflect their health needs and included as part of the child's overall Care Plan.
Derby and Derbyshire Clinical Commissioning Group (CCG) 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 in Care without any undue delay and irrespective of whether the placement of the child is an emergency, short term or in another CCG. This also includes services to a child or young person experiencing mental illness.
The local authority should always advise the CCG when a child is initially accommodated. Where there is a change in placement that will require the involvement of another CCG, the child's 'originating' CCG, outgoing (if different for the originating CCG) and new CCG should be informed in line with the East Midlands Protocol.
Both the local authority and relevant CCG(s) should develop effective communications and understandings between each other as part of being able to promote children's well being.
- 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;
- That others involved with the child, their 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);
- When a child becomes a Child in Care, or moves into another CCG 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 Child in Care should always be registered with a GP, Dentist and Optician 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 CCG, e.g. where the child is placed in an out of authority / out of area Placement, (see Out of Area Placements) the 'originating CCG '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
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;
- Ensuring that consents and permissions with regard to delegated authorities are obtained to avoid any delay. Note: That while every effort will be made to contact those with Parental Responsibility, 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);
- 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, the social worker should, where necessary, 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 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 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 carers 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 where appropriate that the child has a copy of their Health Plan. (At the child's final review this should always be provided).
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. It is also vital to obtain information about parental and/or family health information, to ensure any relevant information is available for the child in the future or when required in the best interest for the child. 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 in Care must have a Health Assessment at specified intervals as set out below.
- Statutory Guidance requires that the first Health Assessment be completed within 28 days of the child or young person first becoming looked after;
- For children under 5 years, further Health Assessments should occur at least once every 6 months;
- For children aged over 5 years, further Health Assessments should occur at least annually.
If a child is transferred from one Looked After Placement to another, it is not necessary to plan an assessment within the first month. In these circumstances, the social worker should furnish the carer/residential staff with a copy of the child's existing Health Care 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.
3.3 Who carries out Health Assessments?
The first Health Assessment must be conducted by a registered medical practitioner / paediatrician. Subsequent assessments may be carried out by a registered nurse or registered practitioner, who should provide the social worker with a written report and Health Care Plan (see Section 3.4, Arranging Health Assessments).
3.4 Arranging Health Assessments
The social worker should contact the Children in Care Health team as soon as the child comes in to care and liaise with the carer/residential staff to arrange the first assessment with the Children in Care paediatrician. Subsequent Health Assessments are carried out for all children by CiC nurses in the city and within a 20-30 mile radius. For those children placed out of area, the CiC health team liaises with hosting Health Provider to arrange an assessment according to their local arrangements, with the support of the CCG.
Before a Health Assessment takes place, social workers must fully complete the Consent Form, Parental History and ensure there is clear consent to obtain health history for the child and parents (where possible), to ensure it is available at the time of the appointment.
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 Information Plan / Initial Health Assessment Form at the point of becoming Looked After. Where a Care Order is in place, evidence of this and the local authority consent will suffice and a confirmatory letter should be sent to the CiC Health team when the Order is made.
The health professional conducting the assessment will complete a relevant Initial Health Assessment documentation and a develop Health Plan in conjunction with the child, carer, which should be passed to the child's social worker - who should give copies to the child's carer and the child's GP.Workers should give appropriate consideration to whether there is a requirement for an interpreter to be present, and arrange accordingly.
See also Leaving Care and Transition Procedure.
3.5 Consent to Health Assessments
A valid consent will be necessary for a Health 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. Upon a child or young person coming into care, enduring consent is obtained but should be reviewed when the young person is deemed competent, have mental capacity to make their decisions.
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.
4. Health Plans
Each child's Care Plan must incorporate a Health Plan in time for the first Looked After Review, with arrangements as necessary incorporated into the child's Placement Plan.
The Health Care Plan and any actions should be reviewed after each subsequent Health Assessment and at the child's Looked After Review or as circumstances change.
4.1 Strength and Difficulty Questionnaires
Understanding a 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, of 5years and over, before a child has been in care for 12 months. The timing should coincide with the closest Health Assessment.
The SDQ, 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. It is therefore encouraged that the SDQ should be completed prior to the Health assessment, so that this can inform the assessment more robustly. It should be completed by the child's foster carer or residential worker, supported by the fostering support worker, and in consultation with the child's social worker. Support and services for the child should then be identified as required.
4.2 Out of Area Placements
Where an Out of Authority placement is sought, Derby City Council 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 CCG, the current CCG (if different) and the proposed area's CCG 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 [updated] 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 (see also Out of Area Placements Procedure).
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; and arrangements for this can be discussed at the joint Health and Social Care Complex Needs Panel. Click here to view Appendix 1: Complex Cases Panel Referral Form.