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3.7.1 Health Needs Assessments and Individual Health Plans

SCOPE OF THIS CHAPTER

This guidance applies to all Children Looked After, and summarises the arrangements that should be made for the promotion, assessment, planning and actions regarding their health care.

This chapter should be read in conjunction with DfE and DHSC - Statutory guidance for local authorities, clinical commissioning groups and NHS England on Promoting the Health and Well being of Looked After Children (March, 2015)

See also 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)

AMENDMENT

In February 2019, a new Section 3.4, Consent to Health Needs Assessments was added to provide information on the circumstances when young people can consent to their own Health Needs Assessments and medical treatment.


Contents

1. The Responsibilities of Local Authorities and Clinical Commissioning Groups
2. Principles
3. Health Needs Assessments (HNA)
  3.1 Planning
  3.2 Frequency of Health Needs Assessments
  3.3 Arranging Health Needs Assessments
  3.4 Consent to Health Needs Assessments
  3.5 Merging Health Needs Assessments/Health Checks
  3.6 Black and minority ethnic children
  3.7 Children in secure settings and/or on remand
  3.8 UASC and Refugees
4. Individual Health Plans (IHP)
  4.1 Strength and Difficulty Questionnaires
  4.2 Out of Area Placements


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 Children Looked After, 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 Looked After needs to have a Health Needs Assessment so that an Individual 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 Needs Assessments and provide any necessary support services to Children Looked After 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.

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 well being.


2. Principles

  • Children Looked After should be able to participate in decisions about their health care 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 Child Looked After 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 Looked After 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 Needs Assessments (HNA)

The purpose of Health Needs Assessments (HNA) is to promote children's physical and mental health and to inform the child's Individual Health Plan.

3.1 Planning

Role of Social Worker in Promoting the Child’s Heath

The social worker has an important role in promoting the health and welfare of Children Looked After:

  • Working in partnership with parents and carers to contribute to the Individual Health Plan;
  • Ensure that necessary 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 while every effort will be made to contact those with Parental Responsibility this must never delay any necessary medical procedure. 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 3.4, Consent to Health Needs Assessments);
  • Ensure that any actions identified in the Individual 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, liaise with the Virtual School Head as necessary to ensure any adverse impacts are minimised for the child. (Should there be any delay in the child’s Individual 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 a 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 Looked After 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 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 Individual 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 Needs Assessments

Wherever possible, each child who becomes Looked After must have their first Health Needs Assessment completed within 28 days of first becoming Looked After - in time for the first Looked After Review (see also Looked After Reviews Procedure).

For children under 5 years, further Health Needs Assessments should occur at least once every 6 months.

For children aged 5 years and over, further Health Needs Assessments should occur at least annually.

These are a statutory requirement for all Children Looked After up to the age of 18 years.

If a child is transferred from one Looked After Placement to another, it is not necessary to plan a Health Needs 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 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 Arranging Health Needs Assessments

The social worker is responsible for ensuring that Health Needs Assessments are undertaken. They will be arranged by the child's social worker making a referral to the Administrator for the Health Team for CLA.

In order for the Health Needs Assessment to be conducted, the social worker must ensure that the consents section of the child's Placement Plan has been completed and signed by the parent. A copy of the health related section must be sent with the first request for an HNA. For all HNAs section A of the relevant CoramBAAF HNA form should be completed by the social worker and sent to the CLA Team Administrator.

Once notice of an appointment has been received, the social worker will inform the child, parents and staff/carer of the purpose of and arrangements for the Health Needs Assessment, and either accompany the child and parents or arrange for staff/carers to accompany the child, as appropriate. Carers have a responsibility to encourage and assist the child/young person to attend their assessment. Carers will be requested to complete a Strengths and Difficulties Questionnaire (SDQ; a STATUTORY assessment of the child's emotional health and well-being).

3.4 Consent to Health Needs Assessments

A valid consent will be necessary for a Health Needs 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.

The child should be encouraged to take advantage of the opportunity of the Health Needs Assessment to discuss health issues. Where the child/young person refuses a Health Needs Assessment, this must be recorded. There is DNA/Refusal Guidance in place. This states that a request for HNA should still be sent to the CLA Team Administrator when due indicating the young person's wishes. A Specialist CLA Nurse will then contact the young person to discuss this to ensure that an informed decision has been made. They will also have a discussion with the carer/social worker to ensure any unmet health needs or opportunities for health promotion are made available despite refusal.

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.)

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

3.5 Merging Health Needs Assessments/Health Checks

Some Children Looked After receive a great deal of health intervention, and it may therefore be appropriate to combine review Health Needs Assessments with other necessary health checks. For example, if a child has an Education, Health or Care Plan or when children are known to have complex medical needs and regularly attend hospital. A request for a HNA should still be made in the usual way. The Health Team for CLA will endeavour to avoid duplication of assessments and ensure that an Individual Health Plan is produced.

3.6 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 Needs Assessments to use the language in which they feel most confident.

3.7 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.

For further information the Child Health Team can be contacted.

3.8 UASC and Refugees

Unaccompanied asylum seeking children/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.


4. Individual Health Plans (IHP)

Each Child Looked After must have an Individual Health Plan in time for the first Looked After Review, with arrangements as necessary incorporated into the child's Placement Plan.

The Health Practitioner will draw up the child's Individual Health Plan based on the information in the Health Needs Assessment, in conjunction with the child, staff/carer (as appropriate), GP and any other relevant professional. The plan will then be passed to the child's social worker who will update the child's electronic records and arrange for copies to be sent to the child (depending on age), the parents and the staff/carers. A copy will also be sent by the CLA Team to GP and School Nurse/Health Visitor as appropriate.

Where the child expresses a wish not to disclose the contents of the Plan to their parents and this is accepted by the social worker (having regard to the child's age and understanding and after consultation with their manager), the parents will not receive a copy.

The child's social worker is responsible for ensuring that the actions from the Individual Health Plan are carried out and will do this with the assistance of the health professionals identified in the plan. The specific responsibilities of the staff/carers/others will also be identified in the Plan.

The Individual Health 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 ( including CAMHS) and/or any specific treatment, strategies or remedial programmes 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 activities which it is known or suspected the child is engaged in which may be harmful to the child's health and well-being, and the interventions/strategies to be adopted in reducing or preventing the behaviour. (This includes safeguarding issues, specifically Child Sexual Exploitation which Children Looked After are at an increased risk of. This is assessed and recorded on the Individual Health Plan. Other examples include substance / alcohol misuse, sexual activity);
  7. Whether there are any mental health/emotional wellbeing issues. Include the Strengths and Difficulties Questionnaire score, outcomes and any therapeutic support required for both the child and their carers;
  8. Identify any needs the carer may have in respect of their own professional development/awareness and/or to enable them to best support the child in their care.

This Individual Health Plan must be reviewed after each subsequent Health Needs Assessment or as circumstances change.

For advice regarding Health Needs Assessments or other health related issues contact the Health Team for Children Looked After via the Team Business Support on Tel: 0113 305 5156.

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.

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 Individual Health Plan.

(See Appendix B of the ‘DfE promoting the health and well-being of looked-after children’, Strengths and Difficulties Questionnaire.)

See also Strengths and Difficulties Questionnaire Procedure.

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 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 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.

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.

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