- Follow established best practice processes and adhere to original regulatory requirements wherever possible.
- Liaise locally to agree workable arrangements and review regularly.
- National directives and regulatory amendments and Government guidance differ across the four UK countries.
Covid-19/coronavirus has resulted in General Practitioners (GPs) being required to prioritise other areas of work that may result in fostering services and adoption agencies experiencing serious difficulty in obtaining required medical reports. Some GPs may not be in a position to offer any input to adult health assessments, but in some localities, capacity in primary care is more available and assessments may be delivered as usual. GPs may be able to offer records-based medical reports or virtual appointments instead of standard physical examinations. We know that in some areas, medical advisers cannot deliver their statutory role in adult health assessment and providing expert advice from a child placement perspective. Agencies should liaise with their medical adviser and designated LAC team to determine the current situation in their area and agree local arrangements that best enable acceptable working practice.
Communicating with GP practices across a wide area is difficult, but the designated doctor for looked after children (DR LAC) and Named GP Safeguarding for a Clinical Commissioning Group (CCG)/Board should be able to assist.
The Adoption and Children (Coronavirus) (Amendment) Regulations 2020 were introduced on 24 April and have amended existing regulations in England that set out the requirements for the completion of health information in fostering and adoption assessments. These are separately set out below.
Assessments being undertaken under the Fostering Services (England) Regulations 2011 (FSR) would usually require ‘details of the carers’ health to be supported by a medical report’. The Adoption and Children (Coronavirus) (Amendment) Regulations 2020 have removed the requirement for a medical report to accompany the health information. However, wherever it is possible for a medical report to be completed, this continues to be best practice. Feedback indicates that this has been possible in some areas but not others.
Earlier guidance from Ofsted recognised that medical checks may prove difficult to complete as GPs were having to prioritise other matters, and advised fostering providers to gather as much information as possible for the assessment (Yvette Stanley, Ofsted’s National Director, Social Care, 27 March 2020).
Local CCG-level discussion and decision-making should determine what is achievable in relation to completing adult health assessments, and fostering services should communicate with their medical advisers to agree how best to access medical information in this context.
In some areas, GPs are not able to offer surgery appointments but have agreed to complete Form AH using a video consultation.
When a GP-completed Form AH is not available, foster carers are completing a self-description of health using Part B of Form AH, or the CoramBAAF ‘Self-Declaration of Health Form for use during Covid-19 Pandemic’.
Where this self-declaration is being used, it is best practice to corroborate this information with the GP record, and different localities are achieving this by various methods. Local arrangements may be dependent on medical adviser capacity and their availability.
The following are examples of such practice:
- Clinical Commissioning Group staff with appropriate competencies, such as a named GP/designated LAC health professional, review the applicant’s GP records, with consent, and transfer the relevant information to the medical adviser.
- An electronic summary of the applicant’s GP record is requested, with consent, which is then viewed by a medical adviser.
- The medical adviser views the applicant’s electronic GP record, with consent. (This is only possible in areas that operate specific record systems.)
CoramBAAF continue to get inquiries about the meaning of the government guidance (updated 6 May 2020) that states that ‘the assessment process can continue to the second stage whilst awaiting medical information and DBS (criminal record) checks… [and]… the fostering service will still need to have the medical information and DBS checks, along with the other information specified in Schedule 3 of the regulations’. For the avoidance of doubt, the requirement in schedule 3 is now for ‘medical information’ to be included in the assessment, but there is no longer a requirement for a ‘medical report’. This means that it is possible to approve a foster carer based solely on self-reporting about their health. However, in most cases it should be possible to supplement that self-reporting, as discussed above. If the fostering panel believe that more medical information is required to make a judgement about suitability, and that information can be accessed, they should defer making a recommendation in order to get that information. The position of the Decision Maker remains unchanged in that they can also seek more information before making a decision if necessary. As with all assessments the emphasis is on the analysis of information not simply the acquisition of information. Social workers and their supervisors should ensure that where medical information is unavailable a thorough analysis is undertaken as to the significance of this within the overall assessment.
Medical adviser role
In normal circumstances, the medical adviser will complete Part C of Form AH and provide a summary report and any further advice to the fostering panel and the agency. It is particularly important in current circumstances that the medical adviser identifies how the health information has been obtained and whether there is important missing information. The medical adviser can give an opinion about the sufficiency of the information available and advise on further information that is required.
It should be noted that in the Fostering Regulations for England (2011), the assessment requirements of Schedule 3 are a minimum outline of the information required, and that the priority given to each element of the assessment may vary according to the circumstances of the individual prospective carer. It is impossible to be prescriptive, but a fostering service provider should be less ready to compromise on the detailed health information required when considering a person with identified health conditions, putting themselves forward as a long-term carer for a physically demanding young child, than they might for an apparently fit and healthy person offering themselves as a respite carer.
It is important that the fostering service records note the reasons for non-adherence with normal health review processes, and that they are clear about any further actions that may be required when restrictions are lifted. If foster carers are approved without a full medical being undertaken, then the medical should be completed at the earliest opportunity, and always in advance of the first foster carer review.
For carers being given temporary approval as a foster carer under regulation 24 of the Care Planning, Placement and Case Review (England) Regulations 2010 (CPPCR), existing regulations state that the assessment requires ‘(c) their state of health including their physical, emotional and mental health and medical history including any current or past issues of domestic violence, substance misuse or mental health problems’. The regulation does not specify the need for medical reports.
Health assessments for foster carer reviews are not stipulated in legislation, and fostering services will have their own policies in addressing this issue. Additionally, they may wish to use CoramBAAF’s ‘Self-Declaration of Health Form for use during Covid-19 Pandemic’,where they identify the need to update health information.
The England Adoption Agencies Regulations 2005 (AAR) require the adoption agency to obtain ‘a written report from a registered medical practitioner about the health of the prospective adopter following a full examination during Stage 1 (the pre-assessment stage).
However, the Adoption and Children (Coronavirus) (Amendment) Regulations 2020 allow the adoption agency to make a decision that allows the prospective adopter/s to proceed to Stage 2 assessment, even if medical checks have not yet been completed. This has extended the timeframe of two months, to note that this should be achieved where reasonably practicable.
In order to progress the assessment of prospective adopters where the medical report cannot be completed during Stage 1, adoption agencies could ask the applicant/s to complete CoramBAAF’s ‘Self-Declaration of Health Form for use during Covid-19 Pandemic’ during Stage 1. This provides a basic level of information and may identify key issues to be explored during Stage 2.
When all the information required in Stage 1 is completed as far as possible, the adoption agency may then be in a position to agree to the applicant/s being able to progress to Stage 2. Where there are health issues that have not been fully addressed, these should be identified and discussed with the medical adviser (if one is available) to identify any potential risk factors that might need further exploration during Stage 2.
Statutory guidance highlights that:
…mild chronic conditions are unlikely to preclude people from adopting provided that the condition does not place the child at risk through an inability of the individual to protect the child from commonplace hazards or limit them in providing children with a range of beneficial experiences and opportunities. Agencies should bear in mind the possibility of providing support in appropriate cases to assist in overcoming any possible negative consequences arising from disability or restricted mobility. More severe health conditions may raise a question about the suitability of the prospective adopter, but each case will have to be considered on its own facts and with appropriate advice. (ASG 3.36)
The Adoption and Children (Coronavirus) (Amendment) Regulations 2020 have clarified that applicants cannot access the IRM if their assessment is terminated during the Stage 2 assessment and the reasons they are assessed as not suitable to adopt result from either their health assessment or their DBS check.
Applicants should be made aware of this clause when they are asked whether they wish to proceed to Stage 2. The amended Regulations have also removed the six-month time limit for prospective adopters to give notice of their intention to proceed to the Stage 2 assessment.
The Adoption Regulations are clear that the agency can delay making the decision to proceed to Stage 2 if they feel that they need further information about the adopter in order to proceed to a full assessment (AAR 27 (3a)). If the applicant has highlighted that they have health conditions that the agency believes require further medical information from their GP or a health consultant before proceeding further, they may decide to place the assessment on hold until a full medical can be completed.
During Stage 2 of the assessment, the agency must obtain ‘a summary, submitted by the agency’s medical adviser, of the state of health of the prospective adopter’ (AAR 30 (2b)), which will include the medical adviser’s view on the adequacy of the medical reports received and whether additional specialist opinion should be obtained. Guidance states that agencies have a duty to satisfy themselves that prospective adopters have a reasonable expectation of remaining sufficiently healthy over the longer term. The Adoption and Children (Coronavirus) (Amendment) Regulations 2020 state that an adoption agency must not make a decision about the adopter’s suitability to adopt until it has obtained the health information required by AAR 26(b). This is identified as a ‘written report from a registered medical practitioner about the health of the prospective adopter following a full examination’.
Similar wording is used in the regulations in Wales and Northern Ireland. In Scotland, the regulations require a:
…comprehensive medical report on the prospective adopter prepared and signed by a registered medical practitioner including such details as the medical adviser to the adoption agency considers necessary in the circumstances of each prospective adopter.
GP’s use of video consultations to complete adult health reports: are they compliant with the requirement for a full examination?
The information obtained from an applicant’s GP records is an important component of the Adult Health assessment. The GP also records medical conditions, current health issues and lifestyle factors.
Using record review/history taking and online conversation, the usual face-to-face process can largely be replicated via video. If the applicant has attended a health appointment and been examined physically in the previous year, the GP should have access to this information and could utilise it.
It would be important for the GP to obtain a blood pressure check and urinalysis result, and for them to ask the applicant to supply measurements for Body Mass Index (BMI) calculation.
The physical exam section in Form AH would not be completed in the usual way, but GPs are experienced in using appropriate questions and history taking. If a GP noted a clinical reason for a further physical exam during a video consultation, they would then arrange this.
There is now an optional section for the standard Form AH with alternative questions replacing the face-to-face part of the physical examination, which help to elicit symptoms or signs of undiagnosed conditions in the way a physical examination seeks to do. (These questions have been drafted by GPs from North Yorkshire and kindly shared.) Agencies that are licence-holders for Form AH can insert this optional section at Part C (7) if required. An updated Form AH with this addition included will be circulated to licence-holders.
A GP record review alone cannot be described as a full examination. CoramBAAF has consulted with its expert health group membership and has agreed that if a GP is able to complete an Adult Health report using a quality video consultation as described above, that this will provide the information that is required in the regulations.
Medical adviser role
In normal circumstances, the medical adviser will complete Part C of Form AH and provide a summary report and advice to the adoption panel and the adoption agency.
It is particularly important in the current pandemic situation that the medical adviser comments on how the health information has been obtained and whether there is important missing information. The medical adviser can express their opinion about the adequacy of the information available, and advise on any further information that is required.
The England Adoption Regulations at 26b state that a medical adviser can advise an agency that the “examination and report is unnecessary” to proceed with a recommendation. It would only be “unnecessary” if the level of information that is normally obtained has been sourced by alternative means and is of the same quality as would be expected if it was gathered in the usual way.
These practice points will be updated on a regular basis.