Examination of Witnesses (Questions 66-79)
RT HON.
ED BALLS
MP, RT HON.
ALAN JOHNSON
MP, ANNE JACKSON
AND HEATHER
GWYNN
20 MAY 2009
Q66 Chairman: We now move into the next
evidence session. I was going to ask you, Secretaries of State,
if you want your officials to sit with you, but they are sitting
with you already, so we will regard that as a fait accompli, shall
we?
Ed Balls: Yes, in order to show
the seamless way that, while respecting the independence of the
civil service and mutual roles, we all work as a team.
Q67 Chairman: You are almost colour
co-ordinated, except the Secretary of State for Health seems to
be slightly out of line. Or is it you? [Laughter.] Right.
Are we ready? I am sorry that there has been a delay and we have
kept you waiting. I will have to use names, as we now have two
Secretaries of State before us. We will address you as "Alan
Johnson" and "Ed Balls". Is that all right?
Ed Balls: It is greatly preferable.
Q68 Chairman: Right, let's get
started. This is an extremely important session for this Committee.
Given the wide remit of the Committee, it is difficult to not
have some concerns and worries that there are parts of that remit
regarding children to which you are really not paying sufficient
attention to in terms of scrutiny. You will be well aware that,
as members of the Committee go around the country and take evidence,
very often we find that the Department of Health and the Department
for Children, Schools and Families could work better together
in a more co-ordinated way, so that at the point of delivery in
our communities a better service—a joined-up, seamless service—can
be delivered. We feel strongly about that because we have just
done a major inquiry into children in care and one of the issues
that came back time and time again, particularly in terms of mental
health challenges, was this lack of—we thought—access
to high-quality care at the right time. For many of the children
we met—and the evidence that we were given suggested that
these were children who had been in dysfunctional families and
had very often been abused—we found that it took a very
long time to get any counselling and any professional support.
That really did spark us to say that we ought to get both of you
together to discuss what is going on. Alan Johnson has only just
joined us. Do you want to say anything to start off, Alan, or
do you want to go straight into questions?
Alan Johnson: No, I am fine going
straight into questions.
Q69 Chairman: Okay, we will go
straight into questions. Let us get started by saying to Alan
Johnson—to give Ed Balls a little rest from the previous
session—what do you think the real problems are in delivering
a joined-up service at local level?
Alan Johnson: They are the problems
you find in every attempt to join up government, both at national
and at local level. People have their own grading structures and
their own reporting systems and trying—whether it is through
Every Child Matters, or whether it is through Children's Trusts—to
ensure that you integrate that without disturbing the arrangements
for local authorities and the NHS and primary care trusts and
so on, is always difficult. In some areas they do it very, very
well. In some areas, on a wider issue than just children's health,
the PCT and the local authority work together. I quote Barnsley
and Salford as examples, but there are examples all around the
country. Others pay lip service to that principle, but don't actually
do it, and it is something that I am very keen to break down—not
just with Ed and the work that we have done together, but with
Hazel Blears in the Department for Communities and Local Government
as well. People talk about "our money" in terms of the
health budget and the education budget, but it is actually taxpayers'
money that should be devoted to joint objectives. Those are some
of the problems about doing what everyone says they want to do,
but people do it with varying levels of success.
Q70 Chairman: As we were preparing
for this session, it became clear from the material that we were
looking at that Ed Balls, the Secretary of State for Children,
Schools and Families, because he has direct communication to 20,000
schools and quite a direct line to elected local government, seems
to have a much better ability and much more power to say, "Come
on, these are the objectives we want and we need co-operation
to achieve these objectives." It seems to me that you, Alan
Johnson, have much more difficulty securing delivery at local
level. How do we get over that? PCTs seem so remote and all the
evidence I have read suggests that they don't prioritise children's
issues enough.
Alan Johnson: Let me tell you
about my experience of doing Ed's job previously. I found that
there was a real issue about children's health when I was at Education:
children's health was not high enough up the agenda of the NHS.
Now, I tried to rectify that. We have the ability to be a benign
dictatorship—nothing much has changed from Bevan's day in
terms of the power of the Secretary of State in law, in the NHS.
We have something called the operating framework, which used to
be called the marching orders of the NHS. It goes out every year
in November-December and it sets the trend. If you put something
in the operating framework, it will get done. I brought up children's
health in my conversation with the chief executive of the NHS,
who has spent 35 years in the NHS. He said that he has never had
a Minister suggest that children's health should be part of the
operating framework. It is now—it is tier 1. There are three
tiers, and tier 1 is the one that says, "This must be done."
That is a start to working together with Ed and his Department,
whether it is on obesity, the Child Health Strategy, or the CAMHS
review. We are saying, "Look, this is the example that we
are setting nationally, and has to happen locally," and it
does happen. If you put it in the operating framework, you will
find that PCTs pay much more attention to it. They may have been
late starters in terms of, perhaps, your perception of how far
along they are, but they are doing this, particularly since the
publication of the Child Health Strategy. I am encouraged by the
fact that they are not just doing it, but recognising the need
to do it. One final point is that we don't really have the evidence
yet that shows that investment in child health services produces
better outcomes further down the route. Clinicians go by firm
evidence, which is one of the reasons why the Yorkshire and Humber
Public Health Observatory is being asked to do a job as a child
health observatory to find the levers that show that there is
a direct link between the work we do with children and the outcomes
further down the track.
Q71 Chairman: Ed Balls, one of the
criticisms that we have read from the Health Committee is that
there isn't enough evidence-based policy. A lot of policies have
been running for 10 years with no real evaluation of whether they
actually give value for money and increase the well-being of children.
Ed Balls: In the case of the CAMHS
review, the work that we are doing on speech and language therapy
and short breaks for disabled children requires very close co-operation
in policy and delivery between the two Departments. Those reviews
are quite evidence-based. Can I also attempt to answer the question
that you asked Alan about the difference between health and the
children's services that I deal with? It has been hugely to the
advantage of children around the country to have a Health Secretary
who has come from doing my job and sees things from both sides.
The absolute key to make this work is a culture of leadership
and joint working at the level of the PCT chief executive, the
local authority chief executive, the DCS, the police commander
and the organisations below them, such as the schools, the GPs,
hospitals and the children's services department. Around the country,
we have brilliant examples of best practice and making it work.
It is hard to get that culture right into different organisations.
In other areas, you do not yet have the same degree of really
committed local leadership. The difference between our two Departments
is that at Health, you probably have more powers to say, "This
is what should be done," but it is not always clear—Alan
has been clear about this—that sending an injunction from
the centre is sufficient to deliver change, if what you actually
want to do is empower local leadership. In the case of our Department,
in the end, it works only if the schools and the individual social
workers really want to do it. On the schools side, the winning
of hearts and minds and empowering the local leadership is also
important. What Alan has done is take that understanding of driving
local leadership and decision making into the health and children's
health area. That is why this is the best opportunity that we
have ever had to take the best practice of local leadership and
to try to make that universal across the country. This is a really
significant moment for integrated children's service work at the
local level.
Q72 Chairman: Secretaries of State,
I want to move on, and I realise that I have been terribly rude
to Heather Gwynn and Anne Jackson in not welcoming them to the
Committee. Someone has to ask what their jobs are. Heather, what
do you do in your Department?
Heather Gwynn: I am a director
in the Chief Nursing Officer's Directorate, and have responsibility
for children's health services as part of that.
Anne Jackson: I am the director
of the Child Well-being Group at the DCSF, and I work with Heather
across the range of children's health issues.
Chairman: Thank you, and you are very
welcome. Andy, were you going to start?
Mr Slaughter: I think my questions have
been covered.
Chairman: Do you have anything to add?
Mr Slaughter: I could, but we have limited
time.
Chairman: We will move on to John, then.
Q73 Mr Heppell: The Child Health
Strategy was delayed: it was supposed to be introduced in spring
last year, but actually came out in February this year. I will
ask this question in three parts as we don't have a great deal
of time. Why was there such a delay in releasing the Child Health
Strategy document? How do you intend to report on the strategy's
progress? Thirdly, given that the document is supposed to be about
communicating better with children and families, why has no child
strategy been written specifically for young people, as well as
the one that we currently have?
Alan Johnson: I don't know whether
the delay was from spring last year to early this year—we
certainly said that we would publish the strategy at the back
end of 2008, but we didn't for various reasons. I can't take you
through a blow-by-blow account of that, but you need to have Government
agreement as to where you are in the grid, you need to sort everything
out with the Treasury and you need to have everything in place
with affected Departments as well. Ed and I were keen to get it
out as quickly as we could, but we understand how these things
work—there were other policy announcements to be made—so
for one reason or another, it went out later than we would have
liked. I think the acid test was the reaction to the strategy.
People were concerned that they were never going to see the Child
Health Strategy, and when the people who helped us draw it up—the
voluntary sector, NGOs, people in local authorities and so on—saw
what was in the strategy, they generally welcomed it and no one
now talks about the delay in publishing it. I thought we had published
a user-friendly version.
Anne Jackson: No.
Alan Johnson: Okay—we should
have.
Ed Balls: The other thing to say
is that the Child Health Strategy wasn't just that document. There
were also a number of pieces of work that we were doing around
the Bercow report and the response in terms of joint commissioning
on speech and language therapy; our review of making PSHE, including
sex and relationship education, compulsory in the curriculum;
and free school meal pilots in some areas. All of those things
came out of the work for this review, and in some ways it was
actually better to put all the individual components in place
before producing the final document. At one point, we were thinking
of doing this before we got to the end of the Macdonald review
of the curriculum, but I think there would have been a real gap
in the report. The fact is that, by being a little bit late with
the final report, we were actually able to progress policy on
CAMHS, language education in the curriculum and eating and obesity
considerably further down the track than we expected at one point.
Mr Heppell: I think Anne was trying to
come in.
Anne Jackson: I was going to pick
up on the point about monitoring progress simply to say that we
have a joint programme board across the two Departments that looks
at PSA 12 to improve children's health and well-being. We expect
that board to take oversight and delivery of the strategy.
Ed Balls: Probably what we ought
to do is a "one year on" progress report. Perhaps we
will do a short version.
Q74 Mr Heppell: Presumably, that
won't be late. [Laughter.] There is an awful lot of emphasis
on children's entitlement to the health service being worked out
and publicised locally. How much variation do you expect to see
locally, and what sort of framework will it be set in? What sort
of parameters will you allow?
Alan Johnson: Not an awful lot
of variation. One of the issues here is a bit like adult social
care—a large degree of licence is given to local authorities
on this, just as there is to PCTs. Some 80% of our money now goes
straight out to PCTs—it was only 70% a few years ago—and
they get on with it. That is one of the points about the strategy—there
needs to be consistency in different parts of the country, but
some parts will be spearhead areas, which are generally recognised
as the most deprived areas. For the purposes of the Department
of Health, however, such areas have the worst health outcomes—they
have very high levels of cardiovascular disease, of cancer, of
smoking and so on, so given the health inequalities agenda, they
would perhaps take a different approach from somewhere that doesn't
have those problems in such depth and to such a profound extent.
So there would be changes such as that and there would be changes
in the school system, I guess. Some parts of the country would
have a different type of arrangement for schools, whether selective
education or—
Q75 Mr Heppell: Is this idea—what
has been called the local offer—a new development in policy,
or just a different way of communicating it?
Ed Balls: I think that it is more
than that. We have now got to 3,000 Sure Start children's centres
and we will get to 3,500 soon. Two days ago I was in a Sure Start
in Tonge, Bolton, where as well as the nursery they have on-site
midwives doing antenatal visits, and health visitors and family
support workers working from the children's centre. That isn't
happening everywhere yet, but increasingly we are putting the
health provision within children's centres or right alongside
them. The important thing about that children's centre was that
the health visitors, the midwives and the children's centre together
were now able to ensure that every parent across the area, which
was a more disadvantaged community, would be guaranteed a number
of contacts with the children's centre, including health contacts,
over the first year of the child's life. That is really important
because it ensures that children are not falling through the gap
and that you are really getting out to every family. That is hard
to do, but it is the best practice and is really delivering that
first-year offer to parents and children in a much more effective
way than we have ever been able to do before.
Q76 Mr Heppell: Moving to something
different, the strategy points out the importance of GPs' involvement,
especially on children's trust boards and so on, but it then goes
on to say that the responsibility for that lies with local authorities.
I just think to myself, "How do local authorities persuade
GPs, who may feel that they don't want to sit in boring meetings
for the sake of boring meetings or read great big lengthy minutes?"
How are local authorities going to persuade GPs? Shouldn't there
be something more direct—an appeal made directly to the
GPs saying, "We expect you to do this."?
Alan Johnson: Heather can say
something about the technical aspects. It is really important
for GPs to engage in this way. GPs are the jewel in the crown
of the NHS; they offer access through primary care. But very often,
and this is something that we have said to the BMA over and again,
they are waiting for the problems to come to them. There are some
exceptional GPs out there who have an entrepreneurial spirit and
are going out to the problem and working with other agencies to
resolve these issues. So, it is no good recognising, as we do,
the crucial role of the GP and then saying that we are going to
have all these partnerships and this integrated working that Ed
spoke about but that the GP will get this second hand, because
it is nothing to do with them as their time is too precious for
them to go along to these meetings. I do not accept that at all.
When we see GPs really grasping these issues of health inequalities,
child health and obesity, and being part of the team that is focusing
on them, as they should be through a primary care trust—a
primary care trust is about primary care—I don't accept
the argument that they are too busy to get engaged in this way.
Heather Gwynn: In terms of ensuring
that the involvement happens, we are looking to primary care trusts
as members of the children's trust boards to work with the local
authority and ensure that the right GP membership is found. I
think that we have said that we would expect, for example, the
PCT professional executive committee, which exists in all cases,
to be one good source of GPs. In the many areas where there is
a strong GP commissioning group, again that would be a natural
point with which to make a strong connection. We have been talking
to the GP commissioning bodies nationally about that and will
take it forward as trusts develop. So there is a number of obvious
starting points that we will work with. Exactly who is best placed
to do this and who will be the right leader will vary from area
to area, but we are committed to looking at how that works and
we will learn as we go on.
Ed Balls: As a way of making sure
that the GP voice is heard, we hope there will be a lead GP with
a speciality in children's health on the children's trust, who
will hopefully corral some of their colleagues to participate
as well. That is a step forward too.
Q77 Mr Heppell: One final question
on children's mental health. The CAMHS review recommended setting
up regional boards to support and challenge the roles of the Government
officers and the strategic health authorities. Is there an acceptance
that support for local services across all child health areas
needs to be much more coherent?
Alan Johnson: I think there is
an acceptance of that. We accepted all 20 recommendations of that
review. It was an independent review, carried out by people whom
Ed and I continually challenged, saying, "Look, make this
as radical as you want to make it. Tell us what the issues are."
They are all people who worked in children's mental health for
years. They did point out that problem, hence that recommendation.
By the end of the year, the support programme should be in place.
I think you will see pronounced benefits from that.
Ed Balls: I have seen CAMHS in
the area that I represent as an MP changing fast. Historically,
there has been a bit of cultural divide between the clinical side
engaging when there is clear evidence of symptoms, and head teachers
wanting more emphasis on early intervention. My sense is that
the CAMHS review is bringing those cultures together and making
early action very much part of a more primary care-orientated
approach from CAMHS. That is really welcome to schools. As I said,
you now have CAMHS teams out there in schools, working on a daily
basis with every school in the area, rather than at the end of
a phone or a bit of a distance away, operating in a more traditional
health kind of way. That is very positive.
Chairman: We are going to move on. Fiona,
you want to ask about safeguarding.
Q78 Fiona Mactaggart: I shall
cheat and add a final question on the Child Health Strategy. One
of the things that we heard from previous witnesses was that you
can have the right strategy, but it really depends on investment
on the ground for it to be developed, and that this area of investment
has not got perhaps the salience of things like cancer targets
and so on. Dr Adams concluded that it is about the Government
putting pressure on primary care trusts and strategic health authorities
to invest—she said in the health visiting service and the
health visiting team, because she was focusing on that at the
time. What are you doing to make sure that happens, Secretary
of State?
Chairman: Don't go into health visiting,
Alan—that's the next section.
Fiona Mactaggart: I was merely using
health visiting as an example. She talked about the Government
applying pressure at the PCT level. The PCTs feel pressured on
their targets for times and things like that. I don't think they
feel sufficiently pressured on these issues.
Alan Johnson: This goes back to
an answer I gave when you were out of the room—it's the
operating framework. If you put it in the operating framework
and you make it a priority there, it will happen. If you put it
down as a tier 3 in the operating framework it means that you
have discretion in this and that there are issues that you might
want to tackle. If you put it in tier 1, they are the issues that
you have to tackle. It has never been in tier 1 before and it
is now.
Q79 Fiona Mactaggart: Okay. My
real concern and what I would like to focus on is the evidence
from the Healthcare Commission, among others, that the safeguarding
performance of the health service is not what we should expect.
It suggested in the March 2009 report that significant weaknesses
were still evident in relation to child protection training. We
all felt in the accounts that we heard of the life of Baby P that
health service personnel had been part of—there were others
too—the failure there. Yet we really do depend on health
service personnel in this area. What steps are being taken within
the NHS to respond to these concerns about the relatively low
priority and the lack of expertise in safeguarding in both GP
and hospital services?
Alan Johnson: We have just had
the report from the Care Quality Commission that looked at the
four trusts involved in Baby P. First, they make the point that
they have all come on leaps and bounds since the Baby P incident.
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