Looking out for looked-after children

20 November 2020

GP Jeremy C Gibson and nurse Heather Peet discuss ways to keep this most vulnerable and overlooked sector of society safe and hopeful for the future. 

According to the Children Act (1989), looked-after children are those who are in the care of, or are provided accommodation by, a local authority for a continuous period exceeding 24 hours. Every local authority has a legal obligation to safeguard all children in its care and to promote their welfare and educational achievement. Wherever possible, it must ascertain the wishes and feelings of these children and those of their parents or carers when making decisions about them.

How many children are looked after?

The number of looked-after children is increasing. In England alone during the year to 31 March 2019, local authorities were looking after nearly 80,000 children, 72% of whom were in foster care. Just over 6% of the total were unaccompanied asylum-seekers (Department for Education, 2019). Although the proportion of looked-after children aged five and under has been falling, there has been an increase in the proportion of teenagers in local authority care. Some of them may have special educational needs, while others may have experienced child sexual and/or criminal exploitation, been involved with urban street gangs and/or become drug traffickers and abusers.

Who has parental responsibly for looked-after children?

If the biological parents submit to a voluntary agreement that permits the local authority to accommodate their child, they will retain parental responsibility. A care order will give a local authority permission to take a child into care if it believes that the child is suffering, or is at risk of, significant harm.

In England, a care order lasts until the individual’s 18th birthday, or until an order is made that grants parental responsibility to another person through adoption or special guardianship, or until a court lifts the order (UK Government, 2020). Throughout the duration of the care order, the local authority shares parental responsibility with the biological parents.

In England, a placement order suspends a care order and authorises the local authority to place a child for adoption. Throughout its duration, the local authority will continue sharing parental responsibility with the biological parents. It is only once an adoption order is granted that the adoptive parents assume parental responsibility.

A special guardianship order can appoint one person or more to be the child’s special guardian. Although they share parental responsibility with the biological parents, they can make decisions about the child without the biological parents’ consent.



What are the specific health and educational needs of looked-after children?

Many looked-after children experience frequent house moves and changes of social worker and general practitioner (Children’s Commissioner for England, 2019a and 2019b; Williams et al, 2001). This makes their lives even more unstable and presents a risk to their mental health.

As well as being at increased risk of emotional and behavioural problems, looked-after children are more likely than average to smoke, misuse substances, engage in criminality, perform less well educationally and generally be in poorer health (Department for Education, 2019; McNicholas et al, 2011; McCrystal et al, 2008; Ford et al, 2007; Viner and Taylor, 2005). In Scotland, only 4% of looked-after school leavers go directly to university, compared with more than 40% of all school leavers (Adams, 2019).

Looked-after children are particularly opposed to the use of the acronym 'LAC', with its implication that they are lacking something

On entering the care system, looked-after children often have poor dental care and low rates of immunisation (Williams, 2001). Health outcomes improve once a child has been in care for a year. Of all the looked-after children in England as of 31 March 2019, 87% were up to date with their immunisations, 90% had had an annual health check and 85% had visited a dentist (Department for Education, 2019).

Looked-after children dislike being labelled as such (Bundle, 2002). They are particularly opposed to the use of the acronym ‘Lac’, with its implication that they are lacking something. They would far rather be called by their own name or, if an official label is required, ‘the local authority’s child’ or ‘child of local authority’ (TACT Fostering and Adoption, 2019).

They don’t appreciate being treated differently from their peers either. They report the feeling that other people’s facial expressions convey perceptions about them ranging from sympathy to disapproval. They can feel misunderstood and may struggle to fit in socially (Bundle, 2002).

Looked-after children: the lowdown

More children than ever are being looked after by local authorities in the UK. There are almost 80,000 in England alone (Department for Education, 2019).

For the duration of a care order the local authority shares parental responsibility – including the right to make healthcare decisions – with the child’s biological parents. Looked-after children are at greater risk of mental health problems, drug misuse and criminality. They do less well academically, they can feel self-conscious about how others perceive them and they find it hard to fit in socially.

They can experience numerous house and school moves, and changes of social worker and GP. Stability may lead to better outcomes. Social care should, therefore, minimise the number of placements. It may help for a looked-after child to see the same practice nurse or doctor each time they visit their GP surgery.

A health passport may be a useful tool to optimise the health needs of looked-after children. All care should be child-centred.

How best can we support looked-after children?

It must never be forgotten that looked-after children and young people are still children and young people. Organisations and clinicians should always take a child-centred approach. This is to ensure that, whenever possible, the rights, needs and wants of the child are satisfied (Voice and National Children’s Bureau, 2005). These children should be heeded and believed. They should be referred to by their names, avoiding all unneeded terminology. When appropriate, if others are asked to take action on their behalf, they should be allowed to do so.

General and community practitioners should be conscious of the physical and mental health needs of these vulnerable individuals. It may be helpful, for the sake of consistency, for a looked-after child to have an appointment with the same practice nurse or doctor whenever they are visiting their GP surgery.

Since placement stability seems to be associated with better outcomes, children’s social care should do everything it can to minimise the number of placements (Jones et al, 2011). In Scotland, 18 universities are offering guaranteed undergraduate places to students who have been in care at any point in their lives (Adams, 2019).

Guidelines published in 2015 by NICE emphasised that the loss of personal health information can harm the health of looked-after children. The NHS personal child health record (the ‘red book’), which charts the development of babies and young children, is not usually passed on to looked-after children. Locally, in response to this, we developed a ‘health passport’ for them. Like the red book, this personal, patient-held record is designed to collate health information in one place to ensure that looked-after children have ready access to their own health history and (where appropriate) that of their family. This may prove valuable in helping these young people to make choices about their health and medical care, such as primary prevention against ischaemic heart disease and stroke (Care Quality Commission, 2016).

We suggest that it may be possible to mitigate some of the health risks faced by looked-after children by taking a child-centred approach, by limiting the number of placements they experience and by optimising the quality of their personal health record through a health passport.  

Jeremy C Gibson is a named GP for safeguarding children and Heather Peet is a designated nurse for looked-after children at NHS Derby and Derbyshire Clinical Commissioning Group. 


Adams R. (2019) Scotland’s universities to offer guaranteed places to care leavers. See: theguardian.com/uk-news/2019/jul/25/scotlands-universities-offer-guaranteed-places-students-in-care (accessed 28 September 2020).

Bundle A. (2002) Health information and teenagers in residential care: A qualitative study to identify young people’s views. Adoption and Fostering 26(4): 19-25.

Care Quality Commission. (2016) Not seen, not heard: a review of the arrangements for child safeguarding and health care for looked after children in England. See: https://www.cqc.org.uk/sites/default/files/20160707_not_seen_not_heard_report.pdf (accessed 28 September 2020).

Children Act (1989). Children Act 1989. See: legislation.gov.uk/ukpga/1989/41/part/III/crossheading/duties-of-local-authorities-in-relation-to-children-looked-after-by-them (accessed 31 August 2020).

Children’s Commissioner for England. (2019a) Stability index 2019. See: https://www.childrenscommissioner.gov.uk/wp-content/uploads/2019/07/cco-stability-index-2019.pdf (accessed 28 September 2020).

Children’s Commissioner for England. (2019b) Children’s voices: children’s experiences of instability in the care system. See: https://www.childrenscommissioner.gov.uk/wp-content/uploads/2019/07/cco-childrens-voices-childrens-experiences-of-instability-in-the-care-system-july-2019.pdf (accessed 28 September 2020).

Department for Education. (2018) Children looked after in England (including adoption), year ending 31 March 2018. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/757922/Children_looked_after_in_England_2018_Text_revised.pdf (accessed 31 August 2020).

Department for Education. (2019) Children looked after in England (including adoption) year ending 31 March 2019. See: gov.uk/government/statistics/children-looked-after-in-england-including-adoption-2018-to-2019 (accessed 22 September 2020).

Ford T, Vostanis P, Meltzer H, Goodman R. (2007) Psychiatric disorder among British children looked after by local authorities: comparison with children living in private households. British Journal of Psychiatry 190(4): 319-25.

Jones R, Everson-Hock ES, Papaioannou D, Guillaume L, Goyder E, Chilcott J, Cooke J, Payne N, Duenas A, Sheppard LM, Swann C. (2011) Factors associated with outcomes for looked-after children and young people: a correlates review of the literature. Child: Care, Health and Development 37(5): 613-22.

McCrystal P, Percy A, Higgins K. (2008) Substance use among young people living in residential state care. Child Care in Practice 14(2): 181-92. 

McNicholas F, O’Connor N, Bandyopadhyay G, Doyle P, O’ Donovan A, Belton M. (2011) Looked after children in Dublin and their mental health needs. Irish Medical Journal 104(4): 105-8. 

NICE. (2015) Looked-after children and young people. See: nice.org.uk/guidance/ph28/chapter/3-Considerations (accessed 28 September 2020).

TACT Fostering & Adoption. (2019) Language that cares: changing the way professionals talk about children in care. See: http://www.tactcare.org.uk/content/uploads/2019/03/TACT-Language-that-cares-2019_online.pdf (accessed 28 September 2020).

Ward J. (1998) Substance Use Among Young People 'Looked After' by Social Services. Drugs: Education, Prevention and Policy 5(3):257-267. 

UK Government. (2020) If your child is taken into care. See: gov.uk/if-your-child-is-taken-into-care (accessed 28 September 2020).

Viner RM, Taylor B. (2005) Adult health and social outcomes of children who have been in public care: population-based study. Pediatrics 115(4): 894-9.

Voice, National Children’s Bureau. (2005) Start with the child, stay with the child: a blueprint for a child-centred approach to children and young people in public care. See: https://coramvoice.org.uk/sites/default/files/Blueprint%20main%20doc.pdf (accessed 28 September 2020).

Williams J, Jackson S, Maddocks A, Cheung W-Y, Love A, Hutchings H. (2001) Case-control study of the health of those looked after by local authorities. Archives of Disease in Childhood 85(4): 280-5.




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