Health Care Assessments and Plans

1. Health Care Assessments

Many children who need to be accommodated or come into care of the Local Authority have been through adverse life experiences and may have missed out on routine child health surveillance. They are more likely to have unmet health needs, sometimes multiple and complex. These would include general health needs and deficiencies in areas such as dental care and preventative health care. Also there may be undetected problems with vision and hearing, as well as concerns about development and emotional and behavioural well being.

The purpose of statutory Health Assessments, which should include a Strengths and Difficulties Questionnaire, are to promote the child's physical and emotional wellbeing and to ensure that an individual Health Action Plan is formulated. Where a placement is made in an emergency, an Initial Health Assessment (IHA) must be completed as soon as possible and always within 20 working days. Social Workers must endeavour to promote compliance with health assessments with children and young people were engagement may be an issue.

An initial health assessment should provide an opportunity to engage children and young people in positive discussion about their current health and other health-related issues and concerns. It should provide a positive experience that will encourage children and young people to take their health seriously and reduce fears and anxieties about contact with health professionals. Considerations must be given to what are age appropriate in terms of consent issues, (see Section 1.8, Consent to Health Care Assessments) and the content of the health check. Younger children are expected to follow the advice on health matters of their parents, who have a responsibility to ensure they receive any necessary health care they require. Older children, particularly those over the age of 14, are regarded by health agencies as competent to make some choices about their health. It is important that information and advice is available for both groups of children to emphasise the importance of appropriate health care. 

Before the health assessment the social worker should discuss with the child/young person what they want to get from the health assessment, any particular issues which they want the opportunity to discuss and how that might affect who they want to be present. There may be a professional other than a doctor that they would prefer to see.

See also: Who Pays: Determining Which NHS Commissioner is Responsible for Commissioning Healthcare Services and Making Payments to Providers.

1.1 Frequency of Health Care Assessments

The Initial Health Assessment (IHA), must be completed before the child's first Looked After Review (unless the child has had a medical assessment within the preceding 3 months), each Child Looked After must have his or her IHA carried out by a registered medical practitioner. Social Workers must complete a CF31A and notify the Looked after Children Health Team that this has been completed prior to an IHA or and RHA.

Second and subsequent Review Health Assessments (RHA's) must be conducted by a suitably qualified practitioner (including school nurses or health visitors); who should provide the carers with a written Health Action Plan. The Looked after Children Health Team will ensure that the child/young person's individual Health Action Plan is uploaded to their electronic children's social care record on completion.

• The IHA must be conducted within 20 working days of the child first becoming Looked After - usually in time for the first Looked After Review;
• For children under age five years, an RHA must be completed every six months;
• For children aged over five years, an RHA must be completed 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 Individual Health Care Plan.

In no plan exists, the social worker should contact the Looked after Children Health Team to facilitate an assessment within a month of the placement so that a Health Action Plan can be formulated.

1.2 Who Carries Out Health Assessments?

The IHA must be conducted by a registered medical practitioner. Subsequent assessments (RHA's) may be carried out by a registered nurse or registered midwife under the supervision of a registered medical practitioner. The LAC Health Team will ensure that an individual Health Action Plan is created and uploaded to the child/young person's children's social care electronic record.

1.3 Arranging Health Care Assessments

The social worker is responsible for ensuring that Health Care Assessments are undertaken through liaison with the LAC Health Team. They must provide the LAC Health with a completed CF31A and contact details of the child's:

• GP;
• Health Visitor or School Nurse;
• Dentist;
• Hospital Doctor (Where Appropriate);
• Optician;
• School;
• Any other Health Professional (E.g. specialist, CYPMHS).

The social worker will inform the child, parents and staff/carer of the purpose of and arrangements for the Health Assessment, and accompany the child and parents (or arrange for staff/carers to accompany the child, as appropriate).

In order for the Health Assessment to be conducted, the social worker must ensure that the Consent section of the child's Placement Plan has been completed and signed by the parent or person with parental responsibility. Confirmation of this must be clarified in the CF31A.

Where the child refuses a health assessment, this must be recorded by appropriate practitioners and contained within their case record. The child should be encouraged to take advantage of the opportunity of the health assessment to discuss health issues and have them addressed appropriately.

1.4 Merging Health Care/Health Checks

Some Children Looked After receive a great deal of health intervention; it may therefore be appropriate to combine Review Health Care Assessments with other necessary health checks. For example, if a child has disabilities or an Education, Health and Care Plan or when children are known to have complex medical needs and regularly attend hospital, the medical information already available should be accepted as being the child's health record. In these circumstances, the child's social worker in conjunction with his or her Children's Social Care Manager can decide to record the dates of medical examinations as the dates of the child's Health Assessments. The reasons for this must also be recorded and shared with carers.

1.5 Black and minority ethnic children 

Black and minority ethnic children can suffer considerable health disadvantage.

They can be vulnerable to certain hereditary illnesses (e.g. sickle cell anaemia), can be predisposed to certain forms of diabetes, and there is evidence of high levels of depression amongst certain ethnic groups. It is important that:

• An accurate family history is taken;
• 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.

1.6 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.

1.7 Refugees

Unaccompanied refugee children are unlikely to have medical records from their country of origin, and any medical history they themselves give is likely to be incomplete. Their immunisation status may be unknown, and they may have had no previous health surveillance. Good interpretation services are likely to be necessary, and consideration should be given to seeking a link worker familiar with the child's culture and able to advocate on their behalf.

1.8 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.

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 Delegated Authority Procedure).

For further information on consent, see Department of Health and Social Care's Reference guide to consent for examination or treatment.

2. Health Action Plans

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

The practitioner completing the health assessment will draw up the child's Health Action Plan based on the information in the Health Assessment, in conjunction with the child, staff/carer (as appropriate), and any other relevant professional. The Health Action Plan will then be uploaded to the child/young person's children's social care record by the LAC Health Team and be available to the social worker and Independent Reviewing Officer (IRO). A copy of the health action plan should be given to the child/young person and their main carer by the practitioner completing the assessment. The practitioner will consider the age and understanding of the child/young person. The social worker should arrange for a copy of the health action plan to be provided to the parent of the child/young person if appropriate. Where the child expresses a wish not to disclose the contents of the health action plan to his or her parents and this is accepted by the social worker (having regard to the child's age and understanding), the parents will not receive a copy.

The child's social worker is responsible for implementing Health Action Plans for Children Looked After, and will do this with the assistance of the health professionals identified in the plan. The specific responsibilities of the staff/carers will also be identified in the Plan and agreed at a care planning meeting.

The Health Action Plan will set out how the health care needs of the child will be addressed, including the following matters:

1. Whether it is necessary for any immunisations to be carried out and if so, when;
2. When it is necessary for a dental check to be carried out;
3. When it is necessary for any hearing or vision checks to be carried out;
4. Whether there are any specific health care needs - and how they will be met, including future hospital appointments, referrals to specialist services and/or any specific treatment, strategies or remedial programme's required;
5. Whether there are any health or education issues to be addressed, for example, nutrition, sexual health and relationships, substance misuse, personal hygiene;
6. Whether there are any illegal or other activities including self harming which it is known or suspected the child is engaged in which may be harmful to the child's health, and the interventions/strategies to be adopted in reducing or preventing the behaviour.

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

See also Sexual Health and Relationships Procedure - to follow in relation to the provision of advice to children Looked After on sexual health, sexual relationships and contraception.

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