Adult Medical Reports in Family Placement Guidance

Version 6: 3 February 2021 (PDF version)

Ellie Johnson, CoramBAAF Health Consultant, Elaine Dibben, CoramBAAF Adoption Consultant, and Paul Adams, CoramBAAF Fostering Consultant

KEY POINTS

• Follow established best practice processes and adhere to original regulatory requirements wherever possible.
• Liaise locally to agree workable arrangements and review regularly.
• National directives, regulatory amendments and Government guidance differ across the four UK countries.

Practitioners from Wales can access country-specific guidance at AFA Cymru. Practitioners from Scotland can do so at: AFA Scotland.

Covid-19/coronavirus has resulted in General Practitioners (GPs) being required to prioritise other areas of work resulting in fostering services and adoption agencies experiencing serious difficulty in obtaining required medical reports. Some GPs are not in a position to offer any input to adult health assessments, but in some localities, capacity in primary care is more available and assessments have been delivered as usual. In a small number of areas these difficulties have persisted. GPs may be able to offer records-based medical reports or virtual appointments instead of standard physical examinations. 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.

ENGLAND

The Adoption and Children (Coronavirus) (Amendment) Regulations 2020, that were introduced on 24 April and amended existing regulations in England that set out the requirements for the completion of health information in fostering and adoption assessments, have now been replaced by Adoption and Children (Coronavirus) (Amendment) (No.2) Regulations 2020.

These new amendments continue some flexibilities in the provision of medical reports. The amendments allow medical reports to be obtained in Stage 2 of assessments if they have not been obtained in Stage 1, in both fostering and adoption.

Fostering assessments

Assessments being undertaken under the Fostering Services (England) Regulations 2011 (FSR) require ‘details of the carers’ health supported by a medical report’. Department for Education guidance published following the changes to the regulation amendments recommends that the medical report should be sourced but that there is flexibility in terms of when in the assessment the report is required.

Medical checks - fostering
The temporary regulations allow fostering agencies to proceed to obtaining the information required under regulation 26(2)(a) of the Fostering Services (England) Regulations 2011 without having received medical reports.

The temporary regulations do not remove the need for medical reports as they still must be obtained before the fostering agency can consider the suitability assessment of the prospective foster carer and their household. A final decision cannot be made without a medical report being obtained and considered as part of the suitability assessment. If medical reports are available at the initial stage, they should still be obtained and considered then.

As good practice, agencies should let prospective foster carers know that if their application is progressed to the next stage, their medical information, when received, could affect the outcome. Equally, if agencies are aware of medical history that could affect the outcome of the application, they may decide not to progress the application until the relevant information has been received from the GP or other health professional.

The decision to use this flexibility must be recorded.

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 and ensure the provision of medical reports. 

In some areas, GPs are not able to offer surgery appointments but have agreed to complete Form AH using a video consultation. 

There are ongoing availability issues across the UK, exacerbated by the current vaccination programme.

When a GP-completed Form AH is not available, foster carers are completing a self-description of health using Part B of Form AH/ CoramBAAF ‘Self-Declaration of Health Form for use during Covid-19 Pandemic’.

Where this self-declaration is being used, it should be corroborated by information from 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.)

Ofsted made some suggestions re foster carer adult medicals in their newsletter recently with some messages about flexibility Message from Yvette Stanley, Ofsted National Director Regulation and Social Care, 15 January 2021:

“Foster care: Medical reports and annual reviews of carers 

We are very aware that, in many areas, the pandemic has exacerbated ongoing problems in obtaining the necessary medical reports to progress and approve foster carer applications. The recruitment of suitable foster carers has never been more important than now, when capacity is seriously threatened by COVID-19. We have seen how temporary flexibilities in the regulations (as set out in the Adoption and Children (Coronavirus) (Amendment) (No.2) Regulations 2020) have allowed assessments to progress pending medical information.

However, the requirement for approval decisions to be properly informed by a medical report still stands. We are unable to waive legal requirements. We do not wish to take an overly-prescriptive approach to this issue. For example, while it may be entirely right in the majority of cases that an applicant’s General Practitioner (GP) completes the medical report, the regulations do not require this. Medical reports may be provided by other relevant health professionals instead of the GP, where appropriate, and the agency may take into account a range of information that can inform recommendations and decisions, including the applicant’s own self-assessment of their health. The agency medical adviser too can often play an important role in interpreting the health information to help decision-making.

The level of detail required, and the health professional best placed to provide the report, should be determined on a case-by-case basis.”

If the fostering panel believes that more medical information is required to make a judgement about suitability, it 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 full 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 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.

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.

Adoption assessments

In England the 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 allowed 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. This flexibility remains under the Adoption and Children (Coronavirus) (Amendment) (No.2) Regulations 2020 which were introduced on 25 September 2020 and remain in force until 31 March 2021. 

As a useful tool in 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. This provides a basic level of information and may help the adoption agency to identify key issues to be further explored during Stage 2.  

When all the information required in Stage 1 is completed as far as possible, the adoption agency can then consider whether it is 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, or that should be addressed before progressing to Stage 2. 

Adoption 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 Disclosure and Barring Service (DBS) check.  

Applicants should be made aware of this clause when they are asked whether they wish to proceed to Stage 2.  

The Adoption Regulations are clear that the agency can delay making the decision to proceed to Stage 2 if it feels that it needs 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, it 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).

GPs’ 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.