Examination of Witnesses (Questions 1-19)
DR CHERYLL
ADAMS, FIONA
BLACKE, PAUL
ENNALS AND
DR SIMON
LENTON
18 MARCH 2009
Q1 Chairman: May I welcome Paul
Ennals, Cheryll Adams, Simon Lenton and Fiona Blacke to our deliberations.
It is good of you to give your time to give evidence to this Committee.
This session will in a sense be an educational one for us because
members of this Committee and the previous Committee are not experts
on health, but we know that our responsibilities as the DCSF Select
Committee run wherever children are. We are told that that runs
across 10 Departments, including the Treasury, and it certainly
runs across health. Much of the work we do leads us to an understanding
that health must be a vigorous partner in how we sort the problems
that challenge us in terms of dealing with children. We have just
finished a major inquiry into looked-after children or children
in care. That was very clear from that evidence and in a sense
it is very appropriate, as we have tucked that away and will be
launching that publicly in the next week as a report, that we
get more into the health sector. Your help is greatly appreciated.
I am not going to use titles. Is that all right? We are going
to go to first names because that makes it more collegiate. Paul,
can I ask you—I do not want you to tell us about your CV.
All of that has been read. This is, as you know, a fact-finding
session. Is there anything you want to tell the Committee or do
you want to go straight into questions?
Paul Ennals: I am happy to say
four very brief things, Chairman. First, NCB is the umbrella organisation.
We undertook the consultation with children and young people to
feed into the development of the Child Health Strategy. I am happy
to say more about that if it comes up in questions. A second role
is that NCB convenes the children and youth inter-agency group,
which brought together all the major agencies around children
and youth: the Local Government Association, the NHS Confederation
and others. They were involved with the two Departments in seeking
to develop this. The group very much welcomes the strategy, but
it has some issues about how to ensure that it is implemented
in an effective way. Thirdly, NCB also hosts the Every Disabled
Child Matters campaign that was particularly pleased to see the
recognition of the £340 million from the Department of Health,
but it is anxious about how that will work its way through into
change practice on the ground. Fourthly, I chair the Children's
Workforce Network, which brings together all the bodies involved
in different parts of the workforce. The development of the children's
workforce is an important thing within the Child Health Strategy.
It is not unproblematic, to be frank, to ensure that staff from
across all the different agencies are able to work towards common
aims in a way that takes account of each of their abilities.
Dr Adams: Our organisation represents
health visitors and school nurses in the community, but also paediatric
nurses and community nursery nurses. We are clear regarding the
contribution that health needs have been making to the children's
agenda. We are not sure that that has always been properly understood,
which explains the disinvestment in a nearly 150-year-old health
visiting service. The contribution of health visitors has been
the missing link in early intervention. There is a great deal
of talk about early intervention, but unfortunately I am not sure
that there is always understanding of exactly what that means.
The other thing that really concerns us is that we have moved
into a world of box-ticking and competencies, as opposed to looking
holistically at family needs. If you are really going to change
behaviour in and understand what is going on in families, you
need to have a relationship with that family. It has to be a trusting
relationship, involving a skilled professional who, when there
are changes in family behaviour—sometimes subtle changes—can
pick up and act on them early. To give you an example—the
mother coming to clinic with her child. Everything has been fine,
the family is middle-class and the father could be a doctor or
a High Court judge, but there is something about the mother. She
is a bit flat, and the baby seems stressed. The skilled health
visitor will not just weigh the baby; she will also inquire as
to what is going on with that family; she may offer to do a home
visit. It may be that, behind that, the father is drinking heavily
and there is a big relationship problem. That, obviously, can
have a huge impact on the family. There is that additional skill,
which is worth investing in and which will deliver the outcomes
for children in the longer term. It is not enough to think that
others can do the job. Others can do part of the job, but it is
very important that the right skills are doing the right bits
of the job. That is one of the big messages that I would like
to give. Equally, around the school nursing workforce, people
talk about school nurses but they often do not realise that there
are slightly fewer than 900 trained school nurses, who are specialist,
community public health-trained. They have much more senior training,
can work at a public health level and look at health in the round
in a school-age population, support and advise schools and run
drop-ins for vulnerable young people. They are very trusted. However,
many of the school nursing workforce are staff nurses, who can
deliver the organisational programmes—they do height and
weight programmes—and a lot of the technical, skills-based
work; but that more difficult work, of looking at the school in
the round and seeing if there is a drug issue or whatever, requires
those advanced public health skills. Unfortunately, we have about
3,200 secondary schools—there was a commitment from Government
that there should be a trained school nurse in every school, but
we have fewer than 900. There is a big issue there in moving the
children's agenda forward.
Q2 Chairman: Okay. We shall drill
down on that. Simon.
Dr Lenton: The Royal College of
Paediatrics and Child Health has been leading a piece of work
called Modelling the Future over the past three years,
looking at how we can better provide children's health services
in the future. We welcome the Child Health Strategy, with its
focus on earlier prevention health promotion programmes, but we
need to make sure that those prevention programmes link into targeted
and specialist services. For me the most important chapter of
the Child Health Strategy is chapter 7, "Making it Happen:
System-Level Transformation", because it reinforces the messages
coming across in the NHS review and NHS Operating Framework, which
essentially say that we must align services on the pathway that
children and families take through those services. For me, the
two important messages are alignment and improvement. What we
would like to see is commissioners, providers and regulators working
together, obviously on commissioning, providing and regulating
services, but basing services on children's pathways, constantly
looking for the weakest link in that pathway—I can give
you some examples later on—and then investing in improvement
at these points. The outcomes for children are only as good as
the weakest link. So far, we have seen the early development of
Children's Trusts as commissioning bodies, but at the moment their
capacity is relatively small in comparison to the task ahead of
them. Investing in commissioning capacity to deliver the Child
Health Strategy would, to me, be the most important element.
Fiona Blacke: The National Youth
Agency is the national charity for improvement and advocacy in
the youth sector. We welcome the strategy. We own the Department
of Health-funded youth health team who have been involved in the
development of the Healthy Youth Work guidelines. We have a particular
interest in the involvement of non-formal education in promoting
the health of young people. We have been involved with the development
of Teen LifeCheck and a range of other health developments. We
play a significant role in terms of the support of local authorities
and their partners in the development of integrated and targeted
youth support services. We have a critical interest in how this
strategy will actually support joined-up working at local level
around young people to make a real difference to their lives.
Finally, we are the developers and owners of Hear by Right standards,
which are the standards around young people's participation in
services, and we were intimately involved in the development of
the Youth Opportunity Fund and Youth Capital Fund, which is the
experiment enabling young people to have control of 25% of local
authority budgets by 2018. We have a particular interest in seeing
young people's voice and influence being made a reality through
this strategy, not only in education but much more broadly.
Chairman: Excellent. That gives us a
good start. Let's get straight into questioning. Graham, you are
going to start us off on the strategic issues.
Q3 Mr Stuart: Before we go into
that, I would just like to follow up on some of the points that
you made, Cheryll, on both health visitors and school nurses.
Why is it, when we have had such a major investment in health
and education over the last dozen years, that these particular
services seem to have fared so badly in terms of support, and
in fact numbers have reduced?
Dr Adams: I think that there are
a number of reasons. Unfortunately, health visiting was taken
out of statute in 2001. The view was that health visitors were
nurses and hence in policy the words "nursing and midwifery"
were modelled, but not the term "health visiting", and
I think that gave a message to primary care trusts that when they
needed to cut and save money, which as we know they have had to
do over the last few years, they have disinvested in health visiting
services. Health visiting is quite a complex job but, looking
in, it can appear quite simple. One can see why commissioners
might feel that it is something that does not need to be invested
in. So I think that there have been a number of reasons. There
have also been educational issues over the last 13 years. In 1995
health visiting training got reduced from 52 to 35 weeks, and
that was not delivering the outcome in terms of practitioners
who were able to do the job that had been previously done, so
there may have been some loss of confidence in the role from that
time onwards. I am glad to say that there was reinvestment in
proper training from 2004, so that is beginning to be felt now.
The other thing is that, of course, public health services deliver
long-term outcomes, and it is easy to make a cut if there is another
pressure on you to spend money on something that is much more
immediate.
Q4 Mr Stuart: Would you welcome
it if public health budgets were ring-fenced?
Dr Adams: Yes.
Chairman: Could you get on with
the strategic now, because we will come back to that and drill
down later?
Q5 Mr Stuart: Okay. Could you—we
are all split up on this—talk us through the collaboration?
The reason that this Committee is meeting with you today is because
we have to scrutinise the working of the DCSF, which, absurdly,
is responsible for youth justice, education, health—you
name it—even though, like this Committee, it does not have
the competent skill base in order properly to do that. So one
of the big challenges strategically is making people collaborate
together and work effectively in order to deliver an improvement
for people, delivering a holistic service. How well do you think
that central Government are leading that process, and where are
the biggest weaknesses in the system in terms of supporting child
health?
Paul Ennals: There is some real
progress. I understand the complexities of, for example, this
Committee managing areas across different parts of government
and different parts of children's lives. But children's lives
themselves tend to be joined up and so I think that the previous
models of governments and structures and services being very tightly
separated out have not served children and families well. The
process of trying to develop collaborative working is not easy
and it is only at relatively early stages of getting it to work.
But personally and from NCB, we strongly welcome the idea of dual
key, of joint working across the two Government Departments, and
I believe that practitioners across the piece have felt that we
need to find a better way of joining up the delivery of services—the
governments, the planning, the commissioning, the training, the
delivery at all levels. That is not the same as making everybody
the same, but making sure that the services themselves come together.
In some ways, I think that the statements within the Child Health
Strategy about integrated working are the strongest that the two
Government Departments have brought forward. In some ways they
are only following on the best practice in some areas, because
some areas of the country moved towards shared commissioning,
shared planning and shared delivery some years back, but the statements
are ahead of other parts of the country. I think that this area
of collaboration, particularly between health and the wider world
of children's services, is one that shows greater variability
than perhaps any other area of public service. We have examples
of really effective joint working and we have many examples of
where that simply is not the case.
Q6 Mr Stuart: Could you give us
some examples of particularly good practice?
Paul Ennals: It is a bit invidious,
but one would be Enfield in London, which has brought together
the governance planning, commissioning and delivery of child health
services with wider children's services. The North of the Tyne
PCT in Northumbria, which works across a lot of different local
authorities, is working with three local authorities, but the
quality of delivery around child health services is of a very
high standard. The director of children's services in the Brighton
and Hove local authority is also responsible for the delivery
of child health services through a collaboration with the PCT
where the areas are coterminous. There are a few more than those
three, but I will stop there. To be frank, there are many more
that I could have said, but maybe I will not, where the collaboration
is woeful.
Q7 Mr Stuart: Would anybody else
like to come in on this? I think that the Health Select Committee,
when it did a report, suggested that one of the weakest areas
for the DCSF was on the health agenda for young people.
Dr Lenton: Yes, I would like to
pick up on that. I completely echo Paul's comments that collaboration
is the most important issue but it is also the most difficult
to achieve. When I say, "achieve," I mean making a difference
for children and families to improve their lives. We are emerging
into an era where there is greater collaboration between DH and
DCSF but there is, I believe, a long way to go. If you like, what
happens at central government level needs to be mirrored at a
local level. To give an example I am going to talk about meningococcal
septicaemia, which is a fearful disease, but in its early stages
it is very difficult to differentiate a viral illness from something
that is more serious. It is the appearance of a non-blanching
rash that changes—if you like—a viral illness into
a medical emergency. From a parent's point of view, at that point,
they need good emergency services: emergency care practitioners,
ambulance services, resuscitation in the emergency department
and retrieval to a paediatric intensive care unit. All of those
services need to be in place and working well, but from a commissioning
perspective, you would want everything in place: high levels of
immunisation uptake, programmes in-school that educate children
in health—biology, recognising an acute illness and the
significance of a non-blanching rash. You want people in primary
care for example General Practitioners to be able to recognise
the sick child and take appropriate action, which would be an
injection of penicillin, and right the way through that pathway
you would want competent practitioners, doing the right things
in the right way at the right time. Sadly, some 10% of children
who go to intensive care come out with some residual disability,
and in the case of meningococcal septicaemia—
Chairman: What percentage?
Dr Lenton: About 10%, the commonest
problem being hearing impairment. So from that point on, you not
only want a system to screen all children for hearing impairment,
but for those who do have a hearing impairment, you need to have
speech and language therapy services, hearing therapy services
and, obviously, appropriate support services in the school setting.
The reason for talking you through that example is that, from
a commissioning perspective, you would need practice-based commissioners,
PCT commissioners, local authority commissioners and specialist
commissioners all coming together to make sure that they commission
the various component parts. And then, for each component part,
you need evidence-based services, delivered by competent practitioners
in the right place at the right time, as I have said, that is
a highly complex process—the beginnings, if you like, of
which are in the Child Health Strategy. There are words in there
about commissioning pathways rather than elements of care, and
there are statements about finding the weakest link, because that
is where you need to start your improvement process as that will
have the maximum impact on outcomes. Translating those aspirations
into reality at a local level requires complex, trusting, collaborative
working relationships between the various agencies.
Q8 Mr Stuart: Thank you. It also
requires that the priorities, targets and performance measures
in each of the organisations are all in parallel and all fit together.
If they don't, the incentive isn't there and they won't co-operate.
They will be driven by that which drives them—obviously.
A criticism of the Children and Young People's Plan was that it
laid out a world everyone could buy into, but did it actually
help bring together all the other services to make it happen?
That would be the question that I would put to you with this Child
Health Strategy. People often hear about joining in the vision
of this collaborative, smooth, seamless world in which the child,
rather than their own departmental view, is always the centre
of everyone's focus. Are you convinced that enough work has gone
into ensuring that this health strategy can bring the agencies
together and ensure that they work together?
Chairman: Fiona, would you like to come
in on that?
Fiona Blacke: I would like to.
Having visited 82 local authorities and talked to Directors of
Children's Services about the implementation of joined-up services,
I think the strategy can be as strong or as good as it likes,
but the reality is that it is down to local leadership. Paul referred
to places where it has worked, and that is due to incredibly strong
leadership, not only in the local authority but in the health
authority. Those are the critical elements. You talked about joined-up
performance targets and processes, but one of the critical factors
is that you need a common understanding of what the needs are.
In order to have that you need some common processes for gathering
data and understanding your locality. Those two things—leadership
and a robust understanding of the needs of local children and
young people—are the critical factors and the strategy is
there to support them. The role of government to some extent is
to be the backstop when that leadership does not do what it is
supposed to do. I am not sure that you can drive from the centre
that kind of joining-up and rapport.
Dr Lenton: I would like to add
to that the need to have a clear service model. If we shift from
how we do things now to delivery based on pathways on which children
travel through a range of services, you commission programmes
or pathways, you deliver pathways and then you regulate on pathways.
At the moment, the regulatory agencies tend to regulate organisations
or professional groups. They don't take that patient-centric view
of the world. Probably the most important message that came out
of the Darzi NHS Review is that we need to align our forces and
have appropriate metrics—and there is a lot of work being
done at the moment on quality metrics—and then that needs
to be associated with an improvement process. Again, the three
different agencies have different approaches to improvement, so
an alignment of the improvement agencies would also generate a
force for change to improve children's outcomes and achieve the
aspiration to make the UK the best place for children to grow
up.
Dr Adams: Leadership is absolutely
critical, but it has to happen at different levels. The role of
clinical leadership, particularly in the communities, has been
somewhat lost over the past few years. I am thinking about the
health visiting workforce who were clinical leaders for children
and hopefully will be again with the Child Health Promotion Programme,
but that does need to be understood and invested in. It is really
important that the Department of Health and the DCSF are working
together on this but, in public health terms, there are other
Ministries that need to be involved. I am thinking about housing
issues. Sometimes changing a child's housing can make a huge difference
to their health, much more than any of us practitioners can do.
That is important.
Q9 Mr Stuart: I would like to
move on to the issue of children's trusts. As you will be aware,
the Apprenticeships, Skills, Children and Learning Bill is going
to put children's trusts on a statutory footing. Again, everyone
would agree with the idea of where children's trusts should be
and that should bring things together, but the Audit Commission
report was fairly savage about the fact that children's trusts,
up to now, have not delivered that much improvement. But it was
early days. Do you feel it is right at this time to put children's
trusts on a statutory footing, and is there an alternative way
to the way that is currently being driven by Government so that
we could create the pathway-based rather than the institution-based
systems we want?
Paul Ennals: I do think it is
right, but it is not sufficient. It is necessary, but not sufficient.
The Audit Commission report was, as you say, early days. Indeed,
it did its fieldwork before every authority was even required
to have a children's trust, so it is a little bit unfortunate.
At the same time what we all know from the point of view of partnership
is that requiring people to come together is not necessarily the
best way of making people want to come together. I thought your
previous question was really insightful about picking up on things
like the performance measures and framework, and, as it were,
the language of management, which is often the biggest barrier
to making things happen. I welcome the creation of a statutory
framework for children's trusts boards and, more importantly,
I welcome the idea that the Children and Young People's Plan will
become owned not only by the local authority, but by the Children's
Trust partners. It will start, therefore, to bring together the
planning of PCTs and local authorities in a way that has worked
in the best areas but not only there. Underneath that we need
to find a way of ensuring that it is not simply a matter of a
senior person from the PCT being dragged screaming to the table.
They must feel that it is in their interests, understand that
it is the best way for them to deliver the outcomes for which
they also are responsible and see that working with their partners
in the children's trust is the most effective way of getting the
most out of their own staff. Legislation may be necessary, but
it is certainly not sufficient. And that will come through a process
of spreading the good practice and recognising, as the evidence
starts to emerge, that outcomes improve where services are working
more effectively together.
Q10 Mr Stuart: So should we leave
it that way? Should we put them on a statutory footing and then
allow them to sort it out themselves? The other way would be to
compel from the top; a pooling of budgets, for instance. The Audit
Commission report said that people were all turning up, but they
did not bring authority from their organisation. They did not
bring budget. That is why it did not lead to the transformation
that people would have hoped for from so much senior input.
Paul Ennals: There are times when
I have been really tempted by that as a solution, but I think
I have been persuaded by colleagues closer to the front line in
local authorities and PCTs that it would be a blunt and, dare
I say it, centrist instrument that would not necessarily bring
about the changes that we are looking for on the ground.
Dr Lenton: The issue is that at
the moment commissioning capacity is inadequate for the task ahead.
The aspirations here are enormous. We are talking about a transformation
in the way that the system delivers services for children across
the board from acute health services, right the way through to
mental health services and services for vulnerable children that
you have heard about before. That requires a change of mindset.
It is about having a clear purpose, a set of values both working
with children and within services and a clear model of service
delivery. Although it is tempting to put things on a statutory
basis and oblige the pooling of budgets and so on, until you have
the capacity to deliver on that, there will be some risks involved
with that approach. It is important to get a regulatory framework
in place so that you are regulating the commissioning process.
At the moment, regulation of commissioners is relatively weak
compared with regulation of organisations. That comes back to
your point about having a metric system to decide whether services
are being delivered. But actually the important point is that,
year on year, services should be improving and that should lead
to improved outcomes. At the moment, the system out there is not
ready for statutory, obligatory pooled budgets.
Mr Stuart: I see others nodding.
Dr Adams: It is something that
we need to work towards. One of the concerns is that there has
been a lot of expenditure on the bureaucracy and less expenditure
on clinical delivery.
Q11 Chairman: What expenditure
on what bureaucracy?
Dr Adams: The systems. I am just
thinking about some of the work that has come out around the Baby
P case and some of the child protection issues.
Q12 Chairman: We have lots of
people here, and we have a lot of competence on this Committee
in understanding complex issues, whether in health or education,
but a lot of people come before this Committee and talk about
bureaucracy in a rather vague sense. You are alleging that money
has gone from the front line to bureaucrats. Which bureaucrats?
Dr Adams: There is a lot of accountability
at the clinical level now, and to feed that accountability you
have to have the structures higher up to collect that information
and process it. I shall give you an example—a very practical
example I was given yesterday. A health visitor does a new birth
visit; it takes an hour, and she then spends an hour entering
that into a computer system. That type of bureaucracy needs systems
above. So I think it is very important that the administrative
systems are as streamlined as possible to ensure that the money
goes to where it is needed, which is close to children.
Q13 Chairman: But you would not
want health visitors not to write up their notes in a competent
manner would you?
Dr Adams: I am not suggesting
that, but I am suggesting that we are in a situation now where
many clinicians, such as health visitors—and obviously I
can speak about health visitors—are spending 50% of their
time on non-clinical duties.
Chairman: Did you say 15 or 50?
Dr Adams: Fifty. That is obviously
part of the process of having to feed in information in various
forms, which is okay for monitoring what is happening for children,
but, actually, a little freeing-up of clinical time might do more
in terms of child outcomes.
Q14 Mr Stuart: My last question
is about mental health services, described as the Cinderella role,
not least in the area of children's health. Can you tell us where
you think that fits within the new plan, how effective you think
it will be, in CAMHS, for instance, with serious delays in being
able to access services in different places around the country?
Do you believe that the Children's Health Strategy will deliver
a transformation in mental health services for young people?
Chairman: Who wants to take that? There
are eight sets of questions, so you do not all have to feel that
you need to speak on every one.
Paul Ennals: I have to say, briefly,
that the Children's Health Strategy said very little about CAMHS,
but to be fair that is because there is a very recent report that
summarised, looking forward on CAMHS across the piece. I think
there was a sense in the two Government Departments that they
did not want to replicate a great big report that they issued
only a few weeks earlier. I think the framework is right, but
that is simply not the same as saying that the problems are over.
This, I think, is one of those issues where we all just have to
be very grown up and realise that there is no easy solution. The
view that I think the great majority of people hold is that the
more we can be tackling emotional difficulties at a very early
stage on the front line, within tier 1 services—teachers,
early years workers and so on—the better it will be. If
we only focus on trying to strengthen the highly specialised CAMHS
services, then we will probably be going down the wrong road and
actually ending up with ever more children going that way. But
the overall structure is just about right now. It is just going
to take a long time, in my view, before we see any real significant
change. And it will take that much more awareness, understanding
and training of a very large number of people—not so much
the psychiatrists, but more on the front line.
Fiona Blacke: I have two points.
One is a recognition that the emotional and mental well-being
of young people is very much down to what they do with their time.
As Paul says, an emphasis on tier 1 services—not just schools
and preventive services, but positive activities, things to do
and opportunities to be with one's peers and significant adults—is
quite an important part of ensuring young people's mental health.
Secondly, we have, as part of our organisation, a body called
Youth Access, which is a representative body for voluntary sector
youth advice and counselling organisations. Those organisations,
at the moment, are reporting huge withdrawals in the level of
funding that they have received, particularly from health authorities
and yet, as first-line, front-line services for young people,
those are organisations that tend to be at the cutting edge of
mental health services. I think there really needs to be a look,
in terms of commissioning, about how you build up, from an existing
very strong local infrastructure, to a coherent framework of support
for young people. I do not think that that is there at the moment
and I think, if there is a weak area in the strategy, that is
the one for me.
Q15 Annette Brooke: Could I pick
up on the Children and Young People's Plan. At the moment, perhaps
apart from in Haringey, there is clarity about the fact that the
buck stops with the lead member and the head of children's services.
When this is a joint plan signed off by a statutory children's
trust board, will not the question of who is accountable for any
failure to perform be more complex, or will it be divvied up,
with people saying, for example, "Oh, that belongs to health"?
Let us take a target on teenage pregnancy, as obviously the statistics
on that have just gone up across the board. Where does the buck
stop when things do not work, and when you are all tied into it
formally?
Mr Stuart: They are all passing the buck.
Dr Lenton: It is an extraordinarily
good question. Ultimately, the director of children's services
should be the lead person in the Children's Trust board. Ultimately,
it will be the chief executive of the Children's Trust board who
will have to take responsibility. If we are envisaging a world
in the future where truly all children's budgets are pooled, then
clearly that crosses a lot of traditional boundaries, and it is
very unclear how that will be resolved in the long term. You effectively
need some collective responsibility, but ultimately, as you rightly
say, someone has to carry the can. It is difficult to know at
the moment quite what children's trust structures will look like.
I assume that they will start mirroring some of the traditional
organisations, with a chairman and a chief executive, but we are
not yet at that point. Essentially, the person at the top of the
organisation is responsible for the work of the various organisations.
Paul Ennals: It is of course a
very good question, but in my view there is a fairly clear answer:
a decent Children and Young People's Plan will set out not only
what will be delivered, but the accountabilities, not only at
the very top, important though that is, but on delivery. You picked
out the example of teenage pregnancy, and that is a classic example
of where effective delivery of a strategy has to involve schools,
but it also has to involve child health services and contraceptive
delivery services, from a range of people. A lot of agencies will
need to be involved, and a good, effective Children and Young
People's Plan will make it clear who is responsible for what part
of that delivery. I very much hope that, once the legislation
comes through and once the guidance is available, that will become
very explicit.
Q16 Annette Brooke: It sounds
as though we should be asking for guidance on that to make sure
that it is there.
Paul Ennals: I am sure you should.
I cannot remember the detail, but I believe that there is guidance
and a clause in the Bill setting out that there will be guidance.
I would be surprised if the Committee did not look to see some
indication of what will be in it, as the committee for that Bill
rolls through.
Q17 Annette Brooke: Secondly,
I want to move on to another example. I know that we are supposed
to be covering strategic issues, but I think that the examples
do tease out the problems. Simon has mentioned speech therapy,
which for me is the classic case. I have lived through many years
in which it has been the case that someone says, "That's
health and that's education", and the child in the middle
does not get any speech therapy. On the real issue of the health
strategy and the tightening up of the structures as they already
exist, can you talk me through how speech therapy for a child
will be accessed? Perhaps I could go back a stage. Suppose I,
as a mother, go to my GP and am told, "Oh no, don't worry.
He's just slow at starting to talk." There would not be a
proper recognition of that. How will that all work through? Can
someone talk me through the process?
Dr Adams: There are a lot of ways
in which a speech difficulty could be recognised by the parents,
but not always by a professional in a pre-school setting. Obviously,
at the moment the process is that the referral would then be made
to the speech and language therapy department, which sits within
health. I understand that unfortunately, referrals have gone down
in the pre-school period and fewer children are being recognised
until they go to school, so referrals then come from school to
the speech therapy department. Does that answer your question?
Q18 Annette Brooke: Not entirely,
because I have always seen it as such a huge problem, in that
there is speech therapy that can be given within the school system,
but also a specialist health-type speech therapy. I have been
to projects where the two have worked together but I think that
they are few and far between in this country.
Dr Lenton: I think that what you
are alluding to is that you want a robust, multidisciplinary,
multi-agency, community-based team that supports children and
families where children have a range of disabilities. Part of
that resource is obviously speech and language therapy. But we
also need to take one step back and say that we know that speech
and language problems are not evenly distributed right across
society. So, preventive programmes—encouraging language
development through the Healthy Child Programme—as well
as a system for picking up parents' concerns, easy access to a
more specialist opinion, and if necessary access to even more
specialist speech and language therapy, for children with autistic
spectrum disorders for example, all need to be built into the
pathway that I have been describing, which is delivered by a range
of people all working together within a wider network. There are
teams out there. Some are school-based and some are community-based
but it is not very clear where their roles and responsibilities
lie. At the moment we often lack that clarity and that leads to
the kind of gaps in services that I think you have alluded to.
The new model is based on teams coming together in a way that
we have not managed to achieve in the past.
Q19 Annette Brooke: So, models.
I just wish to further the GP point because there has been a lot
of debate about whether GPs should have been brought in to multidisciplinary
working rather more formally. I think that at the Children Act
stage we were arguing that GPs should be in there, because people
can get very different experiences of their gateway into the services
if they go to their GP. Do you think that GPs should be given
a greater role in the model?
Dr Lenton: I have to preface my
comments by saying that I am not speaking on behalf of the Royal
College of General Practitioners, but I think that their college
acknowledges that it would welcome a longer period of training
for GPs, particularly relevant to the common problems that children
present with. There is an issue here about the competence and
capacity of general practitioners to recognise and act on the
concerns which parents sometimes present. GPs obviously are autonomous,
independent practitioners. They are involved with practice-based
commissioning and have a place on the PCT Professional Executive
Committee and advise the PCT from a GP perspective about the services
that are required. Clearly, there needs to be a similar arrangement
with Children's Trusts, where there should be GP representation,
and obviously that is recommended in the Child Health Strategy.
I think that there is the broader issue of the competence and
accreditation of primary care teams, and again the Child Health
Strategy states that it would like to see child-friendly accreditation
of primary care systems, together with more measures within the
quality assessment framework for general practitioners. So, there
are a number of issues about the engagement of all the members
of primary care teams—not just GPs—in this process
of recognising children who might have a speech and language therapy
problem. The role of people in primary care is largely to identify
that there is a problem and then refer it on to the community
team.
Fiona Blacke: I just want to turn
your question slightly the other way around and talk about young
people's experience of GPs. I think that GP services could be
so much more effective in supporting young people's health outcomes.
For many young people GP services are very inaccessible. That
is not to do with the GP but with the receptionist—how much
they want to know when the young person walks in, and the approach
that they take. I also want to give a very quick vignette of an
example of a young woman involved with the local youth services
who had had two terminations following unplanned pregnancies.
She moved to a new area and went to see a GP who said, "Actually,
the injections that you are receiving, the contraceptive device,
are very bad for your long-term health. I think we should move
you to oral contraception." This was a very disorganised
and chaotic young woman, and—surprise, surprise—she
ended up having her third termination. For me, that suggests that,
of course, GPs operate from a clinical basis and think about what
is best for young people's health, but they are not always linked
into that broader understanding of the other issues that may be
impacting on and affecting young people's lives. Therefore, from
a strategic point of view, in terms of both the training and development
that they and their staff receive and their understanding of the
lives of young people, we have to involve GPs, because they are
front-line services. That was a contorted answer, but it was what
I wanted to say.
Chairman: That is very interesting.
Paul Ennals: The issue was about
the engagement of GPs in children's trusts, as I read it. This
is a tricky one, and I think that it is one where the Child Health
Strategy tiptoes around a little. On the one hand, it is absolutely
clear that GPs have an important and major role in meeting the
health needs of children and families, and they will doubtlessly
continue to do so. The GPs whom I know—I know many—know
that most of the effects on improving health outcomes are ones
outside their immediate control. So they know that they want to
need to be engaged with, influencing and working with the various
other services out there. But they, in some ways, are a bit temperamentally
like head teachers—they do not want to be attending meetings
for the sake of meetings, nor do they want to have to go through
minutes and all that kind of clobber. They perceive children's
trust boards and the paraphernalia around them as running the
risk of being that. So at the moment, the Child Health Strategy
suggests that they should be coming in to provide professional
advice to the children's trust boards. In my view, that is probably
a necessary step at the moment, so that they can become more involved.
If it was the opposite—if it was saying, like all others,
you come under the duty to cooperate, and you kind of have to
be there—the GPs whom I know just would not do it. They
are such an important part of the delivery framework that there
must be a way of engaging them, using their skills and involving
them in a voluntary way. I believe that in three to four years,
the mood will change—GPs will almost be demanding a seat
on the board, because they will see that that is where the delivery
of a joined-up service to children and families is steered.
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