Examination of Witnesses (Questions 80-99)
RT HON.
ED BALLS
MP, RT HON.
ALAN JOHNSON
MP, ANNE JACKSON
AND HEATHER
GWYNN
20 MAY 2009
Q80 Fiona Mactaggart: Not every
trust is going to have such a desperate tragedy to act as a spur
to coming on in leaps and bounds.
Alan Johnson: That is true, but
you had Laming a few weeks ago, which made some very important
points about health visitors that we will come on to. The Care
Quality Commission specifically focused on the NHS failures. The
child saw a paediatrician, most tragically, the day before he
died—he had a broken spine and broken ribs, but it was not
picked up. The mother took Baby P to A and E four times, and it
was not picked up that he was on the child protection register.
The health visitor went to see Baby P. Where was the NHS in all
of this? The Care Quality Commission says that it has put an awful
lot of investment and work into those four trusts, to make sure
that those fundamental problems are resolved. We need to do something
much wider. GPs are an important issue, which comes back to the
point that we made earlier—GPs are crucial in all of this.
GPs need to be absolutely up to date with the latest information
on how to identify such problems, even if there are no obvious
signs in the early stages. How you get that early intervention
is important. All the agencies involved recognise that you cannot
put too much emphasis on ensuring that safeguarding becomes part
of the everyday life of the NHS.
Ed Balls: There is a clear link
to the structural changes. As well as the individual professional
issues around training, health visitors and GPs, we also have
the fact that we are making the Children's Trusts statutory, which
means that when the safeguarding board says that there are issues
around the co-ordination or the engagement of health for other
professionals, it is the Children's Trusts' job together to get
that sorted out at the local level. That local accountability,
with the new public members that we are putting on, will be important.
Also, the national unit that our new national adviser on safeguarding,
Sir Roger Singleton, is leading, will be cross-government. There
will be health expertise in that unit, with officials from Alan's
Department. So, nationally and locally, we shall be able to press
on that engagement. In the end, what matters is whether the GP
or paediatrician comes to the case conference, in the individual
case. That is something that is complex—it needs to be properly
co-ordinated, it needs to happen—but really goes back to
training and professionalism.
Chairman: We certainly feel, having extended
our inquiry to cover some of the safeguarding issues, that this
period when the child is relatively invisible—nought to
three, before it gets into nursery—is so important. The
GPs and health visitors—that team—are aware. But I
am not going to ask a question—Edward, you are coming in.
Q81 Mr Timpson: Yes, on school
nursing, and I am asking a question of the Secretary of State
for Health. In the 2004 White Paper, Choosing Health, a
commitment was made to have at least one full-time, year-round
qualified school nurse in each secondary school, also involving
a cluster of primary schools around that secondary school. That
was a commitment to be done by 2010, as I'm sure you know. We
know that, four years on, September 2008 being the most up-to-date
figures available, out of the 3,334 secondary schools, there are
1,447 qualified school nurses in position. From a report a few
weeks ago, that equates to nearly 5,000 children per nurse. That
is still very far short of the commitment made by the Government.
What are you doing about it?
Alan Johnson: We are increasing
the number of training places for school nurses. The Prime Minister,
in his speech to the Royal College of Nursing on Monday 11 May,
recommitted us to that objective from the 2004 White Paper. We
mention it in the Child Health Strategy as well. We should be
further on than we are. For various reasons, we are not at the
right level that we should be in 2009. We have another year, and
we are working at this very hard. I think that it will be difficult
to hit it spot on, to be frank, but we can really ramp up the
number of school nurses that we put in. You are right, it is one
nurse not for every primary school, but for a cluster of primary
schools around one secondary school.
Q82 Mr Timpson: I take it from
your answer that you are still wanting to hold that commitment,
but you have some reservations about whether it is achievable,
given the current position, which I have just quoted to you.
Alan Johnson: Realistically, given
the current position, it is going to take an awful lot to do it,
but we have recommitted ourselves to it. The Prime Minister did
that as recently as the week before last.
Q83 Mr Timpson: Asthma UK has
commented that "the ambiguous recommendation for every area
to have a School Health Team seems to be a real step back from
the Government's previous pledge to resource comprehensive provision
of school nurses by 2010." Is that something that you are
struggling to agree with? What response would you have to Asthma
UK?
Alan Johnson: You do need a team.
You need to ensure that the school nurse is part of a team, the
same as a health visitor is now part of a team. Once upon a time
these were very isolated jobs. They were working in isolation.
There is a much bigger focus now on a team. It comes back to your
original question, Chairman, about how you integrate all the various
elements of protecting children. Instead of having social workers
over here doing their own thing, GPs over here, health visitors
over here, the school nurse over here, they have to integrate.
I stand second to no one in my admiration for Asthma UK but it
isn't a matter of either/or. You can meet the school nurse target
and also have them as part of the team.
Q84 Paul Holmes: Personal, social
and health education, PSHE, has become a statutory part of the
curriculum. Apart from the issues of overloading the curriculum,
which we always talk about, can I specifically ask how is that
going to be delivered in an effective way? When I was a head of
year 12 and 13, I ran a tutor group of nine different tutors.
One of them might be very confident about doing sex and relationships
education with 17 and 18-year-olds but another one might say,
"There's no way I'm doing that," and the rest might
do it in a very mediocre way. They are not trained. They are chemistry
teachers, they are history teachers, they are maths teachers.
They are not trained to teach sex education or relationship education.
How are you going to get round that?
Ed Balls: The important thing—which
the Macdonald review makes clear and we have accepted—is
that it is not enough to say that it should be statutory; you
have really got to make it happen. On the one hand, when it was
not statutory, there were some schools that were not doing it
or were doing it in a rather cursory way. Similarly, we must make
sure that, once we make the expectation universal, it is done
with quality. While saying that individual schools need to decide
how to do this, we are not trying to be detailed in our prescription
into the curriculum. It is also recommended in the review that
part of initial teacher training should include training in PSHE
and that we need a dedicated cohort of specialist teachers as
part the work of the Training and Development Agency for Schools
for initial teacher training. We also need to see whether we can
have an enhancement option allowing for a possible PSHE specialisation
as part of the masters in teaching and learning which we are progressively
trying to roll out to include all teachers. We also need to see
the ways in which we can do this as part of standard continuing
professional development. There is no doubt that this is a challenge
in terms of training and personal development of teachers but
it is something we need to do over the next two or three years.
It was a particular feature of the Macdonald review, whose recommendations
in this area we have accepted.
Q85 Paul Holmes: Some of the best
education I saw was when you had health workers coming into school,
for example, rather than just asking the chemistry teacher to
do it. How do we link with the Department of Health? Can it afford
to send specialists into schools anyway?
Alan Johnson: School health teams.
Ed Balls: I was looking at these
figures. It was quite striking. Alan said it was a challenge to
get to every school, but at the same time, the number of school
nurses has gone up by 50% in four years, by over 1,000 more. The
number of post-registration school nurses has gone up by 70%,
which is almost 800 more. There has been massive investment in
the NHS, delivered by the national insurance tax rise for the
health service, which has delivered this big increase. The point
of school nurses is to be part of the curriculum in the same way
as within safer schools partnerships we now have police officers
in the community participating in the teaching of citizenship
in the curriculum. These two agendas integrate. We need to make
sure that the health teams in the school, with the school nurses,
are helping us to teach PSHE.
Q86 Paul Holmes: In the context
of a previous inquiry, this Committee heard from people from faith
schools. When we were talking about delivering sex and relationship
education—including issues of homosexuality, age and so
on—they smiled and said, "Well, we're not going to
do that." Are you happy with that?
Ed Balls: We have said that how
individual schools choose to deliver sex and relationship education
will be done within the context, values and ethos of the school
as now. But at the same time that must be consistent with the
core entitlement to that education. We need to ensure that schools
and governing bodies understand fully their responsibilities—and
young people too. We will not require every school to teach it
in exactly the same way, but at the same time every child in every
school will be entitled to proper, core sex and relationship education,
unless, as in a minority of cases, parents exercise the opt-out,
which Alasdair Macdonald recommends that we continue.
Q87 Chairman: But you haven't
answered the question, Secretary of State. Faith schools told
us there is no way that they will teach it.
Ed Balls: Faith schools—in
the case of Oona Stannard, for example—were part of the
working group that the Schools Minister chaired and which made
this recommendation. Those organisations have supported Alasdair
Macdonald's review. Consistent with their ethos and the context
of the school, they have a responsibility to teach citizenship
and other parts of the curriculum, which will include sex and
relationship education. It's really important that they do that
well.
Q88 Paul Holmes: But we heard
from—again, we can send you the evidence from the particular
report—heads of sixth forms and deputy heads of three different
faiths. They all said, "We're not going to do that."
They said it very nicely, but they said it none the less.
Ed Balls: Consistent with their
ethos, it will be part of the national curriculum.
Q89 Paul Holmes: So how will the
Department decide that these taxpayer-funded schools are not delivering
these strategies and do something about it?
Ed Balls: It is the responsibility
of the governing body to ensure that they are doing it properly.
Children, young people and parents will see the way in which it
is occurring, as too will the inspectorate. I do not doubt that
there will be some issues to deal with along the way, but we are
making the right decision to ensure that all children have a proper
understanding of these issues. It will help us to reduce teenage
pregnancies, which is important for all children of all faiths.
Q90 Paul Holmes: My local PCT,
in Derbyshire, told me categorically that there is clear evidence
that schools that don't do sex and relationship education have
more teenage pregnancies and specifically said that faith schools
are an example of that.
Ed Balls: That is why it is important
that all schools, including faith schools, teach sex and relationship
education.
Q91 Paul Holmes: So you will expect
Ofsted to pick up on that and report very clearly so that action
will be taken against these taxpayer-funded schools?
Ed Balls: Of course.
Q92 Paul Holmes: When the Health
Committee looked at the national healthy schools programme, it
said that it was a classic example of a big Government programme,
in place for 10 years, but that there is no research base to say
that it actually works. Research was due in spring. Has that happened?
Anne Jackson: We are getting an
initial sight of the first year of the research. It is a three-year
research programme by the National Centre for Social Research.
The early indications show that it is having an impact. It is
welcomed by heads, and there are some slight positive correlations
with academic outcomes in schools too. So we are very keen to
pursue it.[1]
Ed Balls: It is not published
yet, and the truth is that it is not good enough. The Child Health
Strategy sets out a substantial strengthening of the healthy schools
programme and moves it away from schools simply showing that they
have got the right processes in place—that is a good thing,
because it is really good to ensure that you can do lots of things
to ensure that children are healthy—and on to outcomes.
We will now move to a more enhanced healthy schools programme
where we will measure things on the basis of, for example, whether
obesity is improving and healthy eating take-up rising. I think
that we have learnt quite a lot from the first phase of the healthy
schools programme. I have found schools very proud to show off
the fact that they are healthy schools. However, we need to—Alan
has been very clear about this—translate the obesity strategy
into really measurable outcomes for children's health. That is
what we will do in the next phase of the programme.
Q93 Paul Holmes: And when is the
report due?
Ed Balls: It says here, shortly.
I haven't actually seen it yet, which is why I didn't immediately
answer the question; but we will publish it shortly. Is shortly
soon?
Anne Jackson: Yes.
Q94 Chairman: This may be prejudice,
but in the early years of the strategy I thought there was much
more commitment from the private sector. You saw Tesco, Asda and
the Co-op having children from schools in their stores to learn
about healthy food and identify food that perhaps was new to them,
and so on. That seems to have all dropped away. Is the private
sector commitment waning?
Alan Johnson: No, quite the reverse.
Asda and Tesco are part of the Change4Life campaign. Sainsbury's
is kind of flitting around on the edge there. They are doing lots
of things to help. Tesco, for instance, has a "Change4Life
4 Less" programme, where it points out that it is cheaper
to buy fresh carrots and vegetables, and that ramps up over the
coming year. Ed and I were listening to ideas about how the major
supermarkets can help with healthy school lunches, and have a
part of the supermarket dedicated to just going and getting a
lunch pack, where parents find it much more convenient to find
all the things. They are brilliant with ideas on this; they are
very helpful.
Ed Balls: Also, there was the
cook book for year 7 pupils that we published last year—over
500,000 copies went out last September—which we will repeat
again this summer for year 7. We have had Aldi and Sainsbury's
promoting the recipes on the websites in their stores, encouraging
children to get their parents to buy the ingredients and have
a go at cooking at home. The partnership is quite deep now, in
our schools.
Chairman: That is good news. We don't
want to miss out health visitors.
Q95 Mr Stuart: Can I seek both
your reassurances on health visiting, particularly because of
the backdrop? Over the last 10 or 12 years we have had big launches;
we have been told that the Government are taking health visiting
seriously; in 2004 the "A Healthy Child" programme said
we were going to take on more health visitors and increase the
number; now, following Lord Laming's report, we have the "Action
on Health Visiting" programme. I believe there was going
to be agreement on the programme on 5 May. Yet we find that health
visitors are at the lowest level for 14 years. Lord Laming finds
that case loads are far too high. One of the difficulties in our
job, as a Committee, of holding you guys to account is how we
can be assured that this time the Government are going to do what
they have perfectly happily been prepared to provide statements
and reassurances about before, and then, as far as I can see,
signally failed to deliver. Do you think health visiting is important?
Alan Johnson: It is, it is crucial,
but let us get this into context. The reason numbers of health
visitors went down was the same as the reason the number of midwives
went down: the birth rate was reducing. It reduced year on year
in every developed country. There is a very clear ratio of numbers
of health visitors and midwives to children. Now, the birth rate
started to go up around three or four years ago and the statisticians
told us it was a blip. They said, "It will just return to
normal." The second year they said it was a blip. The third
year we thought, "This is a bloody long blip." That
is why we then started to concentrate on what we need in a completely
different situation of a rising birth rate. That is point No.
1. With midwives we have said very clearly that we think we need
about 4,000 midwives, and we have recruited the first 1,000 in
the first year. For health visitors we are not too sure about
the numbers. I think in the Child Health Strategy we referred
to a "substantial" number. I can't really put a figure
on it. The reason for that is the second issue here, which goes
back to something I was saying earlier. The profession has changed.
There was a very important report commissioned by my predecessor
in 2004-05 about the role of the health visitor. It used to be
working in isolation as a kind of individual, when there was not
a focus on community. You are right about numbers of health visitors
going down, and I have explained some of the reason for that,
but the number of nurses working in the community has gone up
by 37%. The report on the profession, by people in the profession,
showed that health visitors had not had enough help and support
to adapt to this new position; because really they are team leaders.
Their skills are so vital, but the skills they need now are as
the team leader, which was never part of their training in the
past. So the profession itself, particularly through the Community
Practitioners and Health Visitors Association, recognises all
of that. We need more support for the profession to become more
attuned to this world that it is operating in. We also need more
health visitors and we need to define very clearly what their
role is within a team. As I have said, my view is that they should
be team leaders. So, what we launched on 5 May was a very important
summit of all the people representing health visitors, including
the NHS, the strategic health authority and so on, with all of
them saying, "Now we are really going to tackle this over
the next six months". There will be another meeting in October.
We are working with the representative organisations to define
the role for health visitors and to find out what needs to be
done to improve their training and support. We have a very low
vacancy rate for health visitors—0.3%. So it is not a problem
of attracting people into health visiting. That is a problem with
midwifery, so there is a lot of return to practice with midwifery.
With health visiting, however, we have a low vacancy rate, so
increasing the numbers is important, yes, because the birth rate
is going up and they are crucial to dealing with that. Ensuring
that they are used to their new role of working within a team
and providing them with the support and development that they
need is the total agenda. It is not as simple as just raising
numbers, but raising numbers is a part of it.
Q96 Mr Stuart: That was a very
persuasive answer, as ever. However, one of the questions was
about holding you to account. You say that, in a sense, the role
of health visitors is changing. Lord Laming was more straightforward.
He said that a health visitor should deal with 300 families and
400 children, maximum. That should be the target case load. However,
he said that 20% of health visitors, which is an awful lot of
health visitors, are dealing with 1,000 children. That doesn't
quite accord with the picture that you just painted, when you
said, "Oh, it's just that the birth rate went down and therefore
naturally health visitor numbers went down." In at least
a fifth of cases, it sounds like you have people with a completely
unreasonable overload. Does this new team-working and the additional
health nurses in the community mean that Lord Laming was wrong
and that, in fact, that level of case load is perfectly adequate,
or not?
Alan Johnson: No. I had this discussion
with Lord Laming himself and he recognises how things are changing.
A health visitor doesn't need to go to every single family. A
health visitor, as a team leader, can ensure that all those other
nurses are used. As I have said, there is a 37% increase in community
nurses, who are qualified nurses working in the community, from
PCTs, Sure Start centres, and so on. Those nurses can take the
work load off the health visitors, so that the health visitors
can concentrate their attention on the children and the families
that they really need to get to. We will probably not have time
to talk about the Family Nurse Partnership, but that has also
been a crucial part of this strategy.
Q97 Chairman: But there has been
a lot of criticism that health visitors focus on more needy families
and children in needy families. It is said that health visitors
get burned out, like social workers, by only dealing with families
under stress. Also, I said earlier that nought to three is a very
difficult time to identify a child that is in danger. Health visitors
used to be able to be the advance guard in picking up on problems.
Is that diffusion of health visitors away from that general responsibility
not dangerous for child safeguarding, Alan?
Alan Johnson: It depends what
you mean by that. Every Sure Start centre will have a designated
health visitor, as part of the Child Health Strategy. That is
crucial, because Ed would be as frustrated as I was by the fact
that that link was not always there, between education and the
health service. The health visitor is crucial to maintaining that
link. Graham was asking me how we stay accountable for this area.
This is the debate that people are having in the profession. This
is the debate that kicked off before 5 May, but the 5 May summit
brought all these issues to the fore. Regarding accountability,
by October we will have a clear idea, having consulted with the
profession, about what the different roles will be. I would be
very surprised if what comes out of that summit is "back
to the future", because the document that Patricia Hewitt
commissioned made the new role for health visitors very clear.
It means that health visitors help to ensure that children do
not fall through the cracks. It also means that health visitors
are not overburdened. Lord Laming was absolutely right; some of
these health visitors are overburdened with cases and there is
not enough help from the team to support them.
Q98 Mr Stuart: But Lord Laming
said that he was surprised and concerned about the lack of universality.
You have said that you will use the teams, but what you also seem
to have said is basically that the universal health visitor service
will end. By having health visitors in a leadership role, you
hope that the health visitors can use other professionals to deliver
the same service. I guess that the question is this: can they
do so? Do community nurses have the skill base? Will they be able
to provide the same reassurance and pick up the issues that the
Chairman has just mentioned? If you do not send a health visitor
to every home, you have ended the universal health visitor service.
You might be producing another universal community service, but
you would have to persuade this Committee that that is the right
way to go and that that team can deliver the service that you
previously said was going to be delivered by more health visitors.
In all the programmes to date—and we have not been told
about 5 May—we were always told that you were going to deliver
the service and you were going to recruit more, but you haven't.
Now you are telling us that you may not.
Ed Balls: I feel as though this
part of the conversation is entirely disconnected from our earlier
conversation about how you delivered effective and integrated
working between health, children's services and local government.
As I explained earlier, Sure Start—the one I went to in
Bolton—had an overall manager of the centre and, working
within that centre, there were midwives, health visitors and family
support workers who had a clear programme that ensured multiple
contacts for every child and parent in the area. Some of those
contacts would be triggered by the midwife. Some would be triggered
by people coming into the children's centre, and some by the health
visitors going out. The multiple contacts were being co-ordinated
across the range of different services. The health visitors, who
I am sure were probably stretched—and we would like to have
more of them—were part of an integrated team. That must
be a better way to do it, rather than saying we will have a group
of health visitors here who go to every family and who will be
separate from the midwives and the children's centre, because
there is no effective integration. The other thing is that the
wrong way to deliver on our desire to drive up the number of health
visitors would be substantially to cut back the Sure Start children
centres' budget. That would be totally self-defeating and counter-productive,
and not something that we would ever contemplate.
Alan Johnson: May I make it clear
that this is not the end of the health visitor? It is a health
visiting programme, not a health visitor programme. The numbers
will increase. We need more health visitors as part of the health
visiting programme.
Q99 Mr Stuart: How do we know
they will? We've been told that before, and the numbers went down.
Alan Johnson: You will see the
numbers go up. We are recruiting and putting a lot of effort into
that. This debate will define how they are used to best effect
in the teams we have been talking about in a health visiting rather
than health visitor programme.
1 Note by Witness: National Centre for Social
Research: Evaluation of the National Healthy Schools Programme:
Interim Report: published May 2009. The Report finds that
the Healthy School Programme is welcomed by schools because they
believed that promoting physical and emotional health is part
of their core role in preparing pupils for life. Back
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