Examination of Witnesses (Questions 180-199)
HELEN CHAMBERS,
SUE DUNSTALL,
DR RITA
HARRIS AND
DR CATHERINE
M. HILL
28 APRIL 2008
Q180 Mrs Hodgson: When a child or
young person enters care, I understand that there must be a health
assessment within 14 days. We have received written evidence,
and we have also heard evidence, of the complexity of these children's
physical and mental health needs. The statistics are staggering
in that 66% of them have at least one physical complaint, while
45% have some form of mental health problem. Three quarters of
that 45% will also have at least one physical disorder; the problem
is complex. My first question is whether the current system of
health assessments for children entering care is fit for purpose.
Sue Dunstall: No, I do not think
so. In fact, the current assessment process is perilously poor,
particularly in its inconsistency. I am sure that there are areas
where health assessments are conducted excellently and with rigour,
but such action is taken with tremendous inconsistency throughout
the country. It is simply not acceptable that a child or young
person who is assessed as requiring x or y service in one borough
would be assessed entirely differently in the adjoining borough.
That is not an acceptable way to treat children. My sense is very
much that because there are particular expectations surrounding
the attainment of physical health issues, such as immunisation
and dental checks, there is tremendous focus on physical health,
while the assessment of mental health, particularly emotional
well-being, is parlously poorly looked at. That is one of the
reasons why the NSPCC has been fighting extremely hard in respect
of the Children and Young Persons Bill to get the assessment process
undertaken with considerably more rigour than at present.
Q181 Chairman: Can I butt in here?
Is there a parallel between that and the assessment of a child
for special education needs? When the previous Committee looked
at the matter, it made the criticism that the people who were
assessing were very close to the people who had to provide the
resources that came out of the assessment. Is that one of the
inhibitors? Is there a parallel in that, yes, you have to assess,
but you have to provide the resources to fund what the assessment
suggests?
Helen Chambers: I am not aware
of that. Cathy might contribute more, but my understanding is
that health services are commissioned, so the doctor or nurse
who does the health assessment should be able to say what the
health needs of the child are. That should feed a health plan,
and the health plan should feed into the care plan. When a child
is placed—unfortunately, on occasions, that might be out
of the local authority or borough area—the needs of that
child will be met in that placement. How services are commissioned
and what services are in place is then the responsibility of the
child health commissioner in the placing PCT. In a sense, what
the doctor or nurse says is needed will reflect back to what can
be provided. I am not aware of how that difficulty is sometimes
resolved. It is not necessarily that the doctor or nurse is aware
of the budget, but actually what the assets can provide.
Chairman: Sorry, I butted in.
Q182 Mrs Hodgson: As for not being
fit for purpose, we heard from Catherine about the extremely skilled
senior consultant nurses with experience. Where has this fallen
down? Is it an issue of co-ordination? I have read evidence about
co-ordination and how it often falls to social workers operating
outside the NHS. If the assessment is not fit for purpose, where
has it fallen down? Whose responsibility is it, and is it working
properly?
Dr Harris: May I say something
about the gaps. One of the things that I am aware of being lacking
in health assessments is the psychological needs of the child.
While some paediatricians and doctors are well equipped to do
that sort of assessment, not all of them are. A lot of early psychological
difficulties are overlooked because the health assessment is not
holistic enough. I do not think that it is as broad as it could
be. I suppose one of the difficulties is that the children's services
commissioning and the CAMHS commissioning often come through separate
streams and are not necessarily joined up. So, the gap is probably
more with regard to emotional well-being and looking at psychological
difficulties than with physical health. I do not know if that
is fair, but my experience is that it is more variable in that
domain than in physical health.
Dr Hill: Can I just clarify? I
am sensing a bit of a message, or perhaps a misinterpretation
of a message, around the health assessment being ineffective.
I have heard—I am looking for verification—that it
is not to do with it being ineffective, but with quality being
variable. That comes back to fundamental training, support and
funding of competent practitioners.
Dr Harris: It is the delivery
that is ineffective.
Dr Hill: I think that is correct.
I do not want to paraphrase anyone, but the issue about emotional
health and well-being is critical—both the assessment of
and provision for. A project in which we at BAAF have been engaged
over the past year is to develop tools for that very thing. The
tool is called the Carers report, which is about to go to press
in the next month or so. It is designed, for the about two thirds
of local authorities that are using the system, to be a part of
the initial—and every—health assessment. The group
that developed this comprised our representative from the Royal
College of Psychiatrists, as well as a lead advocate within the
clinical psychology group for looked-after children. This was
very much a multidisciplinary development model. It was piloted
in the field and we had feedback from foster carers, social workers
and practitioners as to how it worked. It is designed to do that
very thing: improving the practitioner's ability to screen front-end
emotional and behavioural problems—I think it is a gap;
Rita is absolutely right. Given the nature of the seniority and
expertise of many of the people in the field, if that could be
duplicated and replicated across the country, and appropriate
training and competencies could be assured, tools like this would
be a very good way of screening these children. Then, of course,
you have the much more vexed issue of provision of support. I
am sure that other people at this table have a lot more to say
on that. Certainly, from my personal practice locally, CAMHS is
often very reactive. It is often good at meeting the needs of
children who present the most overt problem: the children with
conduct disorders—typically children who sit on the roof
at school, throw furniture around, or are very overt with their
problems. It is not as good, necessarily, at responding to the
sad, withdrawn child with more internalised problems. I hear from
my clinical psychology colleagues—I am sure that we will
have a lot more to say about this—that they are very frustrated
about their inability to do long-term work with these children.
They would dearly love to do long-term remedial work, but they
simply do not have the time and resources. That seems to be a
big deficit, but there are people here who are more expert than
me in that area who I am sure would like to comment.
Q183 Mrs Hodgson: So, this is picking
up on the delivery more than the assessment. Are we all going
to agree on that?
Helen Chambers: I think it is
the planning as well. Something can be assessed, but there must
be follow-through into the health plan and then into its monitoring,
particularly when a child is placed out of the local authority—that
is a really significant issue. There is an understanding that
health requires more than health professionals to be working,
which is why it must be integrated into the care plan. As colleagues
are saying, it is very difficult for child and adolescent mental
health services to provide adequate services as things are. The
four tier CAMHS structure means that foster carers and residential
social workers are not identified as being part of the children's
work force at tier 1 of provision. I think that it would be very
helpful if they were, and if training was put in place at that
multi-professional end of the work, but other services will be
needed to support the health needs of looked-after children, carrying
through from assessment into planning and monitoring and, a year
later, assessing how things have changed. I know that that is
the importance of the regular health assessment, but the issue
is also how health needs may be met in terms of reports going
to the independent reviewing officer, who will look at the child's
care on a yearly basis. There is very patchy practice in that
way, too.
Q184 Mrs Hodgson: I understand that
the guidance is that PCTs are supposed to give looked-after children
timely access to services, and they are supposed to give local
priority to looked-after children and to put structures in place
to manage and monitor their health. Do you think that PCTs are
not giving enough emphasis and importance to the guidance?
Helen Chambers: Again, performance
is patchy. Saying that would genuinely not do justice to some
excellent local authorities across the country, but I really feel
that the health of looked-after children falls between the high
demands that health services, including public health services,
have on their time and resources, and that the DCSF or directors
of children's services have. The health of looked-after children
is everybody's business, but actually it is nobody's business.
Dr Harris: One of the things that
I have observed is how much more effective it is to have dedicated
CAMHS services for looked-after children rather than to expect
them to fall into the general melee of a CAMHS referral. There
is a lot to be said for protecting specialists for work with such
children. They would understand their needs and be able to work
with them over a longer period of time. I want to echo what Helen
said about the breadth of the professionals who look after children's
health. Often, a child might prefer to see a youth worker rather
than a CAMHS professional about some mental health issue, or they
might want to go to a location other than the health location.
If one were to use what are, despite the growth in such services
of late, rather small CAMHS resources and to be able to use that
work force to help train, develop and support a much broader work
force, it would be much more likely that some of those things
would be thought of. Often, people do not recognise mental health
need until it is overt: when children act up, are difficult, or
whatever—the ones on the school roof, for example. It is
the quiet, withdrawn, compliant little girl about whom everyone
says, "Oh, isn't she good?", who will probably become
a depressed and acting-out adult who will deliberately self-harm
or have other serious psychological difficulties.
Q185 Mrs Hodgson: I would like to
change tack slightly for my last question. Rita mentioned things
falling through the gaps. One of the things that I worry will
fall through the gaps is health promotion, especially in respect
of sexual health. Another category of statistics that I looked
at show a higher prevalence of teenage conception and pregnancies
among 15 to 17-year-old looked-after children as opposed to those
who are not looked-after children. What more could be done? I
know that carers must be willing to enter into sex education,
or that it is often done in schools, but children might miss out
if they are moving schools.
Helen Chambers: I would be happy
to comment on that. We often focus on sex education, but it is
sex and relationships education. One way we learn about relationships
is through our experience. Of course, some of our children come
from a background of abuse and neglect, so their whole experience
of relationships is really poor. How they are cared for by their
everyday carer and what is modelled in their environment of care
is one of the ways in which they understand more about relationships—almost
through osmosis. Also, the relationships that they see around
them between the social worker and the foster carer, and the respectful
negotiation of what is wanted, are important. I sometimes say
that if you cannot choose whether to have salad or cabbage, how
can you choose whether to have sex, particularly if you have been
abused by somebody who gave you no choice? Working in sexual and
relationships education brought me into working on the health
of looked-after children. A leaving care manager once said to
me, "When they make a public service agreement to achieve
a curriculum appropriate for a girl who knows that her mother
prefers a schedule 1 sex offender to her, I will understand something
about sex education." There is an issue about not only how
looked-after children have frequently missed school—I am
sure that that will change—but what is appropriate, good
sexual and relationships education for looked-after children.
In a sense, we must let them know that they can enjoy positive
and happy sexual health and happy relationships, despite what
might have happened to them in the past. Our foster carers and
social workers need to feel much more supported and to know how
to handle such situations. I sometimes need to work with foster
carers coming to a panel for selection. Often people say, "Oh,
I would talk to my social worker if I was asked about sex by a
looked-after child." If you watch EastEnders in the
evening, you might hear a young person, as our own children do,
ask potentially embarrassing questions. In such situations, foster
carers need to know—and probably have rehearsed—the
answers. The Family Planning Association and the NCB have worked
together on "Making it Happen" training for foster carers.
I was part of a multi-agency group convened by the teenage pregnancy
unit to look at guidance for foster carers. Good policy and guidance
are important, but it is difficult to actually make it happen,
especially in hung local authority governments. Condoms, sex education
for abused children and so on are very difficult and sensitive
issues for local authorities to take on board.
Chairman: We shall move on to mental
health because, in a sense, we have been moving on to the quality
and sophistication of health assessments and advice that is given.
Do you want to take us through that, John?
Q186 Mr Heppell: In some respects,
we can be more specific and deal with CAMHS, rather than health
generally. There seems to have been a failure to access children's
services, some of which seems to have been due to assessment,
and some the lack of provision. How difficult is it for looked-after
children to access services, and why and how does that vary in
different parts of the country?
Chairman: Who wants to take that?
Sue Dunstall: I shall.
Chairman: You share out these questions
very well—like a good trade union.
Dr Harris: It is teamwork.
Sue Dunstall: As I said at the
beginning, about 60% of children are in care for reasons of abuse
and neglect. We also know that about 45% of those in care, which
equates to about 27,000 children, have some sort of mental or
emotional disorder. In fact, the most recent figures from CAMHS
tell us that about 10,000 children in care receive the service,
which does not sound too bad, until you put it the other way around
and consider that it actually means that 17,000 children did not
receive it. I am not clear—[Interruption.]
Chairman: There is a Division in the
House, which means that we shall suspend the sitting until we
are quorate again.
Sitting suspended for a Division in the House.
On resuming—
Q187 Mr Heppell: To follow up that
question—I thought that it had not been answered—and
accepting that it will be more difficult for these people to access
services than the general population, we have given priority in
school admission, so that is an extra in terms of education. What
would be the barriers to doing something similar in health—recognising
that some people have less access and giving them extra priority?
I am referring to mental health services.
Chairman: You are all aware that admissions
policy in education prioritises selection of looked-after children—not
that all schools take notice.
Dr Harris: Yes, and there is the
rub. I suppose that the short answer is yes. In the same way that
looked-after children are given priority for school admission,
they should be given priority for the health services that they
need. Mental health services would need to be protected and fully
funded, because one problem with giving someone priority is that
the services need to be available to meet that need. I think that
what we have been talking about is the variety of services that
are available, and whether they are dedicated to this population
or are part of a wider, more general remit. My short answer is
that I would welcome that.
Helen Chambers: Yes, and there
are some excellent services that support foster carers and residential
social workers in dealing with what is ordinary adolescent behaviour
or ordinary behaviour when a child has experienced trauma. In
that way, they can greatly help placement stability. I think that
expertise grows with looked-after children in those designated
CAMHS. I was wondering whether we have sufficient CAMHS staff
to meet the needs of looked-after children if they were prioritised.
I would be delighted with that, and colleagues may have the figures.
In theory, prioritising looked-after children within CAMHS would
be great.
Sue Dunstall: I just want to be
clear that for me, this is not just about CAMHS; it is about a
much greater diversity of provision that goes well beyond CAMHS
provision. It is about creative and thoughtful commissioning on
the part of health commissioners and local authorities, probably
through children's trusts. It is about being much more creative
in how they commission things; about thinking outside boxes; about
understanding that these children are not just about mental health,
but emotional well-being, regaining and restoring some sense of
self-esteem, and just having some control over their life.
Q188 Chairman: Do you think we have
the skilled work force to deliver on that sort of demand?
Helen Chambers: Perhaps I may
pick up on the point that Sue has just made. I had the opportunity
to work with Worcestershire on a creativity project, funded by
the Arts Council, with looked-after children and to consider how
to embed creativity in the lives of looked-after children. I saw
some superb work with a variety of looked-after children, including
those with a variety of diagnosable mental health conditions.
That has been supported by a multidisciplinary mental health team,
backed by a clinical psychologist, including front-line practitioners
who have a shared understanding of looked-after children within
their multidisciplinary team. It was made up of leisure services,
art services, CAMHS, social services and youth services, which
have a shared understanding of how to promote the emotional health
and well-being of children. That sort of multi-dimensional model
has much to recommend it.
Mr Heppell: That is not the norm, though.
Helen Chambers: No.
Q189 Mr Heppell: You are saying that
non-specialist areas, such as schools and so on, do not at present
have enough understanding of what is needed for looked-after children.
Helen Chambers: Certainly one
of the things that Yorkshire and Humberside region suggested in
its regional health and care partnerships for next year's work
programme is that those practitioners, including teachers and
youth workers, should have a shared song sheet for understanding
the emotional needs of looked-after children and their role in
supporting them. I believe absolutely that looked-after children
need their corporate parent to understand their needs at strategic
and operational levels.
Dr Harris: I agree that the work
force are not sufficient to do that on their own—that is
not what is required. We need a CAMHS work force that can be active
at times, and watchful and supportive at others. Dedicated teams
exist—particularly those that are co-located with other
services within local authorities—who have a shared vision
and brief, who have trained and worked together, and who are very
successful. However, they are also very expensive because they
need to exist over a long period of time, and they must have the
stability of a work force that children need from their social
workers. People come and go and change, but we need to have good
CAMHS input into training, skilling up and supporting the wider
work force. Often, people do not know what they are seeing. Some
of these children's experiences have been so unbearable that at
times, people find it difficult even to want to know what they
are seeing.
Helen Chambers: That includes
foster carers.
Dr Harris: Absolutely.
Q190 Mr Heppell: Following on from
that issue about specialist teams, I am not quite sure what I
drew from what you said. Should such teams be universal? Should
they be everywhere?
Dr Harris: There is a publication
from YoungMinds, which I have brought with me and can leave if
people want, that gives examples of good practice across the UK
in terms of looked-after children's services in relation to CAMHS.
They vary a lot and at this stage, I am not clear whether that
is right and that services should be tailored to different boroughs,
or whether there are some threads that come from all of them that
give models of good practice. I suspect that there are such models—when
I was thinking about them today, I listed 10 things that come
across from all those services. However, it is very difficult
to measure effectiveness. If there is any influence here, I would
make a plea for a piece of decent, long-term research that looks
at outcomes in terms of children, their relationships, placements,
longer-term health and emotional well-being. It needs financial
clout to protect specialist teams, and they must work across agencies.
That is the nub of it. When they are co-located and work well,
they work very well, but they are tricky to set up and take a
huge amount of time and finance.
Chairman: Catherine, have we neglected
you on this one?
Dr Hill: I have a couple of reflections.
Having somebody with a specialist CAMHS role for looked-after
children is not just about delivery; it is about advocacy, understanding
the context and promoting appropriate delivery of services for
those children. One of the issues that we continually come up
against in practice, which differentiates CAMHS from physical
health services, is the opportunity for the practitioner to be
selective about which children they see. Assuming you jump the
hurdle of assessment and recognition of a problem, you must then
jump the entry threshold hurdle to get the CAMHS service. That
is not because people are lazy; it is largely because they are
overstretched. One of the big hurdles for looked-after children
is lack of placement stability. Something that has echoed around
the country for years and still echoes today is the CAMHS practitioner
saying, "I'm sorry, I cannot see this child until they are
in a stable placement". It is a vicious circle whereby the
child will not achieve a stable placement because of their behaviour
or emotional health problems. That is a practised perspective,
but the concept of a specialist advocate within each area to overcome
the hurdle of the "Can't see this child" approach and
to promote local services is a very good one. Like Rita, I do
not have any privileged knowledge about what the best model is.
I suspect that that knowledge is probably not there, but there
may be concepts—I would be interested to hear Rita's concepts,
and those 10 features. Again, I would echo the need for research
to look at what works. We should shore up the strong foundations
that we have and look at what is working out there before we reinvent
something new.
Helen Chambers: The early learning
will come from the Department for Children, Schools and Families'
funded programmes on multi-systemic therapeutic care and the treatment
foster care programme. The treatment foster care programme is
highly evaluated but is in its early stages. As I understand it,
such programmes are about providing support to the carer, and
ensuring that the carer provides boundaried, consistent care.
A lot of support and training go to the carer as the front-line
practitioner. Generally speaking, the carer is there 24 hours
a day, seven days a week.
Sue Dunstall: I just want to be
clear. I think that it is diversity of provision that is absolutely
key here. One of my problems with the multi-systemic therapies
that you were talking about is this focus on cognitive behavioural
therapy. This is not a one-trick pony—the therapy will not
suit all children who are in care. There are an enormous number
of therapeutic services out there. Different ones will be required
for different children at different times and at different stages
in their care. We need to be absolutely clear about that. It is
no good throwing money at CBT and ignoring the wealth of other
interventions that are out there for children and young people.
Sometimes I have a slight problem with research that is focused
on outcomes. The research needs to be focused on the value that
is added to an individual's life. That is subtly different from
a blunt outcomes measurement.
Chairman: Good point.
Q191 Mr Heppell: I hear what you
are saying about diversity, but unless there are some sort of
national criteria for assessment or for the way in which you deal
with the problems, will there not be a difficulty? Are you not
always going to get the situation that people grumble about, in
which, if someone moves from one area to another, the same service
will not necessarily be available? That is a criticism and, in
some respects, that is bound to happen if you have diversity across
different areas.
Helen Chambers: I was just wondering
whether part of that goes back to the planning. If a child is
having an assessment, there is a health plan that says what they
need, and it should be taken into account when a child is placed
in a local authority or in an independent agency elsewhere. Theoretically,
if that provision cannot be guaranteed by the receiving primary
care trust, then the child should not be placed there. That is
not necessarily the practice, but it should be the practice. It
is the responsibility of the placing authority to ensure that
that provision is delivered.
Dr Harris: I wanted to say something
about the question that you just asked, but just before that,
if I am allowed, I want to interject one small thing. You were
talking about the plan, and the assessment came up earlier. John
Simmonds from BAAF said, "You gave us that convenient little
break. Do not forget about the instability of the care system."
One of the problems with plans is—as we would say in my
world—that somebody has to hold the plan and the child in
mind. That basically means that somebody has to have a sense of
the child over time, to stay with them and have a sense of their
needs, and to have experience of them to help them develop, so
that they can have a coherent sense of self and therefore be able
to access all these new ideas that people are providing. They
need a narrative—a consistent story to tell about themselves.
The instability of the care system militates against that. With
the best plan and assessment in the world, if you change social
worker and carer, it is very difficult to hold the child in mind.
Q192 Chairman: So you are arguing
for a mentor, a life-coach throughout childhood.
Dr Harris: In order to develop
secure attachments and to access opportunities, children need
to have a coherent sense of self. In order to have a coherent
sense of self and good attachments, they need stable and continuous
relationships. That is how children usually grow and develop,
and that is what is provided by parents. It is a really tricky
one, for us as professionals, to think about how to provide that
over time for children in the care system, when the work force
is changing all the time.
Chairman: At the very least, they need
one consistent person.
Dr Harris: It would be wonderful.
What children say is, "I'd like to be able to go to my social
worker and get an answer from them, without their having to go
up through all these different levels." They would like to
be able to just pick up the phone. When our kids are at university
they pick up the phone if they are in trouble, but these kids
do not know whom to ring. It is such a fundamental given in child
development, but the system militates against it.
Chairman: You were also coming back to
another point.
Dr Harris: Thank you—I had
forgotten what it was. On your point about how we can have consistency,
you are absolutely right: the diversity should be consistent.
CAMHS should have a range of therapeutic approaches within them,
and that is what people mean when they talk about diversity, not
that the services are different in different areas. I wonder whether
the CAMHS review will help us to gather up some standards for
what the mental health services should provide for looked-after
children as a minimum in all boroughs. One of those things, in
my view, would be to have dedicated teams with a variety of treatment
modalities. The treatments that have been evaluated have been
evaluated because it is easy to do so in a fairly controlled way.
They are quite straightforward and are often manualised, but they
are often one-offs. They are quite useful, but they do not look
at the broader spectrum of what a child and a family need. Bearing
in mind the point about longer-term care and consistency, looked-after
children do not just need an intervention and then that is the
end of it. They need a group of people who come in and out, but
it is tricky.
Chairman: The full package again.
Dr Harris: We want everything.
Q193 Paul Holmes: Helen, you said
that one important thing was to get a proper health plan in place,
but that it was difficult to monitor it, and that it was even
more difficult when the child moved out of area to a new authority.
Can you elaborate on the business of the child moving to another
authority?
Helen Chambers: The health assessment
should be done within the first six weeks and whether that happens
varies. When the health assessment is done, the health plan is
written by the doctor and nurse, usually in consultation with
the child and the social worker, but the social worker is actually
responsible for ensuring that it is done and that action is taken.
The monitoring of what action is taken varies hugely because,
as colleagues are saying, who makes sure that it happens? As parents
we make sure that it happens for our own children. That responsibility
is with the social worker, but on a day to day level, what generally
happens is that foster carers or residential social workers are
the key people to agitate to ensure that provisions are in place,
although that is open for more discussion. The case should then
be picked up within health services and the right services provided.
My experience anecdotally is of very patchy practice. If a child
is then placed outside the local authority, it is very patchy
practice. My experience is that often a child who is placed out
of authority has more complex needs. There may be good reasons
why they have to be placed out of authority, although one would
prefer that they were not. What health services, including mental
services, need to be put in place for them? Who monitors those?
I wish I was confident that the social worker ensures that the
child receives the services needed. I would not have evidence
of how effectively that is done. I know, from some independent
fostering agencies in the annual review, that frequently they
cannot get a report on the child from the social worker of the
placing authority—in other words, the child's own social
worker. In other places, there will be good liaison. So I do not
wish to apportion blame, but just want to look at the caseload.
There is a danger when a complex child is placed out of authority.
Q194 Paul Holmes: There are two different
sets of responsibilities here, are there? If a child moves from
Derbyshire, where I live, to Sheffield, the home authority—Derbyshire—is
still responsible for the child. But Derbyshire PCT is no longer
responsible: it is now Sheffield PCT.
Helen Chambers: My understanding
is that, since the change in the responsible commissioning guidance,
the responsibility has been put back with the placing PCT. So
Derbyshire is still responsible for the child in respect of funding.
If you say, "This child has complex health needs", when
placing them in an independent fostering provider in Sheffield,
those needs must be met by that provider in Sheffield, before
the child is to be placed there. That is not necessarily what
will happen. Derbyshire social services worked on and looked at
its residential provision for looked-after children and used that
as a focus of considerable change in the management and support
of residential social workers. That is one of the things I have
in the back of my mind when thinking about what needs to change.
Actually, what was said by the head of the children's services
team, who has been doing that work was that, without the partnership
working with health, she could not have achieved a quite seismic
change to provide what I understand are good services in residential
care in Derbyshire, although I have no experience of those.
Q195 Paul Holmes: So the responsibility
and the funding are still with the home authority and the home
PCT. Inevitably, the new PCT will be delivering, because that
is where the child now lives.
Helen Chambers: Yes.
Q196 Paul Holmes: What can be done
to speed up the transfer of medical records, for example, from
the first place to the second place?
Helen Chambers: Cathy has some
thoughts on this. Certainly, in terms of systems that talk to
one another and links across areas, that is one of the difficulties.
Dr Hill: We have—unsuccessfully,
unfortunately—put in a section 64 grant application to the
Department of Health on that, in respect of holding and maintaining
within BAAF a database of health professionals by locality. If
a child moves from Southampton to Derbyshire tomorrow, who do
I call? Who do I talk to? Who do I negotiate with? From whom do
I find out what provision there is in your area? That is a real,
practical problem with an extraordinarily simple solution. But
it is about who will fund and support a central database of health
staff. There are, in most areas now—hopefully, with guidance
and statute there will have to be—designated health professionals
who could form that automatic layer of communication. But it is
a real issue in practice. Sometimes, it may be to do with poor
partnership working, but often it is more to do with the realities
of why the child has moved. It may be that the placement has broken
down precipitately or the only available option is across a boundary
and it may happen on a weekend or during a holiday. These are
the realities of the work. I have a sense that, if we are not
careful, it is about health being a process checklist: child has
had health assessment—tick; health care plan in place—tick.
Sometimes, pressured social workers have to step outside that
a little bit and think about prioritising health for the child.
That can get forgotten in transfers.
Q197 Paul Holmes: At the simplest
level, if a child is moving from one area to another—not
just for a long weekend or something like that—one of the
most basic things is moving the general practitioner records from
place A to place B. The Care Matters: Time for Change White
Paper said that it can vary from a few weeks—why?—right
up to a few months, before the records are even transferred. Surely,
that should be a simple thing to crack.
Dr Hill: I think that it will
be cracked. There is light at the end of the tunnel on that one,
because with the NHS electronic records it should be able to happen
at the press of a button.
Q198 Paul Holmes: You are confident
that the electronic records are going to work, then.
Dr Hill: This is going to be in
writing, is it not?
Chairman: A man from Huddersfield will
sort all that out.
Dr Hill: I am optimistic. These
children are the very group of children for whom that change would
work phenomenally well, of course, because unfortunately these
children move rather frequently. What we have gained from the
"Promoting Health" guidance is much more emphasis on
full registration with GPs, because in the pre-guidance days there
was very much a tendency for foster carers to temporarily register
and children with temporary registration did not have transfer
of records. So I think that the transfer of data is an issue and
the electronic records potentially can fix it. However, we also
must not forget that there is also a reservoir of detailed and
relevant health information about the child that has been collated,
usually within a looked-after health team, which needs to transfer.
That was my first point, about devising mechanisms and systems
whereby we can do that more efficiently and I think that that
is simply about maintaining a database.
Chairman: Just one very quick final question.
Q199 Paul Holmes: One of the points
in terms of schools cherry-picking pupils has now hopefully been
dealt with, in that they now have to prioritise children in care
for entry to a school. What about GPs? Again, a child moves from
one authority to another. Do GPs refuse to take certain children
because they think that they will be too much of a problem for
their practice?
Dr Hill: You will probably find
case examples of that. Generally speaking, however, foster carers
often have a long-standing relationship with a GP. The GP will
probably have seen the foster carers for their own health assessments
and will be well aware that that family has transient populations
of children moving through their household. Generally speaking,
my experience has been that there is a friendly arrangement with
GPs and it is also supportive. I do not know if anyone wants to
add further comment to that.
Chairman: I was going to try to push
us on to a broader understanding of the notion of well-being,
and Fiona has been very patient in waiting.
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