The Health Review That Should Happen, and Too Often Doesn't: Statutory Health Assessments for Looked-After Children

Looked-after children are, as a group, one of the least healthy populations in the country. The evidence on this is not marginal and it is not new. Children entering care carry disproportionate rates of undiagnosed hearing and vision problems, unaddressed dental decay, immunisation gaps, untreated physical conditions, and unmet mental health needs — needs that have accumulated, often across years, in environments where adults were not reliably attending to them. The statutory health assessment framework exists precisely to address this: to ensure that when a child enters the care system, a structured, professional assessment of their health needs is completed, recorded, and acted upon, and that this is repeated annually for as long as they remain looked after. The framework is unambiguous. The Initial Health Assessment should be completed within twenty-eight days of a child becoming looked after. The Annual Review follows at twelve-month intervals. The commissioning responsibility rests with the local authority. The delivery responsibility falls to NHS services — typically the Designated Doctor and Named Nurse for Looked-After Children. What actually happens, across a significant proportion of cases, is that reviews are delayed, rescheduled, delivered perfunctorily, or — in cases that would appall any reasonable reading of the statutory guidance — simply not done at all. For residential homes, which sit in the nearest proximity to the child and carry the most detailed knowledge of their daily health needs, the question of what responsibility they bear for this failure is one that is too rarely asked.

The Initial Health Assessment is, in conception, a serious clinical undertaking. It is not a GP appointment, and it is not a tick-box check of vaccination records. The statutory guidance — Working Together 2023, the accompanying Children Act 1989 guidance, and the NICE guideline on health of looked-after children — describes an assessment conducted by a doctor or nurse with specific training in the health needs of looked-after children, taking in a comprehensive physical examination, a review of developmental history where it is available, an assessment of emotional and mental health, a dental and vision check, a review of immunisation status, and — critically — the child's own account of how they feel about their health and what they feel they need. The outcome should be a clear health plan, with identified actions, responsible persons, and timescales. Where a child has a particular health condition or unmet need, the assessment should generate the referral or the prescription or the appointment that addresses it. This is not a bureaucratic document. It is the mechanism through which the state, having assumed parental responsibility for a child, exercises that responsibility in relation to their health. The gap between this intention and the reality of many health assessments conducted within the looked-after children system is one of the care sector's persistent shames. Reviews that consist of a fifteen-minute appointment with a paediatrician who has never met the child and has no background information. Reviews conducted by letter rather than in person. Reviews that identify needs and generate referrals that are then not followed up. Reviews that happen at month three rather than month one, or not at all in the annual cycle, because no one has chased the appointment. A young person who has been in care for two years and has had one health assessment, or none, is a young person the system has failed in a way that no care plan or LAC review can paper over.

Residential homes are not the responsible commissioner of health assessments, and the limitations of that position are real — a registered manager cannot compel the NHS to prioritise a child's appointment or the local authority to exercise its commissioning function promptly. But the limits of formal responsibility are not the same as the limits of practical influence, and the homes that navigate this most effectively understand that the difference between a health assessment happening and not happening often rests on someone in the home making it their business to ensure it does. What this looks like in practice is more active than the statutory framework implies. It means a home knowing, at any given time, which young people have had their health assessment and when it is next due, rather than leaving this to the looked-after children nurse to track independently. It means a keyworker attending the assessment with the young person, prepared with an accurate account of the health needs and changes they have observed over the preceding months, rather than the assessment proceeding on the basis of incomplete records and an unfamiliar adult sitting in the room. It means a home that, when a referral is made at the assessment, follows up actively to understand what happened to it — and flags where referrals have stalled, which they routinely do. It means workers who understand that a young person's refusal to engage with a health appointment is information, not a final answer, and who build the trust and the preparation that makes attendance possible. The home that treats health assessments as an administrative obligation to be noted in the file is a home that is missing one of the most straightforward mechanisms through which a looked-after child's life trajectory can be changed.

The health passport — sometimes called the health record, or the health summary — is the mechanism through which a child's health history should travel with them through the care system. Its existence as a concept is nearly universal; its actual implementation is patchy in ways that produce direct harm. A young person who has moved placements multiple times, or who has moved between local authority areas, may arrive at a new home and a new health assessment with a health passport that is incomplete, out of date, or missing entirely. The receiving clinician is then conducting an assessment without the longitudinal context that would allow them to identify change, deterioration, or the gap between what the child reports and what the records show. Dental history is frequently the worst-maintained element: a young person may be unable to describe their dental treatment history, and the records may not follow them, producing an adult with preventable oral health problems that no single point in the care system caught and addressed. Immunisation records are a persistent problem: children in care are under-immunised compared to the general population, partly because their families of origin were not reliably engaging with vaccination schedules, and partly because no one in the care system took consistent ownership of catching up. The residential home that maintains its own accurate health record for every young person in its care — not as a substitute for the statutory health passport but as a live document that can inform every health encounter — is a home that is providing something the system frequently fails to provide for itself. This matters not only for the health assessment but for every GP appointment, every A&E attendance, every specialist review. The child who has a coherent, up-to-date health record that accompanies them to appointments receives better care than the child who does not. The home is not the NHS, and it does not hold clinical records. But it holds observational knowledge, and the conversion of that knowledge into something portable and useful is within its competence.

The mental health dimension of the health assessment is where the gap between statutory intent and actual delivery is most acute, and where the stakes are highest. Looked-after children present with rates of diagnosable mental health conditions that are, on the best available evidence, between four and five times higher than those of the general child population. The health assessment is supposed to identify this need and initiate the pathway to appropriate support. In practice, the combination of an overwhelmed CAMHS system, referral thresholds that are too high, and health assessments that do not generate strong enough referrals means that a significant proportion of looked-after children with identified mental health needs are not receiving the therapeutic support they require. The residential home sits in an unusual position here: it is the environment in which the mental health of the young person is most immediately visible, and it is the environment least likely to be represented in the clinical system. The consulting room sees the young person for an hour; the home sees them for every waking hour of the day. What the home observes — the nature and pattern of distress, the triggers, the responses to different kinds of relational approach, the behaviours that the young person deploys to manage feelings they cannot name — is clinically relevant information that rarely enters the formal health record in a systematic way. The homes that have built strong relationships with their local Named Nurse for Looked-After Children, that contribute detailed observations to pre-assessment information, that follow up actively on mental health referrals, that challenge — through appropriate channels — referral outcomes they believe are inadequate, are homes that are compensating for a systemic inadequacy. That compensation should not be necessary. The statutory framework already assigns the responsibility. The problem is that the responsibility is not being exercised with the consistency and quality that looked-after children deserve, and that until the commissioning and delivery systems function as they should, the gap will continue to be filled — or not filled — by what individual homes choose to make their business.