Best practice in providing health checks for looked-after children

Some areas are leading the way when it comes to providing health checks for looked-after children, reports Joe Lepper

Children in any situation can find health checks uncomfortable, but for looked-after children, many of whom may have been abused, they can seem especially intrusive.

This means the process must be managed sensitively by local authorities, who are assessed by government on the proportion of children in their care who have received annual health checks. But improving uptake can prove challenging, says John Simmonds, policy, research and development director at the British Association for Adoption and Fostering, because young people in care don’t want to feel stigmatised by health checks, which they have the right to refuse.

Dr Roger Morgan, Ofsted’s children’s rights director, also warns that young people he has surveyed “were telling us that the doctor or nurse would ask them questions, tick their boxes and not give them a chance to talk about issues that they want advice on such as nutrition”.

To address these issues, Hammersmith and Fulham Council set up a dedicated nurse service for looked-after children 10 years ago, and its performance has improved dramatically – from a 62% uptake of annunal health assessments in 2000 to 98% in 2008, one of the best in England.


Central to this has been the involvement of looked-after children and care leavers in shaping the service, as well as a flexible attitude from nurses, particularly towards the 60% of the council’s 261 looked-after children who live outside its boundaries.

“Truro, Darlington, London – it doesn’t matter to us where our children in care are placed, we will give them health checks,” says Lin Graham-Ray, Hammersmith and Fulham’s nurse consultant for looked-after-children. Her three-strong nurse team meets regularly with focus groups of pre-school and school-age children in care. The nurses also run everything, “even a change of letterhead”, past an expert care leaver, says Graham-Ray, “to make sure we are communicating in the best way with children in care”.

Following feedback from children, the council’s promotional materials also focus “much more on how health assessments can lead to happier lives”, she says.

Bridging divides

Graham-Ray’s role is jointly funded by the council and Hammersmith and Fulham Primary Care Trust, but she is based in the council’s children’s services team. She says this structure helps to bridge divides between health and social care.

In one case, the two agencies worked together to help a 12-year-old boy in care who had behaviour issues but also a surprising skill in the gymnastics discipline of baton twirling. Together they secured a grant for his training by focusing on the way baton twirling can improve health and well-being.

Andrew Christie, director of children’s services at Hammersmith and Fulham Council and Association of Directors of Children’s Services policy lead on fostering and adoption, says other councils should follow the route taken by his authority.

“Looked-after children receive the best health service from a dedicated nurse specialist who works closely with the children’s carers and social workers. In the past, significant health issues sometimes went undiagnosed and untreated. We can now stop that from happening.”

Assessment framework

Under the performance assessment framework, councils in England are measured only on uptake of annual health checks, not on the quality of assessments. The average for uptake in England in 2008 was 86.5%, with North East Lincolnshire, North Lincolnshire, Rutland, Wokingham and Poole councils achieving 100%, but North Yorkshire and York only managing 63%.

Some councils have gone as far as offering financial incentives to young people to improve uptake. But Lucy Sweetman, senior projects manager at the National Care Advisory Service, questions whether this conveys the importance of health to young people. “I would hope that as a corporate parent an authority would not need to resort to that,” she adds.

Voice, an advocacy charity for children in care, would prefer to see councils improve continuity of care and communication with young people. Policy adviser Wendy Banks says: “Some children have felt pressured to have these checks without anyone telling them why they were needed. Some had the reverse and were just given a list of local GPs and told to get on with it. It is no wonder uptake is so low in many areas.”

Act as advocates

Meanwhile, Ofsted’s Morgan says social workers need to do more to “act as an advocate” for young people, and ensure professionals are taking their views into account.

“Children’s services are in a tough position,” he says. “On one hand children in care are among those most in need of health services, but on the other hand they don’t want to be treated differently.”

Hannah Smith, the designated nurse for looked-after-children in Calderdale, believes children services in the area are well on the way to achieving this dual aim of offering extra health support for children in care without singling them out.

She has been involved in plans to transform part of the Brighouse Health Centre into a specialist young person’s clinic during 2009. It is already used by looked-after-children for health checks, but the aim is for it to be used by all young people.

Brighouse is working towards the Department of Health’s You’re Welcome accreditation, a quality benchmark to show services are “young people friendly”, and Smith hopes this will attract more services, such as drugs, alcohol and sexual health advice, to the centre.


Young people in care were involved in creating the decor and layout at Brighouse, which has separate waiting areas for older and younger children. They also scrutinise health assessments through a questionnaire that has been checked by Calderdale Council’s young inspectors.

This emphasis on consultation at Brighouse appears to have already had a positive effect; the council achieved a 90% uptake for annual health assessments for 2009, compared with 82% in 2008.

“By making the health assessment process better and the clinic more welcoming it is no surprise that those figures have gone up,” adds Smith.

What do you think about health assessments for children in care? Have your say 

Case study

SALLY Care leaver, 20

‘I like the idea of better continuity of care’

was in care for eight years and had seven placements. Each time I moved placement I had to have a health check with my GP. I was glad this happened but there are definitely things that could have been done differently.

“I like the idea of having better continuity of care, having a nurse who I know and see regularly to talk about my health. For example, I was in care when I started having periods. I didn’t know what was going on and it would have been good to have someone like a nurse who I could talk to about that.

“Perhaps more could be done between health checks. Having someone like a nurse who rings up from time to time would have been good. One example was a health problem I had involving bruising on my legs. This was checked out, but it took a while. Eventually I was diagnosed with a blood condition. Perhaps this could have been spotted sooner if someone was pushing on my behalf to get things done.

“I would have liked to have seen more information about health issues as well, especially on healthy eating. For a lot of children in care, particularly with foster carers, there is an issue with the quality of food provided. Access to cooking courses and nutrition advice would help both carers and those being cared for.”

Key points on health checks

● The uptake of annual health assessments for looked-after children became an indicator related to health outcomes in 2000.

● The latest statutory guidance on health assessments, 2009’s Promoting the Health and Well-Being of Looked-After Children, stipulates that health assessments must be undertaken twice a year for children under five years, and annually for those aged five and over.

● This also outlines the core issues to be addressed in the check: the child’s current physical, emotional and mental health, health history, vaccination information, and ensuring eye and hearing tests have been carried out.

● Information gathered is fed into each looked-after child’s health plan. Councils must ensure that every looked-after child has a health plan laying out detailed courses of treatment and how health problems highlighted in the annual health check will be addressed.

● The health plan is shared with the young person’s carer, and children in care have the same access to their health records as children not in care.

● Uptake of the annual health assessment and whether a dental check has been carried out are jointly measured through a performance assessment framework indicator.

Guidance from

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