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RCGP Safeguarding toolkit

Part 2A: Identification of abuse and neglect

Looked-after children

A child who has been in the care of their local authority for more than 24 hours is known as a looked-after child. ‘Looked-after children’ is an official government term and is widely used among professionals along with the acronym ‘LAC’. However, children report that words like ‘unit’, ‘placement’, ‘contact’, ‘respite’ and the acronym ‘LAC’ (for looked-after children) created a sense of being different, exacerbated low self-esteem and made them feel stigmatised. Children and young people often prefer the term ‘children in care’.

Every UK nation has a slightly different definition of a looked-after child and its own legislation, policy and guidance.

In general, looked-after children are:

  • living with foster parents/carers
  • living with prospective adoptive parents (these children remain looked-after children until the adoption order is granted)
  • living with friends or relatives, through kinship foster care
  • living in a residential children's home
  • living in residential settings like schools, secure units or semi-independent living accommodation.

A child stops being 'looked-after' when they are adopted, return home or turn 18. However local authorities in all the nations of the UK are required to support children leaving care at 18 until they are at least 21. This may involve them continuing to live with their foster family.

Not all children in the care of someone other than their parents have ‘looked-after’ status. For example, they may be in private foster care or cared for under a special guardianship order.

Private fostering is an arrangement that is made privately (without the involvement of the local authority) for the care of a child under the age of 16 (under 18, if disabled) by someone other than a parent or close relative with the intention that it should last for 28 days or more. Private foster carers may be from the extended family such as a cousin or great aunt. However, a person who is a relative under the Children Act 1989 i.e. a grandparent, brother, sister, uncle or aunt (whether of full blood or half blood or by marriage) or stepparent will not be a private foster carer. A private foster carer may be a friend of the family, the parent of a friend of the child, or someone previously unknown to the child’s family who is willing to privately foster a child.

Privately fostered children are not looked-after children. The local authority should be notified if a professional becomes aware of a private fostering arrangement where they are not satisfied that the local authority have been, or will be, notified of the arrangement. The local authority have a duty to ensure that the welfare of the privately fostered child is satisfactorily safeguarding and promoted.

Anyone proposing to privately foster a child must notify the appropriate local authority of the proposal at least six weeks before the date on which the private fostering arrangement is to begin or immediately where the arrangement is to begin within six weeks.

Special guardianship is when a local authority places a child or young person to live with someone other than their parent(s) on a long-term basis. It aims to provide more security than long-term fostering for children where adoption is not the best option. Special guardianship orders are not available in Scotland.

Each child will have their own unique journey into care but the most common reason for becoming looked-after is abuse or neglect. Unaccompanied asylum-seeking children are also children in care. All children in care will have experienced trauma in some way.

Every child in care is a unique child with individual strengths and needs. However, the physical, emotional, and mental health of some looked-after children will have been compromised by neglect or abuse. Children in care:

  • have higher rates of mental health disorders
  • can experience frequent placement moves which can disrupt the support they receive, treatment plans and access to services
  • are at a greater risk of poor educational outcomes
  • have a higher prevalence of special educational needs
  • have a higher prevalence of speech, language and communication needs
  • are significantly over-represented in the criminal justice system.
Health assessments for looked-after children

When a child becomes a looked-after child, they undergo an initial health assessment (IHA). The IHA is a holistic assessment of physical and mental health needs, analysing and assessing past medical health, missed health problems and missed screening opportunities.

Children in care also subsequently have a review health assessment whilst they remain in care. These are every six months for children under five years old and annually for those over five and up to 18 years.

These assessments are completed by clinicians, such as paediatricians or nurses in Looked-After Children teams, with specialist training and are not done in general practice. However, general practice plays a vital role in sharing relevant information to the health professional undertaking the assessment and contributing to any actions required in general practice.

How can general practice support looked-after children?

General practice teams have a vital role in identifying the individual healthcare needs of children in care. GP practices should:

  • ensure timely access to a GP or other appropriate health professional when a child in care requires a consultation
  • provide summaries of the health history of a child who is in care, including information on immunisations and covering their family history where relevant and appropriate, and ensure that this information is passed promptly to health professionals undertaking health assessments
  • maintain a record of the health assessment and contribute to any necessary action within the health plan
  • make sure the GP-held clinical record for a child in care is maintained and updated and that health records are transferred quickly if the child registers with a new GP practice, such as when he or she moves into another area, leaves care or is adopted
  • avoid registering a child in care as a temporary resident as the medical record is not available to the treating clinician
  • be mindful of the particular challenges of parental proxy access to children’s online medical record when the child is in care and whether this should be revoked to ensure confidentiality of the placement and security of the child. (See the RCGP GP online services toolkit for more information.)

In addition, all practitioners working with children in care should be aware of the impact of trauma (including developmental trauma) and attachment difficulties and appropriate responses to these, to help them build positive relationships and communicate well.

Health assessments for prospective foster carers and adopters

This is another important area in which general practice plays a vital role. Fostering and adoption panels assess applications and make decisions on whether adults are suitable to be foster carers, kinship carers or adopters. Many children who are in the care system have a history of neglect and/or physical, sexual or emotional abuse and other adverse experiences. They are therefore likely to have a range of significant individual needs. Prospective adopters and carers must have robust physical and mental health to be able to parent these vulnerable children.

The panel make their assessments based on a wide range of information from different sources including a medical report from the prospective foster carer/adopter’s GP. Health information about prospective adopters or foster carers and its interpretation form only one part of the application and supervision process and will be set alongside other information obtained by the agency in considering the suitability of applicants. It is unusual for health issues to prevent approval as carers/parents. The information provided is also used to assist appropriate matching of carers and children. It is important that agencies satisfy themselves that applicants are able to meet the demands of parenting on a daily basis, and in the case of adoption and long-term placements, have a reasonable expectation of retaining good health to support children to adulthood.

Medical assessments are an important safeguard for both the adults and the children, and they are a statutory requirement in all four UK nations. Adults wishing to become foster carers or adopters are required by regulations to obtain a medical report during their applications process, and for foster carers at intervals during their fostering career their information needs to be updated. To ensure consistency of quality of information obtained across the UK, most adoption and fostering agencies use template documents that are produced by a professional membership organisation ‘CoramBAAF’ and this includes a standard report format to collate medical information including clinical assessment. A final decision cannot be made by the panel without a medical report being obtained and considered as part of the suitability assessment.

Care leavers

There are different definitions of a care leaver. Many young people prefer the term ‘care-experienced person’. The Care Leavers Association’s simple definition is: “any adult who has spent time in care”. The legal definition comes from the Children (Leaving Care) Act 2000 which is that the young person must have been in care for at least 13 weeks (or periods of time that add up to 13 weeks) since they reached 14, including sometime after their 16th birthday. There are specific services and support available from the local authority for those who qualify as a care leaver.

In all UK nations, children leaving care at 18 are entitled to support from their local authority until they are at least 21. Local authorities across the UK have a duty to assess and meet care leavers’ individual needs and to develop a pathway plan, setting out the support that will be provided to the care leaver once they have left care. This should include making sure the care leaver has somewhere suitable to live. In England, Wales and Northern Ireland, care leavers are also legally entitled to a personal adviser to help with the transition.

Outcomes for care leavers remain much worse than for their counterparts in the general population. There are five key issues that impact care leavers as set out in HM Government’s document: Keep on Caring. Supporting Young People from Care to Independence:

  1. Not being adequately prepared or supported to deal with the challenges of living independently.
  2. Barriers accessing education, employment and training.
  3. Lack of stability, safety and security.
  4. Difficulties in accessing the health support they need, in particular help to maintain their emotional health and well-being.
  5. Problems achieving financial stability.

Many of these issues are inter-related. Problems with money are often exacerbated by the fact that many care leavers are not in education, employment, or training (NEET). And the lack of a stable, safe place to live can impact negatively on a young person’s emotional health and put them at greater danger of a number of safeguarding risks, such as sexual exploitation or involvement with gangs. Care leavers also face the added challenge of having to cope with the demands of living on their own at a young age: having to manage finances, maintain a home and manage their lives independently, often without the support from families that most of us take for granted.

are leavers report particular challenges accessing adult services, especially adult mental health services. A third of young people leaving care report problems with drugs or alcohol a year later. A quarter of young women leaving care are pregnant, and nearly half become pregnant within 18 to 24 months.

How can general practice support care leavers?

Please read The Care Leavers’ Association booklet: 45 Care Leaver Friendly Ways. 

This is a short guide on how to work with adolescent looked-after children and care leavers. This booklet has been created by care leavers who were involved in the Care Leavers’ Association health project. It is in their own words wherever possible. They share what would have made a difference to them now and when they were in care as a child. It is also punctuated by statistics on outcomes for care leavers so that professionals can understand how growing up in care can affect an individual for their entire life.

References