Health Care Assessments and Health Plans
SCOPE OF THIS CHAPTER
This procedure applies to all Looked After Children. Children remanded other than on bail will be Looked After Children. Different provisions will apply In relation to those children/young people - see Remands to Local Authority Accommodation or to Youth Detention Accommodation Procedure, Care Planning for Young People on Remand or Youth Detention Accommodation.
This procedure summarises the arrangements that should be made for the promotion, assessment and planning of health care for Looked After Children.
This chapter should be read in conjunction with DfE and DHSC Statutory Guidance on Promoting the Health and Well-being of Looked After Children (March 2015).
RELEVANT GUIDANCEBritish Medical Association Consent Toolkit
AMENDMENTIn September 2018, a new Section 3.5, Consent to Health Care Assessments was added.
1. The Responsibilities of Local Authorities and Clinical Commissioning Groups
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 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 Looked After Children 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 which 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.
Both Local Authority and relevant CCG(s) should develop effective communications and understandings between each other as part of being able to promote children's wellbeing.
- 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 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 CCG 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 CCG, e.g. where the child is placed in an out of Authority Placement, the 'originating CCG' remains responsible for the health services that might be commissioned.
3. Health Care Assessments
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 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 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 CAMHS;
- Ensuring the child has a copy of their health plan.
Each Looked After Child must have a Health Care 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 Care 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 Care Assessments should occur at least once every six months;
- For children aged over five years, further Health Care 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 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.Section 3.4, Arranging Health Care Assessments).
The social worker should liaise with the carer/residential staff to arrange the first assessment with the Named Nurse for Looked After Children.
Before a Health Assessment takes place, social workers must complete Part A of the CoramBAAF 'Initial Health Assessment Form' 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 Record/Initial Health Assessment Form at the point of becoming Looked After.
The health professional conducting the assessment will complete a relevant CoramBAAF Form and a Health Plan, which should be passed to the child's social worker - who should give copies to carers/residential staff.
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.For further information on consent, see Department of Health and Social Care (DHSC) and Social Care Reference Guide to Consent for Examination or Treatment.
4. Health Plans
Each Looked After 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/Placement Information Record.
This plan must be reviewed after each subsequent Health Care Assessment and at the child's Looked After Review or as circumstances change.
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.
From April 2008 all local authorities in England have been required to provide information on the emotional and behavioural health of children and young people in their care. These data are collected by local authorities through a Strengths and Difficulties Questionnaire (SDQ) and a summary figure for each child (the total difficulties score) is submitted to the Department for Education through the SSDA903 data return.
Whilst we are required to submit this return, the advantage of using the SDQ is that it can provide an indication that children and young people require additional, and sometimes specialist, support and therefore it is an important tool to use in our ongoing assessment of a child's needs.
Statutory guidance on promoting the health and well-being of looked after children issued under Section 7 of the Local Authority Social Services Act 1970 sets out that all local authorities are required (paragraph 9.11.2) to make sure that a strengths and difficulties questionnaire (SDQ) is completed for each of their looked after children aged between 4-16 inclusive. Paragraph 9.11.3 of the guidance states how this should be embedded into the child's annual health assessment.
Evidence suggests that mental health problems are over four times more likely for looked after children compared to their peers. This data item covers the emotional and behavioural health of children looked after, as recorded by a main carer in the strengths and difficulties questionnaire (SDQ). It is an important screening tool in helping identify children and young people who may require additional support.
The information is required for all children and young people who have been looked after continuously for at least 12 months on 31 March and who were aged between 4 years old and 16 years old (inclusive) on the date of the last assessment therefore, children aged between 4 years and 16 years 364 days at the time of their last assessment will be included.
What is the strengths and difficulties questionnaire (SDQ)?
The SDQ is a screening tool to assess whether the child or young person has, or may develop, emotional or behavioural difficulties, and consists of a short behavioural screening questionnaire. It has five sections that cover details of emotional difficulties; conduct problems; hyperactivity or inattention; friendships and peer groups; and also positive behaviour, plus an "impact supplement" to assist in the prediction of emotional health problems. The SDQ has been internationally validated and is appropriate for all black, minority and ethnic (BME) groups. Alternative language versions of the SDQ can be downloaded from www.sdqinfo.com.
Placements outside Walsall local authority area
Walsall is required to ensure that all children looked after receive a Health Assessment including completion of the SDQ in line with statutory requirements, irrespective of the area in which the child or young person lives.
Completing the SDQ
In Walsall we have adopted the use of the following from the suite of SDQ tools:
- P4-17 - SDQ and impact supplement for the parents of 4-17 year olds;
- T4-17 - SDQ and impact supplement for the teachers of 4-17 year olds;
- S11-17 - SDQ and impact supplement for self-completion by 11-17 year olds.
The SDQ and impact supplement for the parents of 4-17 year olds should be completed by the child/young person's foster carer or residential worker; where required or requested the foster carers supervising social worker or the Registered Manager should provide support. It must be completed annually at an appropriate time to form part of the child/young person's Health Assessment.
It is the responsibility of the Supervising Social Worker to ensure that carers feel confident about completing the questionnaire. Where the questionnaire is completed by a residential carer the Registered Manager should ensure that the carer feels confident about completing the questionnaire. The supervising Social Worker/Registered Manager should therefore:
- Explain what the questionnaire is for and why it is important for them to complete it;
- Check that they understand what they need to do;
- Explain that it is important to be honest in their assessments and that the SDQ is a screening tool to help the child and is not an assessment of or reflection of how well they care for the child;
- Make sure the carer knows the child well enough to be able to give meaningful insights in responding to questions (for children who have changed carers during the course of the year, the social worker should assess which carer is best placed to complete the SDQ);
- Agree a date for completion of the questionnaire with them.
Whilst the primary carer SDQ does not require input from the child or young person involved, the expectation is that where appropriate it is undertaken with the involvement of the young person, or at least with their knowledge.
Requests for the Primary Carer and the School to complete SDQ's will be generated and sent centrally in good time for the outcome of the questionnaire to inform the Child/Young person's annual health assessment.
Although the results from the Teachers SDQ do not feed into the statutory return if the SDQ completed by the carer suggests that the child's total difficulties score is outside the normal range (i.e. a borderline score of 14-16 or a score of 17+, considered as giving cause for concern), the child may benefit from triangulating the scores from the carer's SDQ with those of his or her teacher and (if he or she is aged 4 to 17) the self-evaluation.
Where children and young people are aged between 11-17 there is a self reporting questionnaire for self completion by children and young people within the age range. These can be used to improve our understanding of the child's needs and in particular help us find out how the child or young person feels about his or her own emotional wellbeing. It is important that the child or young person feels supported to complete the questionnaire and as such the child's social worker should take the document out to the young person, talk through it with them and determine if they need any help and support in completing and returning it.
Once completed, the SDQ's are scored. The 'Total Difficulties' Score is generated by totalling the scores of the emotional symptoms, conduct problems, hyperactivity and peer problems sub-scores; it does not include the pro-social score and this is not included in the calculation. The score for each of the four relevant sub-score domains (five questions in each) should be generated first before generating the Total Difficulties Score. This is a score of 0 to 40, where a low score under 14 is considered normal and a score of 14 to 16 is borderline.
A score of 17 or over will give cause for concern and should be used as an indicator to explore with CAMHS the child's needs and presenting factors.
Where an SDQ score is 17 or more the child's social worker should hold a consultation with CAMHS to determine if a CAMHA referral and a fuller diagnostic assessment is the most appropriate way forward in meeting the child's needs. This consultation must be clearly recorded on the child's record and should be clear about the actions agreed as a result of the consultation.
The focus should always remain on the individuality of the child and the presenting factors. Consultation should take into account the individual dimensions of the SDQ to determine if the scores correspond to events in the child's life or placement and whether there have been any particular circumstances or events that may have contributed to the score. This will allow decisions about next steps and interventions to be based on the child's emotional and mental health needs.
For young people whose score is borderline (i.e. 14 to 16), consideration should be given to encouraging them to seek support from other sources. For Walsall children these can include:
- FLASH ~ a service working directly with carers to reduce the risk of placement instability and the subsequent risk of placement disruption by supporting the child and carers to ensure the child remains in placement, mitigating the need for the child to move into another placement. The service is available for children and young people up to the age of 18 and across a 20mile footprint outside Walsall Contact:
Tel: 01922 607400
- Kooth ~ an online counselling and advice service offering a 24 hour source of help for 11 to 25 year olds, which allows young people to get in touch for help through web chat, email, and booked one to one chat sessions. Kooth have counsellors who have been specially trained and follow BACP (British Association of Counselling & Psychotherapy) guidelines and code of ethics.
Self referrals can be made via their website www.kooth.com
- WPH (Walsall Psychological Help) ~ offer face to face counselling, family work and Triple P parenting groups. There are multiple referral routes including self referral and other professionals. The service is available 9.30 to 5 Monday to Friday with a late night to 8.30 on Tuesday.
55 Upper Forster Street
Where there are particular concerns a discussion with CAMHS may also be useful in determining how a child's emotional health needs might best be met.
The completed suite of questionnaires along with the results is kept on the child's/young person's electronic social care record. A copy of the SDQ and the resulting score is also sent to the Health Co-ordinator/Designated Nurse for Looked after Children to make sure it is considered as an aspect of the child or young person's annual health assessment.
When decisions about placement choices are being made and where changes of placement occur, social workers, working in partnership with health professionals, should consider referral to FLASH and for specialist mental health assessment and treatment where it is appropriate. The SDQ should help inform these decisions and professionals should ensure this information is shared securely and appropriately where changes of placements happen.
All questionnaires and the scoring instructions can be downloaded from www.sdqinfo.com.
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 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 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.