Cared for Children and Young People’s Health

Children and young people who are in care are frequently reported in government research, policy, and guidance to have higher levels of health needs than their peers, and these are often met less successfully – leading to poorer outcomes. They can have significantly more prevalent and more serious emotional and mental health needs (with problems arising from poverty, abuse, neglect, or trauma). They need to receive care in a setting that actively promotes their health and well-being facilitated by their carers and all professionals involved.

Legislation and policy guidance covering aspects of the factors directly affecting the health and well-being of children and young people in care includes:

• Every Child Matters Agenda highlighted the need for Councils to look more closely at models of integrated working and how a range of services can be delivered in local areas at one access point;
• Children Act 2004 and Adoption and Children Act 2002;
• Private Fostering Agreement Regulations 2005;
• The Children (Leaving Care) Act 2000 specifies that health considerations should form an integral part of pathway planning (DHSC 2001);
• The Care Standards Act 2000 places a duty on Care Homes to promote and protect the health of children;
• Care Planning, Placement and Case Review (England) Regulations 2010 provide that child's Care Plan must incorporate a Health Plan in time for the first Looked After Review;
• Legal Aid Sentencing and Punishment of Offenders Act 2012 extends the category of children considered as Children Looked After;
• Department for Education Statutory Guidance on Adoption 2013;
• Department of Health Statutory Guidance 2015. Promoting the Health and Wellbeing of Children in care.
• Mental Capacity Act 2005.

To achieve effective continuity of health services, all agencies involved in caring for children and young people should ensure that personnel at all levels of their organisations understand the implications of this procedure and what is required of them to put it into practice. All health services must be familiar with the Intercollegiate guidance: Looked after children: Roles and competencies of health care staff- December 2020 (RCN).

Children and young people will be provided with the knowledge and information to enable them to make informed choices in relation to their health and will be supported in accessing services that can help them. The capacity of the child or young person should be considered when making informed choices. If the child is aged 16 years or over, the principles of the Mental Capacity Act 2005 should be considered.

The local authority, through its Corporate Parenting responsibilities, has a duty to promote the welfare of Cared For Children, including those who are Eligible and those children living in adoptive placements. This includes promoting the child's physical, emotional and mental health; every Cared For 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 Cared for 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 that 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 well being. In Westmorland and Furness, this is shared by local authorities to the ICB commissioned Children in Care health team who have delegated functions on behalf of the ICB.

• Cared For 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, residential and supported accommodation 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 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 Cared For 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 cared for, or moves into another ICB area, any treatment or service should be continued uninterrupted;
• A cared for Child requiring health services should be able to do so without delay or any wait should 'be no longer than a child in a local area with an equivalent need';
• A cared for 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.

Good Health Assessment and Planning- NHS

NHS Practitioners have an important role to play in the identification of the health care needs of children and young people in care. They often have prior knowledge of the child, birth parents and carer, helping them to take a holistic and child-centred approach to health care decisions.

Roles and responsibilities of the Integrated Care Board (ICB)

• Ensure that the health and well-being of Children and Young People in Care, is an identified local priority;
• Ensure that structures are in place to plan, manage and monitor the delivery of health care for all Children in Care;
• Ensure that clinical governance and audit arrangements are in place to assure the quality of Health Assessments and Health Planning;
• Ensure that there is a named public health professional, who will input into children in need issues, including child protection, as necessary. Children in Care are part of this wider group of children in need;
• Identify a Designated Professional (doctor and nurse) to provide strategic leadership and advice in relation to the health needs of Children in Care;
• Where a child is placed “out of authority”, ensure systems are in place to provide continuity of the Health Assessment and planning process;
• Through the commissioning process ensure that Children in Care are registered with GP's and dentists near to where the child is living;
• When Children in Care need to register with a new GP (e.g., when they enter care or change placement), ensure systems are in place to “fast track” the GP held clinical and dental records;
• Ensure systems are in place through the commissioning process to make sure that Children in Care are not disadvantaged when they move from one ICB to another, i.e., NHS waiting lists;
• Ensure that arrangements are in place for the transition from child to adult health services;
• Ensure that an appropriate data set is collected and reviewed annually.

Roles and Responsibilities of the Children in Care Health Team

• The Children in Care health team consists of Specialist Nurse Practitioners, who have responsibility for the co-ordination of health needs of Children in Care and Care Leavers up to the age of 25 years. Key Responsibilities include:
• Co-ordination and facilitation of all Initial Health Assessment (IHA);
• Co-ordination, facilitation and conduct of Review Health Assessments (RHA);
• Quality assurance of Health Assessments using a standardised tool and in-depth auditing of Health Assessments;
• Advisory role for foster carers, social workers, personal advisors and other professionals regarding health needs of children in care and Care Leavers;
• Attendance at multi-agency safeguarding meetings, strategy discussions/meetings, statutory Children in Care Reviews;
• Supporting the wider safeguarding agenda;
• Attending multi-disciplinary meetings for Children in Care and Care Leavers with complex needs;
• Quarterly/annual reporting to commissioners;
• Review and updating health processes in line with government guidelines/ legislation;
• Participation in child safeguarding practice reviews (CSPR) and other learning reviews where applicable for Children in Care;
• Offering bespoke training sessions to professionals and foster carers who are involved with Children in Care and Care Leavers;
• Health advice and support to care leavers to support them to navigate health services and care;
• Co-ordination of the Leaving Care Summary of health letter.

Role of Social Worker in Promoting the Child's Health

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

• 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: 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;
• 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 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, 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 CYPMHS (Children, Young People Mental Health Services);
• Social workers should attend the Initial Health Assessment to support the early identification of health needs and ensuring that the appropriate support is in place as social workers hold significant information about the child's and family history. Also, social workers have a key role alongside carers to ensure that children and young people have a good understanding of what is likely to happen at the Health Assessment;
• Arrange for an interpreter to be available for the Health Assessment appointment, if required;
• Ensuring the child has a copy of their Health Plan where this is appropriate.

It is important that at the point of a child becoming cared for, 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.

Roles and Responsibilities of the Foster Carer/Residential Worker/Worker in supported/semi-independent accommodation

• Ensure that the Child in Care is registered with a local GP and Dentist;
• Keep an accurate and dated record of all health issues and treatment relating to the Child in Care and ensure this record along with any health concerns the carer may have in respect of the child are presented at statutory reviews;
• Proactively ensure the child or young person is enabled to attend health appointments and clinics, to attend with the child or young person unless agreed unnecessary and provide the health professional with any relevant information in respect of physical and emotional well-being, including behaviour;
• Keep the Social Worker informed of any health and dental issues relating to the Child in Care and ongoing health appointments e.g., GP attendances and statutory Health Assessments;
• Involve children and young people in discussions and decisions regarding their health care in accordance with their age, understanding and in consultation with the child’s social worker, including issues around eating, hygiene, alcohol, drugs, and sexual health;
• Promote healthy living home environments and health awareness for all children and young people in our care and encourage the child in age-appropriate personal responsibility for own health and hygiene;
• Encourage children and young people to participate in leisure activities, hobbies, and sport. These should be tailored to the needs of the individual, including those with special needs, seeking the advice and support of their supervising social worker where necessary;
• Provide nutritionally balanced meals with young people being encouraged to eat a varied and healthy diet. They should be encouraged to participate in the planning, purchase, and preparation of food to gain an understanding and appreciation of healthy eating;
• Participate in the development of Health Plans for children and young people, monitoring and initiating any required action. Encouraging and supporting contact and communication with the child or young person’s family, appropriately, as agreed in Care Plans;
• Keep self-up to date on relevant issues important to the needs of Children in Care, e.g., through active participation in knowledge and skill development opportunities, supervision, training, etc.

Roles and Responsibilities of the Independent Reviewing Officer: 

• The Independent Reviewing Officer’s role is to review the care plan for all Children in Care, which will include the health component of the child/young person's care plan. As part of the review process the Independent Reviewing Officer will ensure the views of the child/young person is sought and considered within the review process. These views can be shared directly by the child/young person or by other means including direct work tools, Mind of my Own or an advocate;
• Ensure that there is an up-to-date Health Plan, SDQ and dental check and that this informs the looked after review process;
• If a young person in our care does not wish to have their statutory health assessment, then guidance should be offered, and an understanding explored as to the young person's views. They should be signposted to alternative advice and support in relation to their general health and welfare via their Lead Health professional (Children in Care Nurse or School Nurse. Within the review process the Independent Reviewing Officer will check that this position still stands regarding the young person in relation to having their Health Assessments and that their health needs are being addressed;
• Monitor the effectiveness of Health Plans for children and young people who are in care through the review process and Independent Reviewing Officers case monitoring;
• If the health needs of a child or young person in our care is not being appropriately met, the Independent Reviewing Officer will address this through the looked after review process and case monitoring and ensure that any issues are escalated appropriately;
• Promote the health and welfare of children and young people in our care by ensuring that they are provided with enough information to guide them and support them in making informed choices and taking responsibility for their own health needs in the future;
• Ensure that at the final review, before a young person reaches 18 years old, that the young person understands their entitlement to a Leaving Care Health Summary, have a completed health summary or plans are in place to have this completed and to confirm whether the young person consents to their Personal Advisor to hold a copy of the health summary to be shared with relevant professionals for continued support and future reference.

Each cared for Child's Care Plan must incorporate a Health Plan in time for the first Cared for 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 Cared For Review or as circumstances change.

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

Overview

We complete SDQs for all our children and young people in care. They are used to assess and track the emotional, behavioural, and social needs of our children. They are another tool in our toolbox to screen, assess and review the emotional wellbeing of our children and young people.

The questionnaire is broken into five areas;

1. Emotional needs;
2. Conduct needs;
3. Hyperactivity/inattention;
4. Friendship and peer group needs;
5. Pro-Social behaviours and strengths.

As Corporate Parents for our children and young person it is essential we are all working together to continuously assess, review and plan according to the child’s presenting needs. The SDQ should not replace any other processes and knowledge of the child and their strengths and difficulties. An SDQ is another tool to use. The scores should be reviewed and discussed at multi-agency meetings and the responsibility of any delegated actions as well as timescales should be added to the child’s Care Plan.

It is important to note, the SDQ can be completed at any time if there are concerns regarding emotional health and wellbeing of a child in our care. This will help measure the impact of the support in place to reduce any high SDQ score and should be agreed and reviewed as part of multi-agency care planning.

Who needs an SDQ

All children between the age of 4 and 18 who are cared for by the Local Authority require a yearly SDQ.

Children with severe or profound disabilities

For children with a severe or profound disability consideration needs to be given to whether completion of an SDQ will result in a false score and therefore, an incorrect assessment of the child's emotional wellbeing.

In these instances when a child is open to the Children with Disabilities team, if it is not appropriate to complete an SDQ due to a child's disability, the Team Manager should complete management oversight stating that it is not possible to complete the questionnaire due to severity of the child's disabilities ". This should be done within 3 months of the child becoming cared for and yearly thereafter.

When a child has a disability that is not considered severe or profound, the usual process is to be followed.

SDQ Process

Initial SDQs

It is the role of the allocated worker to initiate the process by asking the child/young person’s carers and education provider to complete a copy of the relevant SDQ questionnaire within 3 months of the child or young person becoming cared for. The checklists are found in the appendices at the end of the guidance document. 

It is the role of the allocated worker to undertake the questionnaire with the child/young person as direct work during their visits.

When the allocated worker has collected the questionnaires, they are to return them to the business support team who will score the questionnaires using the computer software package that they have been trained in. They will add the overall score to ICS in the Strengths and Difficulties tab.

For children and young people placed within Westmorland and Furness footprint

For all children and young people placed within Westmorland and Furness, the SDQs will be undertaken by the CLA health team as part of the review health assessment (RHA). They will score and send them to Business Support who will upload the score to ICS and allocated worker will be emailed with the score. It is then the role of the social worker to progress the support required depending on the score outcomes. 

For children and young people placed outside of Westmorland and Furness footprint

For children and young people placed out of county and for many unaccompanied minors, the allocated worker will need to complete the SDQ with carers and young people yearly and request one from school. Once they have all three questionnaires these can be scored by the Business Support Team and uploaded to ICS.

Care Experienced young people

Where a pathway advisor has worries around a young person and their emotional wellbeing, they will be able to complete a post 18 strengths and difficulties questionnaire following the same process.

Scores, Offer and Actions

Scaling the questionnaires – Outcomes

Overall stress score is based on:

Overall stress score 0 – 13 is close to average (low),

Overall stress score 14 – 16 is slightly raised (medium),

Overall stress score 17 – 19 is high,

Overall stress score 20 – 40 is very high.

Score for the impact of any difficulties on the child's life 4 (3 - 6 is VERY HIGH)

Overall stress scores graded as ‘low’ to ‘medium’ or ‘high’ to ‘very high’ will help to screen for different types of Emotional Health and Wellbeing support (see table below).

Once the questionnaires have been scored and scoring added to ICS, allocated workers should follow the following actions;

Action

Where the score is Low or Medium and there are concerns about a child’s emotional health and wellbeing the allocated worker can email EHWBSouth@Cumberland.gov.uk  to request ‘Help – goals based targeted support’ from the emotional wellbeing team.

• Where the score is High or Very High the allocated worker should email the ICS number to ehwbsouth@cumberland.gov.uk and request an AMBIT session for ‘Risk management and crisis support’ purposes;
• If EHWB and the child’s allocated worker agree that a child does not need to access EHWB for Help, or Risk Management and crisis support, this will be recorded on ICS by EHWB as ‘information and advice’ being provided instead;
• Click on The Emotional Health and Wellbeing Team (padlet.com) for more information on SDQ, Help, and Risk Management and Crisis support;
• The emotional Wellbeing Team will record the outcome on ICS;
• Team manager should record a management oversight of the agreed actions to support the child/young person

Guidance and Process

The need for children in care to have access to and attend a dentist for routine assessments near to where they are living is a shared responsibility between the NHS and local authority as part of their corporate parenting responsibilities. All Local Authorities have a statutory duty to record each time a child or young person has visited the dentist; this information is collated and forms part of our key indicators requested by the DFE.

Process

Placement Planning Meeting

Upon the child moving to a new placement, the Social worker should have ascertained if the child is registered with a dentist. If they are able to remain at their current dentist this is preferred, however this discussion should take place at the Placement Planning meeting to ensure that the child is registered with a dentist be it their current one, or if placed at a distance that is unmanageable, arrangements should be made for the Foster Carer to register them. If the child or young person is under orthodontic treatment then the social worker must also notify the orthodontic team of their new address so their care can be transferred. It is especially important that children and young people with braces are under dental review.

Looked After Reviews

The Independent Reviewing Officer (IRO) should ensure that the child’s health, including their dental health is reviewed at least every 12 months within the Looked After Review, and any actions set accordingly. The details in relation to oral/dental health and required treatment or monitoring of any identified oral/dental care needs should also be documented as well as dates of any appointments, that have taken place within the review period should be recorded within the Review Minutes.

Statutory Visits

During statutory visits to see the child or young person, the social worker is expected to ask about the child and young person’s health including any dental appointments they may have attended, any details in relation to their oral/dental health and required treatment or monitoring of any identified oral/dental care needs. These details should be noted within the statutory visit case note using the agreed template.

Recording of Checks

When a Child or Young Person have not been seen by a dentist in 12 months, an LCS dental alert is generated, this will be re assigned into the social workers tray by the Business Support Team.

Once the Social Worker has received the alert, the social worker should establish the date of the child or young person’s last dental check up.

• On LCS this could be found within;
• The most recent Review Health Assessment (RHA).

For all children and young people placed within Westmorland and Furness, the dental checks will be recorded by the CLA health team as part of the review health assessment (RHA). It is the duty of the social worker to check the RHA for the date and add the Dental Check to LCS accordingly.

For children and young people placed outside of the Local Authority, the check may not be recorded. It is the social worker’s responsibility to check the RHA for the date and add it to LCS accordingly.

• Within statutory visit case notes;
• Within the minutes from the most recent Looked After Review.

Once the date has been established this should be added to LCS in the Health section under Dental Checks.

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 Health Plan are not disrupted through delay as a result of the move.  In Lancashire and South Cumbria this should be communicated via Local Authorities to the Children in Care health teams.

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.

Confidentiality

To plan effectively and meet the needs of Children in Care, it will be necessary to share confidential information between carers, educationalists, health professionals and social care staff. All those providing a service to Children in Care should be aware that the approach to confidential information should be the same, whether it is within your own organisation or an external agency or individual.

The sharing of this information should be guided by a balanced view based on certain good practice principles. Clearly the need to know should be measured against the rights of the child. The principles of the Data Protection Act and the Caldicott Principles help provide this balance. For further information please see: The Eight Caldicott Principles.

All confidential issues should only be shared on a need-to-know basis. All written health information about a child or young person should only be shared with consent from the relevant parties, including the young person depending on their age and level of understanding.

For Further information:

• Promoting the Health and Well Being of Looked After Children (DfE / DHSC 2015) gives guidance on consent and confidentiality issues;
• Information sharing - Advice for Practitioners Providing Safeguarding Services to Children, Young People, Parents and Carers - DfE July 2018;
• General Medical Council (GMC) - 0- 18 years; Principles of Confidentiality;
• What to do if you’re worried a child is being abused: Advice for Practitioners offers guidance on Information sharing, Duty of Confidence, Confidentiality and Consent, referencing the Human Rights Act (1998) and Data Protection Act (2018).