Abstract
Background
Children who are unable to be cared for by their birth parents are looked after in a variety of settings, some of which become permanent through both private and public law processes. This includes Adoption and Special Guardianship Orders (SGOs) among others. For the first time ever in 2019 the number of SGOs granted by the courts overtook the number of Placement Orders (Nuffield Family Justice Observatory, 2019). The laws governing adoption and special guardianship differ in many ways but both are intended to meet the need for children to grow up in permanent families. This note explores those differences from a medical adviser’s perspective and the impact this may be having, and makes recommendations about future practice.
As a medical adviser for adoption and now a designated doctor for looked after children for over 17 years, I have worked with children moving into and out of care, into special guardianship and adoptive placements. As a community paediatrician I sometimes meet those children again (or others like them) in paediatric and neurodisability clinics. I am concerned that the differences in the statutory processes for both adults and children in adoption and special guardianship placements lead to an inequality of care and potentially also outcomes.
The practice of finding stability and permanence for children through adoption is a historic process with strict statute and regulations to ensure the welfare of the child, the suitability of the adopters and the lifelong nature of the commitment. Adoption has been seen as the placement choice to which the highest standards must be applied.
The role of the adoption medical adviser
The Adoption Regulations (2005) lay out the role of the medical adviser in assessing the holistic health needs of both the child and the prospective adopters to ensure that all are fully aware of the child’s needs and the adopters’ capacity to meet those needs in the short and long term as a permanent member of their family. To this end a comprehensive report on the child’s health is produced by the adoption agency’s medical adviser. This includes a summary of their medical and social history and the impact this may have both now and into the future (The Adoption Agencies Regulations 2005). This forms part of the application to court for the placement or adoption order. It supports the welfare checklist (Adoption and Children Act 2002) and helps local authorities to evidence the requirement in the Children and Social Work Act 2017 (section 8) ‘that due consideration must be given to any significant harm that the child had experienced, and that the parenting capacity of the prospective adopters must be able to address the consequences’.
It has also become good practice for medical advisers to meet with prospective adopters to discuss the contents of the medical report and the needs the child is presenting with prior to panel. This is intended to help them understand the complex interplay of social, environmental, genetic and other health history on the child. This meeting also fulfils the process requirement that prospective adopters are fully informed prior to a link being approved at adoption panel. Research suggests that this information-sharing improves the long-term stability of adoptive placements and helps would-be adopters to feel more prepared for the demands that looking after that particular child may have on the family. Hill and Edwards (2009: 45) note: ‘Adopters felt that lack of information also limited their understanding of the child and therefore their ability to offer therapeutic parenting; they were “parenting in the dark”.’
The medical adviser also prepares a report with respect to the adult applicant’s health and the impact this may have on parenting specifically (as laid out in the Adoption Regulations 2015).
The medical adviser, as a member of the adoption panel, also helps to scrutinise the suitability of the match between child and adopter(s) and the Adoption Support Plan, bringing a medical perspective to ensuring that all the needs of the child will be met.
Medical advisers and special guardianship
In an application for an SGO almost none of the above applies. Medical advisers may be asked (depending on commissioning of the service and the status of the guardian, i.e. foster carer or not) to produce a medical report on the health of the adult applicant. S/he is not asked to produce a report on the holistic health needs of the child.
Section 8 of the Children and Social Work Act 2017 still applies to these placements but is not supported by the same level of evidence as that for adoption.
The medical adviser is not asked to meet with the prospective guardian(s) to help them understand and prepare for the needs of the child from the holistic health perspective.
This is not equality.
Children in special guardianship placements come from the same kind of complex backgrounds as those for adoption with potentially similar long-term consequences. In order for parity they deserve the same level of service, information and support. This has been partially recognised by special guardianship families having access to the Adoption Support Fund (ASF) to help meet their ongoing needs although fewer special guardianship than adoptive families tend to apply.
The courts and local authorities are accepting of the use of special guardianship and see it as a viable alternative within in permanency planning (Harwin, et al., 2016) but questions need to be asked about whether the process is meeting the wider needs of the children and carers.
Research has shown that a successful placement can best be promoted when special guardians feel well prepared for their role yet often this is not the case; special guardians feel they have had limited information about the child (Wade, et al., 2014).
The Nuffield Family Justice Observatory’s (2019) report on SGOs clearly identifies the gaps in the special guardianship process that will inform the guidance which, in July 2018, the former President of the Family Division invited the Family Justice Council to draft.
The Nuffield report states that: A plan for action will require a joined-up approach in identifying a future strategy that involves the courts, the Department for Education, Cafcass, the Ministry of Justice, the Adoption and Special Guardianship Leadership Board and the Family Justice Board. Local Family Justice Boards also have a crucial role in helping to promote consistency in decision-making and in developing a local problem-solving strategy consistent with the main findings on gaps in evidence.
I would want to add that health should be included in this long list of partners at a national and local level. This would help to address some of the gaps identified by the research noted above. In order to remove the inbuilt disadvantage we are placing on these children, the Regulations around SGOs need to be enhanced to give special guardianship arrangements parity with adoption (including the health elements).
I am not the first to raise the call for this parity in statute (see Harwin, et al., 2016). Joint working across disciplinary boundaries is vital if the system is to have a truly holistic approach to a family’s needs. In health and social care management we are moving away from silo working into integrated care systems. The care system for our children needs to follow the same model.
A call for ‘permanency’ medical advisers
A first step for the closer involvement of health would be to widen the remit of the medical adviser for adoption to include children and adults in the special guardianship process so that s/he becomes the ‘permanency’ medical adviser. The medical adviser could then be involved in properly supporting SGO applicants and advising those involved in their planning regarding the needs of the child.
As a specialist paediatrician experienced in the complex needs of children in the care system, the medical adviser brings a unique set of skills and a very particular perspective that enriches the knowledge about a child and the analysis of the child’s needs. Any system that removes this diminishes its quality.
Embedding the permanency medical adviser in the process would require an overhaul of commissioning and would be no small task. Despite the role’s statutory nature, the commissioning of medical advisers within regional adoption agencies has been complex, involving working across commissioning boundaries, and remains problematical in many areas.
Such a change would also need alterations to legislation that put the permanency medical adviser in a statutory role as per the medical adviser in the Adoption Regulations.
It could be argued that this should be taken one step further to move from adoption agencies to permanency agencies. This would address many of the gaps identified by the Nuffield Observatory report in so many different ways. It would allow the same process to be followed however a child was to find permanence, the same services commissioned, the same training offered, and so on. This would include the medical adviser role for both the adults and the children. Then all the lessons learned over the years from adoption – the preparation of carers, the expertise of specialist social workers, of medical advisers and others, and the support offered to child and adult alike – could be shared into the wider remit of the new system. Only then, with good multi-agency working would we have achieved equality in permanence for children.