SCIE/NICE recommendations on looked after children: Promoting the quality of life of looked-after children and young people

Health assessments, records and information

Evidence indicates that accurate and up-to-date personal health information has significant implications for the immediate and future wellbeing of children and young people during their time in care and afterwards. Understanding their own ‘health history’ is an essential part of growing up securely. Inconsistent record keeping can lead to wrong decisions by professionals and adversely affect the child or young person.

Recommendation 20 Assess the health needs of looked-after children and young people

Who should take action?

• Commissioners and providers of health services.
• Social work managers.

• What action should they take? Open

  • Ensure that all looked-after children and young people have their physical, emotional and mental health needs assessed by appropriately trained professionals according to ‘Statutory guidance on promoting the health and well-being of looked after children'(12).
  • Local authorities should make notifications about looked-after children and young people who are placed out of the authority's area or across NHS commissioning boundaries in good time and in accordance with the statutory guidance(12).

Recommendation 21 Share health information and ensure consent is obtained

Who should take action?

• Social work managers.
• All service providers including independent and voluntary sector providers.
• All primary and secondary healthcare providers (including CAMHS and adult mental health services).

• What action should they take? Open

  • Consider introducing a protocol into information-sharing processes that addresses legal and confidentiality issues, to assist information flows between health and social care.
  • Ensure that healthcare professionals share health information with social workers and other professionals.
  • Ensure that there is a process for social workers to obtain consent for statutory health assessments, routine screenings and immunisations.
  • Ensure social workers obtain permission to access the child or young person’s neonatal and early health information.
  • Ensure social workers obtain permission to access information on parental health, including obstetric health.
  • Ensure that parental or delegated consent is given to healthcare professionals when they are scheduled to carry out a medical or surgical procedure on any looked-after child or young person.
  • Ensure that a system is in place to monitor, and address failure to obtain, permission or consent for health matters.
  • Ensure that any health information is collected and shared in a sensitive and professional manner. Ensure health information is incorporated into relevant assessments and shared with healthcare professionals, as appropriate.
  • Ensure that physical and emotional health information, and consent for medical procedures, including mental health interventions, follows the child or young person. This may include deciding with partner agencies how hand-held (paper) records can stay with the child or young person.
  • Ensure that early health information is available to enhance life-story work with the child or young person when they are ready (see also recommendations 24, 25 and 48) or to help them make informed decisions when they are ready to start their own family.

Recommendation 22 Update the personal health record (red book) and ensure this follows the child or young person

Who should take action?

• Social work managers.
• Commissioners and providers of health services.

• What action should they take? Open

  • Ask social workers to ensure that the personal health record (red book) follows the child or young person up to the age of 18.
  • Ensure that if the original personal health record is lost or unavailable a new one is provided, and when it is reissued it should include as much information as possible; the issuer will need to look back and incorporate historic information.
  • Share all information obtained from parents and other sources to help complete the reissued record, and if birth parents are unwilling to give up the original personal health record, ensure social workers work with them to relinquish it temporarily to enable information to be copied.
  • Ensure that early health information is obtained, including obstetric and neonatal health information, on all children or young people entering care.
  • Ensure there is a clear process to reissue the personal health record to all new carers for children or young people in their care. Ensure that a contact person is identified to manage the administration of the personal health record.

Recommendation 23 Share information from assessments for court processes

Who should take action?

• Social work managers.

• What action should they take? Open

  Ensure that when assessments are commissioned for court processes, permission from the court is obtained to share this information with health professionals who carry out statutory assessments or advise on health needs.

12.

Department for Children, Schools and Families and Department of Health (2009) Statutory guidance on promoting the health and well-being of looked after children. London: Department for Children, Schools and Families.