EDITOR—Looked after children are among the most vulnerable in our society, with a higher level of health, mental health, and health promotion needs than others of the same age, as discussed by Polnay and Ward.1 Local authorities should ensure proper monitoring of their morbidity and developmental progress, which ideally should be documented in the annual medical reports.

In April this year the records of 60 looked after children in the borough where I work were surveyed to find out whether their health needs have been adequately addressed. All of them were under 5 years old when they were placed in care, and the records were selected randomly from a total of around 150 children of that age group who are currently under care. Twenty one of the 60 were placed with one of their biological parents, while the rest were either with their relatives (11) or with other carers (28).

All of them stayed in care for at least a year, and 24 had at least one change of placement in the first year. Of the 21 children who were placed initially with their parents, 12 had a change of carer subsequently.

Thirty nine of the children had their initial medical assessment within three months of placement, but only 22 had a further check within the following 6–12 months. Of these, 15 had a satisfactory increase in growth variables. Nine of these children developed speech and behavioural abnormalities, which were dealt with by referrals within six months of diagnosis.

Twenty eight of the 39 medical reports were completed satisfactorily, with clear documentation of the current health and behavioural concerns. For 24 of these children, however, the full medical and family history could not be elicited from the present carers.

This survey highlights the high incidence of change of placements and the poor access to the medical and family history. The Children Act encourages local authorities to place children with their biological parents, but, unfortunately, the changes of placements were particularly high among these children. We should also study the long term effects of these various placements on the children's cognitive development. The overall physical and mental follow up and the documentation of the records could be improved. All local authorities and healthcare professionals should safeguard and improve the quality of care in these crucial areas.

EDITOR—The editorial by Polnay and Ward about looked after children raises important concerns about this most vulnerable group of children.1 Of course they need tailor made care plans and not an annual physical inspection.

In the trust where I work, the school doctors and nurses were asked to log all contacts with looked after and adopted children over one term, summer 1999. All 11 doctors and 17 nurses reported contacts, with a total of 122 children seen. The nurses saw 74 children—30 (41%) for a proactive healthcare assessment, 26 (35%) for support for their emotional difficulties, and eight (11%) because of learning and developmental problems. The doctors saw 48 children—only three (6%) for proactive care, and the rest for referred problems. Of these 48 children, 31 had emotional difficulties and nine learning difficulties; the remainder had coordination problems, speech delay, encopresis or eneuresis, poor attendance, poor growth, or poor hygiene.

Both staff groups rated the rapport achieved as “excellent” for a third of the children (doctors 16 (33%), nurses 21 (28%)), with the doctors ranking a further 28 (58%) cases as “good rapport” and the nurses 22 (30%). As the nurses were doing more proactive than referral work they were more likely to experience reluctance from the children (six (8%) children).

A wide range of services were contacted for just over half the children. The doctors discussed their contact with social services for 25 (52%) children and the nurses for 31 (42%). The doctors discussed 10 (21%) cases with child psychiatric colleagues, the nurses seven (9%). Children were also discussed or referred to speech, eye, physiotherapy, and hearing clinics and discussed with educational psychologists, welfare officers, or special units.

The doctors planned to follow up 45 (94%) of those seen. The nurses selected 63 (85%) for planned review. Altogether 58 (60%) children in both groups had a planned review for the following school term. The others would be reviewed later in the school year. We propose to review these contacts in summer 2000 to ascertain how may are still under the care of their school doctors and nurses and how many have been lost to follow up.

These children are undoubtedly a needy group, and it is disgraceful that one still has to argue that the annual review should be replaced with tailor made care plans using school health staff.