Examination of Witnesses (Questions 40-59)
DR CHERYLL
ADAMS, FIONA
BLACKE, PAUL
ENNALS AND
DR SIMON
LENTON
18 MARCH 2009
Q40 Chairman: So if this Committee
looked at the training of health visitors in a robust way, do
you think it would stand up to our scrutiny?
Dr Adams: If the Committee looked
at it?
Chairman: Yes. We are looking at social
workers and teachers, so why not health visitors?
Dr Adams: Yes, why not? That is
fine.
Chairman: Paul, did you want to come
in here?
Paul Ennals: Just a brief addition:
I thought it very helpful that Cheryll said that she is interested
in the option of people coming into health visiting through other
routes, such as psychology graduates. That starts to open up the
area that you are rightly raising. The role of health visiting
is changing, because children's services are changing. The Child
Health Promotion Programme itself sets out new and different expectations
of health visitors, including co-ordinating multi-agency teams,
which many but not all have done in the past.
Q41 Chairman: Why do we not have
a new profession of social pedagogues? Why do we not borrow the
Danish model and get these guys to do everything?
Paul Ennals: I am agreeing with
you, Chairman. I am glad that the Secretary of State for Health
last week, following Laming's report, set up a new review of the
role of health visitors, which will look to see how it can be
made that much more modern and ready to address some of the issues—not
only the issues that legitimately came out of the Laming inquiry;
it is an opportunity to look at this role, which I believe is
extremely important, but I think there is scope for it to be modernised
and for it to work that much more effectively across some of the
other important roles within children's services. I suspect that
that might even be a necessary part of taking it through the next
10 years in a way that will give it hope.
Chairman: Okay. Thank you for that.
Q42 Mr Timpson: The Health Committee
produced a report on Monday on its inquiry into health inequalities.
It said a number of things. First, it said that Sure Start has
still not demonstrated significant improvements in health outcomes
or health inequalities for either children or parents and that
research from Ofsted has highlighted that children's centres are
not yet successfully reaching all the families who would benefit
from the services that they offer. Bearing those two conclusions
in mind, is it right for the new Child Health Strategy to set
so much store on children's centres to deliver better health outcomes
in the reduction of health inequalities for children? Any takers?
Dr Lenton: I think on this whole
issue of growing inequalities, both nationally and internationally,
that inequalities are getting larger over time. We need to examine
the underlying root causes for that. It is something about the
way that a market economy works and the distribution of wealth
in countries. Logically, Treasury macro-economic-type approaches
to reducing inequalities must be a long-term strategy. However,
the health service and other agencies have a role in working with
those families who are most affected by inequalities in today's
society. There are two aspects to that: one is trying to remediate
the underlying inequalities, and the other is trying to improve
access to health services—and other services—for those
who are most vulnerable. The evidence shows that Sure Start was
not particularly successful at reaching the families that were
most vulnerable. Obviously, the Family Nurse Partnership Programme
that is starting now is an evidence-based programme. It works
for those who are the hardest to reach in society. The simple
answer to your question is that we need a variety of approaches
to work with different groups who are relatively excluded in society.
There are issues around black and minority ethnic families, and
issues for immigrants and for the very low-paid and so on. There
is no simple solution, but we must use evidence-based programmes
wherever possible and implement them in a way that works. Over
the years, we have had a number of initiatives. The report that
you refer to, which I have not seen, suggests that there has been
insufficient evaluation of many of the initiatives that have been
put in place to try and redress some of the issues that we are
talking about. A lot of the time, we are not necessarily learning
from the experience of trying to improve the outcomes for these
vulnerable groups. That is an important message for the Committee.
Chairman: That is very important. We
are running out of time. David, you are going to take two sections.
I am sorry—we indulge ourselves in the early questions,
and then we get under great pressure.
Q43 Mr Chaytor: I want to ask
about skills; but before that, I want to raise an issue about
the document as a whole. I understand the importance of streamlining
procedures and adjusting systems to improve the way in which we
deal with a range of regular health issues, from pregnancy and
speech therapy to complex diseases, but the issue in Britain now
is really about drugs, sex, diet and fitness. I do not see much
in here that responds to the fundamental causes of our children's
problems with drugs, sex, diet and fitness. Are you convinced
that this kind of bureaucratic tweaking of procedures and refinement
of systems is seriously going to make a difference when confronted
with the power of marketing in, for example, the alcohol industry,
the food industry, the fashion industry through its increasing
sexualisation of young people and the computer games industry?
There is no reference to the social and economic context in which
the dysfunctionality of our young people's health problems has
developed. Is that a fair comment?
Paul Ennals: If I can start on
that—
Chairman: We are going into rapid mode
here. Some quick questions, which David will now be an exemplar
for.
Paul Ennals: Then I will make
two or three very rapid points. It is largely a fair comment.
The Child Health Strategy itself cannot control every aspect of
human society, nor can government. It is right to say that little
is directly said about obesity and so on. However, that categorisation
of the issues into those four categories—one could always
add the occasional extra one—is an adult orientation. Those
are the presenting issues, but, as Simon was saying, the underlying
causes are much deeper than that. Trying to move towards schools
and children's centres and other services looking at children
and families in the round is more than simply a bureaucratic approach
to starting to address those issues. Of course, it does not address
them fully. I know that the health and inequalities report out
on Monday was surprised that the Government had not felt able
to be much stronger on things like food labelling, where a lot
of the real changes will come. At the same time, I do not subscribe
to the gospel of despair that says, "We simply can't do anything
against these terrible outside forces of commercialisation."
We can, but we cannot stand up to them on our own. In my mind,
the key bit is the empowerment of children and young people, so
that they feel more confident to make their own decisions, regardless
of what the media or any of the other pressures are starting to
force upon them.
Dr Lenton: As a public health
trained person, I have to endorse Liam Donaldson's view that we
need to make alcohol more expensive. We need to make cigarettes
more expensive. We have successfully had an anti-smoking campaign
where you do not smoke in public places. We need more, fairly
bold public health policies for some of these underlying issues.
The only way that you add value to food is by processing it. Essentially,
that adds sugar, salt and fat, and that makes it a health hazard.
Q44 Mr Chaytor: Would this strategy
be strengthened if it confronted those issues as well?
Dr Adams: Yes.
Q45 Mr Chaytor: May I ask you
about schools? Is there any evidence that the development of extended
schools or the launch of the Healthy Schools Programme have had
an impact in recent years? Are schools getting their act together
in terms of taking child health more seriously?
Paul Ennals: Yes to all three
questions. There is significant evidence of the impact of the
Healthy Schools Programme on a range of outcomes. Although the
evaluations commissioned by the Department have tended to look
more at education outcomes, there is quite strong and robust evidence
of improvement in outcomes under a range of headings for children.
On extended services through schools, similar evidence is emerging,
but up to now it is fair to say that that has been a bit of a
tag-on to the key roles of schools, and to a certain extent it
will always be so. I see the Child Health Strategy as at last
starting to join up some of the dots. If we make the delivery
of PSHE statutory, ensuring that we start to upgrade the quality
of the training, support and professionalism of those teachers
who are addressing the life skills of children, add that to what
I hope is a strengthened Healthy Schools Programme that has more
teeth to ensure that schools really have to demonstrate some changes
before they are certified for that, and add further extended services
through schools, we will start to see the picture that is described
in the 21st Century Schools document for the Department,
which shows schools beginning to meet the wider range of children's
needs. I think that the early evidence is pretty robust, and I
would be happy to submit some stuff on that for you.
Q46 Mr Chaytor: May I ask Cheryll
about school nurses? Did you say earlier that there are only x
hundred school nurses?
Dr Adams: There are just slightly
under 900 who actually have the specialist practice training.
Q47 Mr Chaytor: Are they located
within schools or with GP practices?
Dr Adams: They are located on
a community basis but would probably go into school once a week
for a secondary school.
Q48 Mr Chaytor: In terms of schools
moving forward and making a bigger contribution, shall we get
to a position where every school has a school nurse?
Dr Adams: The interesting thing
is that every independent school has a school nurse, but every
state school does not. The thing is that the school nurse is a
trusted brand with children, and children will often disclose
things to a school nurse that they would not disclose to teachers.
In some areas of the country school nurses run drop-in clinics.
That should happen in every secondary school, probably led by
a school nurse or another health professional. That is an opportunity
to support children, particularly around sexual health. Obviously,
in terms of the PSHE programme, there is a suggestion that school
nurses could deliver parts of that with the schools, because there
are some bits that they might do better than teachers, because
of where they are coming from. I think that the potential role
of the school nurse has perhaps not been as well understood in
recent years as it could be. If we could get the investment so
that there was a school nurse in every secondary school, as was
promised in 2004, we would start to see the outcomes they could
deliver alongside schools.
Fiona Blacke: I just want to say
that it would be great to have a school nurse in every school,
but I also think that school nurses in isolation are not what
we need. We need joined-up services around schools, which is the
whole notion of extended schools. Sometimes health visitors are
the best people to deliver health promotion messages, but sometimes
it is youth workers and sometimes volunteers. What there needs
to be is a cluster of professionals supporting both the educational
and social outcomes for young people in schools.
Q49 Mr Chaytor: Cheryll, you touched
on PSHE. What more needs to be done to make it more effective
in improving health?
Dr Adams: I do not think that
I know enough about the content, to be honest, to respond to that.
Fiona Blacke: I will start on
an opener. Paul has great knowledge of PSHE. From our point of
view, there are some wonderful examples of PSHE being delivered
in the partnership approach, with PSHE specialist trained teachers
acting not only as the deliverers but the commissioners of other
people to deliver PSHE in schools. There are great examples in
Coventry of multi-agency teams working to deliver health promotion
messages. I think that the strategy is incredibly positive in
terms of its emphasis on PSHE, but what we need to see is a kind
of embedding of multi-agency practice around that. For example,
there is a school in Bristol where the school council made up
of young people said to the head teacher that they wanted sex
and relationship training delivered not by teachers but by the
local youth service. That has been incredibly effective. We also
know from teenage pregnancy statistics that some places, which
have the same demographics as other places, have made a difference
because they have much more joined-up approaches to a broad PSHE
offer, both in school and out.
Q50 Mr Chaytor: So, in terms of
that specific issue about the variation in the teenage pregnancy
rate, what are the key lessons to be learned from those areas
that have made the most progress?
Fiona Blacke: The first thing,
which perhaps sounds a bit obvious, is that they recognise that
teenage pregnancy is linked to every Every Child Matters outcome,
so it is as much about how well a young person is being served
in school and their ambition and aspiration as it is about health
education. So it is that kind of holistic approach. The other
thing is that there is a co-ordinated approach to both health
education and to access to contraception and services.
Q51 Mr Chaytor: To what extent
should this be a centralised, top-down, national, prescriptive
programme, as against allowing for local variation? Is it legitimate,
for example, to put the responsibility on local children's trusts
to develop their own approaches at the risk of them then not having
the appropriate outcomes? The variation in the teenage pregnancy
rate is a classic example of that, I suppose. How do we get the
balance between what should be determined centrally and what can
be experimented with locally?
Paul Ennals: It is always this
tricky combination of tight and loose. But the evidence is clear
that local areas are most effective when there is co-ordinated
and forceful leadership across the piece, effective delivery of
contraceptive services and effective and focused delivery of sex
and relationship education. If you have those three factors, there
is an almost complete correlation to a systematic reduction in
the number of teenage pregnancies. The detail of that can appropriately
be left to local areas because the first and most powerful factor
is local leadership, and that is most effective when local leaders
have a bit of scope to make their own decisions.
Chairman: I want to get two more sections
in. Briefly, Edward on health services for young people and then
John on health promotion for young children.
Q52 Mr Timpson: I would like to
ask Fiona about health services for teenagers. Anne Longfield,
the Chief Executive of 4Children, has criticised the Child Health
Strategy in that it does not do enough for the needs of teenagers.
She goes so far as to say that it neglects them. Do you agree?
Fiona Blacke: I do not. I think
that the strategy makes a fair fist of addressing what needs to
be done in terms of teenagers. Paul articulated this in terms
of young people's view of what they need. They need to understand
the local offer and to be able to access services in the right
places. They need a joined-up approach and they need to know that
the professionals who are dealing with them have the skills. I
think that the strategy puts in place the framework for that.
It was not entirely clear to me what Anne saw as the additionality
that was not there but was required.
Q53 Mr Timpson: What do you see
as the essential elements—the core aspects—of what
the strategy talks about as a teenage-friendly health service?
Fiona Blacke: I think that the
first thing is that young people are consulted about where they
want to access services and how they want to access them. The
second is about anonymity and confidentiality in the sense that
those services are there for them. The third is probably just
that the people involved in the delivery of those have an understanding
about the challenges of adolescence. The final thing is the option
to tell your story once and not have to tell it many times to
many different professionals in order to get the support that
you need.
Q54 Mr Timpson: Just picking up
on your view that there needs to be an understanding among the
professionals who are dealing with teenagers of the specific issues
that they are raising with them, is there specific training for
health professionals to deal with teenagers and their specific
problems? Is enough being done to ensure that young people have
access to those types of health services?
Fiona Blacke: I think that it
is emergent. The strategy for the children's workforce is going
to support that development of a common core of understanding.
It is not there yet and therefore it is pretty ad hoc. You will
find that in some places people have received training and in
others that they have not. Again, it is sometimes down to the
local leadership developing joint training programmes for staff.
I just want to make this point again because I think that typically
in health services there is an emphasis on clinicians rather than
support staff. One of the things the strategy could helpfully
do is look at the needs of other staff in terms of understanding
children and young people. But that needs more work and more resource.
That is two-way: it is partly about medical staff understanding
young people, but it is also about other young people's services
understanding health services.
Chairman: A good point. Simon.
Dr Lenton: Just to say that the
Royal College of Paediatrics and Child Health is leading a piece
of work on an adolescent project which is about making health
staff—that is wider than just paediatricians—aware
of the needs of adolescents and teenagers so that they more appropriately
deal with their concerns. It covers many of the points that Fiona
has made.
Q55 Mr Timpson: Is that a wide-ranging
review of all the health services that teenagers require?
Dr Lenton: No, this is not a review
of health services. It is about giving staff the skills to work
with young people.
Q56 Mr Timpson: Something we touched
on a little earlier is the access to mental health services. The
general view was that it is not sufficient and that the strategy
perhaps does not deal with it in the way that we hoped and identify
it as a crucial element of the overall health strategy for children.
Is there anyone who would dissent from that view?
Dr Lenton: There has recently
been the CAMHS review, which is very wide-ranging. I think that
most of us at this table would agree with its recommendations.
The Child Health Strategy was, if you like, in parallel with that
and, therefore, rather than reiterate everything that is in the
CAMHS review, the strategy is focused on other areas.
Paul Ennals: They were due to
come out the same day, but the Child Health Strategy was delayed
by some time.
Q57 Mr Timpson: So if the Child
Health Strategy takes on board the recommendations of the CAMHS
review, you will be satisfied that enough is being done to ensure
that the early intervention required for children and young persons
who have mental health issues is being addressed.
Paul Ennals: Broadly, yes.
Q58 Mr Heppell: Can I ask a couple
of questions on protection for vulnerable young people. From what
we have seen in the brief anyway, there seem to be a number of
initiatives that are already in place, but there does not seem
to be much new about the overlapping problems that vulnerable
children will have. For instance, there is the funding for the
family approach, which starts in April 2009. There is an extension
of family intervention projects. One of the other factors is the
Targeted Youth Support that is supposed to pull all the different
agencies together. Have the Targeted Youth Support reforms improved
the provision of health? Has it worked?
Fiona Blacke: In some places,
it has worked. There has been a recent evaluation of Targeted
Youth Support. In some places it has worked; in other places there
is no significant evidence that the young people in receipt of
TYS are those who would not have been identified or in receipt
of services otherwise. I think that it is about the relationship
of the universal to the targeted. In the places where it is working,
there seems to be a recognition that there is a universal baseline
of services, and people who are well briefed and able to identify
young people with particular issues and who have an understanding
of the referral processes that they would need to go through to
get targeted support. People are using those mechanisms, and the
two sets of services are joined, so that a school really understands
who it should contact when it identifies a young person with a
particular health difficulty or whatever, and refers them in.
The systems for assessment are common and there is a single lead
professional who is very well equipped to broker a package of
services around that young person. Most importantly, there are
also systems, for when the targeted support is finished or to
run in parallel with it, for supporting young people back into
universal services. Targeted Youth Support is working well. I
am not sure that health has always been a significant feature
in Targeted Youth Support, or not as big as it should have been.
It has generally been Connexions, youth services, youth offending
services, and I think that the strategy says that Targeted Youth
Support has to engage health services and provide support, and
that will make a big difference.
Dr Lenton: I would agree with
that. I think that health had been a relatively weak partner in
the teams supporting vulnerable children and families, and in
Youth Offending Teams likewise.
Q59 Mr Heppell: Do you think that
the strategy now actually articulates a clear vision? It seems
to me that you are saying that it seems to be a bit ad hoc and
a bit dependent on who is working for whether it works. Is there
a clear vision in this strategy to let people know what is expected
now?
Fiona Blacke: I think that it
is a bit like the Child and Adolescent Mental Health Service Review.
There is a lot of work going on within DCSF to look at the implementation
of Targeted Youth Support and integrated youth support services.
This evaluation has just been done and I am sure that there will
be a response through the Youth Taskforce and the TDA to improve
those services. I do not think that it is all in the strategy,
but at least it recognises that it is an area that needs to be
developed.
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