Why can’t we get our fostering medicals done?

Background

For many years the process of completing the fostering medicals was relatively straightforward.

The first part of the medical form was completed by the applicant and the second part completed by their own GP, whether this be a new application or a review. This was then forwarded to the agency medical adviser who assessed the information and provided their opinion on any health issues discovered.

Whilst this could sometimes take a little time to complete, the process was relatively straightforward, with the occasional delay caused by a GP requesting payment in advance or delays getting an appointment for applicants to attend. On the whole the system worked pretty well.

The landscape is now changing rapidly, with more and more GP practices simply declining to complete the forms altogether. Even when the forms are completed by the applicant’s GP practice, it is rare that the GP knows the applicant well and may never have seen them before, so they are just completing the form from the medical records.

Why are GPs reluctant to complete the forms?

GP practices work as small independent businesses contracted to the NHS to provide a set group of services to their patient population. In return they are paid a fee per person per year, with some additional income from providing extra services and hitting quality targets. Their NHS contract does not include completing any forms such as life or holiday insurance forms, fit to fly forms etc, and this list includes fostering and adoption medicals. Anything outside of the contracted NHS services is considered private work and a GP practice can choose to do it or not and choose how much they charge for it, with the cost varying dramatically from one practice to another. An increasing number of practices are now choosing not to do any private work at all to save their resources to cope with the ever-increasing demand of their NHS services.

This isn’t the only issue. Many GP practices are not solely staffed by GPs. With recent funding from the government to employ a raft of other allied healthcare professionals to do some of the work previously done by GPs, many practices are now staffed by pharmacists, advanced nurse practitioners, paramedics, mental health workers and others, supervised by a reduced number of GPs.

The Fostering Services (England) Regulations 2011 do not state who should carry out any kind of medical examination. Schedule 3, Part 1 para 2 just states “Details of health (supported by a medical report)”. However, many agencies and indeed GP practices have assumed that this must be done by a medical practitioner. The current CoramBAAF form AH and AH2 also reinforce this incorrect notion by having a box to complete with the GMC number, which is only available to registered doctors.

The regulations differ slightly for adoption and state as follows “obtain a written report from a registered medical practitioner about the health of the prospective adopter following a full examination which must include the matters specified in Part 2 of Schedule 4 unless the agency has received advice from its medical adviser that such an examination and report is unnecessary.”, which is likely to have caused some further confusion. Even this does not state that the person filling in the ‘GP’ part of the health form needs to be a medical practitioner, just that the final report (probably from the medical adviser) be written by a medical practitioner.

As appointments with GPs are dwindling and being replaced by appointments with other allied health professionals, the opportunities for GPs to complete the forms is also dwindling.

What about NHS commissioning?

Many years ago, the recommended fees for various medical forms were set nationally, but this has long since ceased and as noted above, practices can charge what they want to provide non-NHS services.

In some areas, there has been negotiation between the local commissioners (ICBs, previously CCGs) and GP practices to complete the medical forms and at a set price.

These are local arrangements and with the increasing pressures on GP practices we are likely to see these fall by the wayside also.

What are the solutions?

Time after time, when a GP practice have said that they point blank will not complete the medical forms, a very carefully worded letter from the head of the agency or even the medical adviser outlining the importance of the medical process in safeguarding vulnerable children has resulting in the initially reluctant GP agreeing to complete the medical form. This is not a standard template letter sent with the form, but a personal letter from one professional to another. I have seen this be very effective numerous times.

If the GP practice still won’t complete the form, then there are a number of private GP services who will complete the form. However, the main issue here is that they need access to the full GP record. This can be requested by the applicant by completing a Subject Access Request (SAR) for free. This can be as simple as phoning or emailing the practice or sending a letter to the practice. The practice is obliged under the data protection regulations to provide this information within one calendar month and should provide the records in the requested format, which is often electronic.

The records received by the applicant may not be the entire record, as the GP practice is obliged to redact any reference to third parties or any information which may be deemed to be harmful to the patient.

The fees for a private GP service completing the forms can be substantial as the medical records supplied are usually unstructured and can often be in excess of a thousand pages. The reviewing GP has no prior knowledge of the applicant, so must review every piece of information. To review the records properly takes many hours to complete.

Beware of the services charging what seem to be very competitive fees to complete this task, as well as to interview and examine the applicant. With the average hourly rate of a GP being in the region of £120 to £150 per hour, you can imagine how much time and effort goes into completing this very time-consuming process for such as small fee.

What about the NHS app?

There are plans in the future to allow greater sharing of NHS health records and patients now have access to their GP data via the NHS app. Patients need to request access to see their full GP record.

Some software companies are working on ways to share this information with third parties, but they are currently very basic and relatively slow. However, it is anticipated that this will improve with time. This will certainly improve the ability for third party private services to complete the ‘GP’ section of the forms.

Most medical advisers will not want to complete this task in addition to their role in scrutinising the information. There is also an element of additional reassurance with independent practitioners completing the different parts of process.

What about self-declaration?

Self-declaration was used as a temporary measure during the Covid-19 pandemic, but it quickly became clear that this was fraught with issues.

Many applicants provided declarations of absolutely perfect health, but when the GP forms were finally available, they regularly revealed lengthy lists of medical problems and long lists of medications.

I don’t think that applicants were intentionally trying to hide anything. I think they just don’t see the things they have lived with long-term as ‘medical issues’ so omitted them.

What is the long-term solution?

The long-term solution needs to come from clarification of the regulations. Hopefully, this will form part of the proposed changes to the fostering process.

There is no reason why an appropriately trained healthcare practitioner could not complete the ‘GP’ part of the process, whereby information is gathered from the applicant, the medical records and if appropriate medical examination.

Changes to the wording of the CoramBAAF forms would help with this, along with some explanation of who can complete the forms. With a greater portion of the medical workforce able to complete the forms, the chance of a GP practice agreeing to do this is likely to increase and the cost is likely to decrease.

Worryingly, I have heard rumours of various proposed solutions to the problem during the recent consultation Department of Education. One of the most worrying solutions proposed was that the assessing social worker would sit with the applicant and flick through the NHS app together, with them deciding what is important medical information and what is not.

Let’s hope this one remains just as a rumour!

About the author

Dr Matt Orr has been a GP for over two decades and fostering and adoption medical adviser for almost as long. For all things fostering medical related check out our advice hub: Fostering & Adoption Medical Advice, Guides & Helpful Tips