UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 356-i

HOUSE OF COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE THE

CHILDREN, SCHOOLS AND FAMILIES COMMITTEE

 

CHILD HEALTH STRATEGY

WEDNESDAY 18 MARCH 2009

DR. CHERYLL ADAMS, FIONA BLACKE, PAUL ENNALS and DR. SIMON LENTON

 

Evidence heard in Public

Questions 1 - 65

 

USE OF THE TRANSCRIPT

1.	This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.
2.	Any public use of, or reference to, the contents should make clear that neither witnesses nor Members have had the opportunity to correct the record. The transcript is not yet an approved formal record of these proceedings.
3.	Members who receive this for the purpose of correcting questions addressed by them to witnesses are asked to send corrections to the Committee Assistant.
4.	Prospective witnesses may receive this in preparation for any written or oral evidence they may in due course give to the Committee.

 

 

Oral Evidence

Taken before the Children, Schools and Families Committee

on Wednesday 18 March 2009

Members present:

Mr. Barry Sheerman (Chairman)

Annette Brooke

Mr. David Chaytor

Mr. John Heppell

Fiona Mactaggart

Mr. Graham Stuart

Mr. Edward Timpson

 

Examination of Witnesses

Witnesses: Dr. Cheryll Adams, Lead Professional Officer, Unite-Community Practitioners and Health Visitors Association, Fiona Blacke, Chief Executive, National Youth Agency, Paul Ennals, Chief Executive, National Children's Bureau, and Dr. Simon Lenton, Vice President for Health Services, Royal College of Paediatrics and Child Health, gave evidence.

 

Q<1> <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 work force. The development of the children's work force 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 work force, 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 work force 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.

 

Q<2> <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 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 based 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. 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.

Q<3> <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.

 

Q<4> <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?

 

Q<5> <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.

 

Q<6> <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.

 

Q<7> <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 supplying 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 recruitment 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.

 

Q<8> <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 work force 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.

 

Q<9> <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.

 

Q<10> <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. 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.

 

Q<11> <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.

 

Q<12> <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.

 

Q<13> <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.

 

Q<14> <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 it 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.

 

Q<15> <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 stats 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 is the 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.

 

Q<16> <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.

 

Q<17> <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?

 

Q<18> <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 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.

 

Q<19> <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 the college acknowledges that it would welcome a longer period of training for GPs, particularly on 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 that 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 is 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 to 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 become 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.

 

Q<20><Annette Brooke:> Could I just have a final question-I am sorry-Chair? I particularly wanted to ask Fiona and Paul about the involvement of young people and children in the service development. We have spent rather a lot of time, but I think that it is an important question that I would like to ask you both to address.

<Fiona Blacke:> Probably the most exciting new development that I have seen in the last five years is the pilots delivered by DCSF around the Youth Opportunity Fund and Youth Capital Fund. Young people were allocated sums of resources to determine how they wanted it to be spent on young people's provision in their areas. Much to everybody's consternation, young people rose to the challenge-they made robust decisions and demonstrated that they can make the right decision, not only for themselves, but for other groups of young people. That has been endorsed through the 10-year strategy in terms of this broader role of young people having control over 25% of budgets. That, if you like, is the front end of a movement where young people are proactively involved in decision making-everything from school councils through to the Youth Parliament, which may well be in your Chamber shortly.

What we are finding is that you get much better outcomes for and buy-in from young people to services in which they have an engagement. One example of this is when I recently went to a local authority with five young women from an ethnic minority background who have been involved in the commissioning of their Connexions service. They set out the framework for what that service should look like, interviewed five private sector organisations and advised with the adults who should be appointed to that. That gives you a real sense of how well young people can do that.

I think the You're Welcome standard is useful, and we certainly welcome it. The use of Hear by Right, which is, if you like, a framework for organisations to look at how they involve young people-not just at a token level, but in all aspects of their decision making-is absolutely critical. I think that Young Inspectors will be helpful. But we are in danger of seeing a system that applies to local authority delivery of services, and a system that applies to health services. I think that one of the things that would be incredibly helpful would be a demand, through the trust, on all the partners to engage a bit more coherently in involving young people.

<Paul Ennals:> We have been supported by the Department of Health to consult young people to feed their views into the strategy. While they said lots of things, there were four headline issues. First, they said that services need to be more transparent: in other words, "We, as young people or children, need to understand what we might be entitled to expect." Secondly, they said that services should be accessible: in other words, "We should be able to get advice and input not by going to a big building that we are scared of, but by going somewhere that is as close and familiar to us as possible." Thirdly, they said that it should be confidential, so they can have the opportunity to speak to people without feeling that the information will be shared. And fourthly, they want to be empowered and supported to make their own decisions to improve their health. Young people talked more about public health issues, such as sexual health, good eating and exercise-those were the areas that they were most interested in-than they did about medical treatment.

To a fair extent, those four headings are reflected in different ways and to differing degrees within the Child Health Strategy. I view the transparency issue as more important than any of the others; it may not seem much, but, in my experience, children and families are not really sure what is on offer, particularly from universal services such as children's centres and schools. Where do they go for health advice and support, and, in particular, how might they expect to get them from the universal services? I think the strategy seeks to address that by describing the Healthy Child Programme.

 

Q<21> <Chairman:> Do you think, Paul, that children know at any age-I am thinking right through from the ages of nought to 21 or 25-what they can get from the health service? The more I listen to you, the more I worry about young people getting their just deserts, because you are suggesting that cultural changes are going to take a long time.

We have just completed a major inquiry into looked-after children, who are some of the most vulnerable kids in our society and want a good deal out of the health service now. They need good psychological and therapeutic help now.

<Paul Ennals:> And some get it; not all of them, but some.

 

Q<22> <Chairman:> Well some get it, but we talked to a lot of young people who did not get it and their lives were blighted by the lack of medical help they got at crucial times; speaking on their behalf, members of the Committee want that now. The Health Committee's report stated that the DCSF is lacking in many respects, but every time this Committee takes evidence or visits people, we are told that it is the health lot that are holding everything back, which is the opposite view. When are we going to break through that, bring those two cultures together and actually deliver something to young people now?

<Paul Ennals:> That is a really good point, which goes back to some of the earlier discussion. You have encapsulated the problem-at national level, the two Select Committees will potentially feel that it is the other Department that is failing, and that is often replicated at local level where the local authority will often say that health does not come to the table at a senior enough level.

 

Q<23> <Chairman:> My local people say doctors will not even turn up unless they are paid.

<Paul Ennals:> Absolutely, but if you then ask the Primary Care Trust, it will say that meetings are called at times that it cannot make and so on. The situation is part of an historic and traditional boundary that does not serve children and families well. That is why I restate the argument that if we simply tell people, "You have just got to get on and bash your heads together," it will not work. If your Select Committee was merged with the Health Committee tomorrow, that would not in itself improve things. But if there were greater collaboration in looking at the programmes together, that could be more effective than it is today. We have to deal with human personalities, as well as ensuring that the service changes.

<Chairman:> And very conservative, professional boundaries.

<Paul Ennals:> Absolutely; conservative with a small "c".

<Fiona Blacke:> Just to add to that, if we are really talking about young people having access on the front line, I do not understand the full range of health services that are available to me, never mind if I was a young person. The critical thing relates to the inter-agency teams and the fact that the youth worker, who is engaged with some of the most vulnerable young people, knows the range of services that are available and knows the health visitor well enough to telephone and say, "I've got somebody here who has a problem with that. Who do I speak to?" It is about local brokerage and how well the local professionals on the front line understand what each other can offer, how management facilitates them to have the time for that understanding and how they are resourced at a strategic level to work together.

 

Q<24> <Chairman:> Fiona, all this language is very complicated. Let us suppose a constituent says to me, "My daughter suffers from anorexia. She has to wait for eight months for an appointment with a psychologist." Anorexia kills a lot of kids. When someone comes to my advice surgery and says, "The anorexia service does not work for me", how do we break through the perception? Here is a need-a need that kills children-but no one seems to know how to deliver the service on time in the right way.

<Dr. Adams:> Underlying a lot of the discussion is mental health. Children are not born with mental health issues. The Child Health Strategy suggests that they start after the age of five. They do not. They often start in the first year of life, and we need to understand that. If we understood that, there would be more investment from the health services in preventing illness, particularly mental health. The investment in breastfeeding is very important in terms of long-term health outcomes, but is it as important as somebody having good emotional health in terms of their long-term outcomes? We know that it affects coronary heart disease. We know that it affects learning capacity. We know that it affects whether they will hit the criminal justice system.

We really do need to take mental health-"emotional" health is sometimes a better word-more seriously with our services. We need that fundamental understanding at all levels. It is there up to a point. In Government, there has been a big investment in CAMHS and the CAMHS review, but I understand that money has been taken out of mental health services recently. I am not sure: it did not go to GPs, somebody told me, but that may be wrong.

<Chairman:> If you have any more evidence for the Committee, Cheryll, I will have to go outside and commit suicide. I am getting very depressed every time you say what has gone wrong. It is even worse than before. Simon, do you want to come in on this?

<Dr. Lenton:> Once again, it illustrates that at the moment services are not commissioned, delivered and regulated as a meaningful whole. For example, for children with behaviour problems in schools, behaviour support services that are local authority-based operate in a classroom setting, but they do not reach out to work with parents. Child and adolescent family therapies-CAMHS-work with families, but they do not always reach into schools. Children are obviously at home, at school and in other places and they need consistent approaches across all those areas to help them manage their behaviour.

For some children, the levels of behaviour are such that they are excluded from school, which is almost a ticket into the criminal justice system. Providing better support in schools for children with challenging behaviour would be one way of keeping children out of the criminal justice system which, in this country, locks up more children than most European countries. It is an incredibly expensive service. We need to talk about reinvestment, as the Child Health Strategy has done, in earlier interventions, but we need a very clear evidence base. We have had a lot of initiatives.

 

Q<25> <Chairman:> Graham Allen gave evidence to this Committee last week from his early intervention campaign, and he pointed out to the Committee that it was dealing with good strategies. In most local authority areas, you know the 50 or 100 families most likely to be in trouble. Why is the health sector not identifying those 100 most vulnerable families and working with them all the time? You do not have to do research on that. We know that that is the case, do we not?

<Dr. Lenton:> Yes, we do, but I think that it requires a joined-up inter-agency approach. It is not just about the health service preventing the most vulnerable in society from having poor outcomes. It is not only about addressing their particular health problems, including dental health services, but it is about the possible drug addiction of their parents, employment status, welfare rights, housing, the local environment in which they live, the peer group the teenagers associate with and youth services. All of that needs to come together and be aligned to achieve the outcomes that we want.

At the moment, a lot of those components work in isolation from one another. We have a Safeguarding Children Board, and we probably need to have similar boards looking at children's mental health, acute services and so on, where you bring the professionals who are delivering the service and those who are commissioning it together around the table to answer questions such as where is it working, and where is it not working. If we have limited resources to invest, where will we get maximum effect?

<Chairman:> Simon, I agree with much of that. It is just that I was expressing the frustration many of us feel.

<Dr. Lenton:> We feel similar frustration on this side of the table.

<Chairman:> Right, we are going to start rattling through other aspects now, and Fiona will rattle us through pregnancy and early years of life.

 

Q<26> <Fiona Mactaggart:> Cheryll, earlier you referred to the clinical leadership role of health visitors in the healthy child strategy and early years provision, then later you talked about a reduction in referrals to speech and language therapy in the earliest years. I was interested in that, because it seemed to me that the programme identifies key trigger points for discussing with parents speech and language issues. If there has been a reduction, is that because health visitors have not been properly prepared for this responsibility?

<Dr. Adams:> Not at all. It is something that health visitors have always done. They have always referred children. They have been the first point of contact around speech and language therapy problems. There just aren't the health visitors out there now. Many health visitors are seeing a so-called normal family just once in the post-natal period. If there are other members of their team such as community nursery nurses, they play a part but, unfortunately, services have been reduced-I am sorry to be negative about this-so children are slipping through the net. They are not getting the regular contacts.

Also, other systems are being used. If parents are considered to be probably fairly normal, I give them a checklist and they are asked to make their own assessment. Perhaps from your own experience you know that parents do not always accurately assess their child's speech. What sounds fine to a parent who is with a child every day does not sound the same to somebody on the outside, so it is about contact. The Child Health Promotion Programme is excellent. It is evidence-based, and that is something that we have all wanted very much, but now we have to make sure that the delivery system is right for children, that it will deliver using the right skills in the right places, and that it is for all children. Developmental delays can cross all social boundaries. You see more of things like speech therapy where there are more inequalities, but other children have speech difficulties, other children have autism. So we must have a concrete, good, universal service as the first line, and after that you target.

That is what we have always done. It has been about making the right needs assessment of families and having a relationship with the families-that is how the health visitor works-then stepping back where she has confidence that the family will contact her and stepping forward where she feels the family needs more support, then facilitating other agencies as appropriate to work with the family to try to deliver the outcomes that the family want for their children.

 

Q<27> <Fiona Mactaggart:> So am I hearing from you that the Healthy Child Programme has failed in its intention to deliver comprehensive integrated support for under-fives?

<Dr. Adams:> You obviously have to have the staff on the ground to deliver it. I don't think that the Healthy Child Programme has failed. It has provided the right framework, but what has failed is the investment by PCTs to ensure that it actually happens. Just to give you one example from the Healthy Child Programme, in NICE evidence there is a very clear statement that every mother should be assessed for post-natal depression around two months and again at four months, and we know from our own work and research how incredibly important that is. There is clear evidence supported by Government funding that health visitors making those assessments will reduce and control post-natal depression. We have also done a piece of work that is just about to be published with the London School of Economics to look at whether there is any economic benefit from a health visitor picking up post-natal depression, and, for the baby, there is a considerable economic benefit as far as their own earning capacity later.

In many trusts, there is not the capacity, unfortunately, in the current health work force to deliver those interventions, and they have been cut. So it is about the Government putting pressure on primary care trusts and strategic health authorities to invest in the health visiting service and the health visiting team.

<Paul Ennals:> If I can add to that last sentence, the Child Health Promotion Programme was published in March 2008 which meant, in effect, that it was probably too late to really influence the commissioning decisions that PCTs made during the financial year 2008-09. I hope that it is starting to impact-it certainly should be starting to impact-on the commissioning decisions that PCTs have been making since then. I would very much hope that it starts to change things. I agree with Cheryll that the Child Health Promotion Programme is good and it is evidence based.

It is partly something about the different cultures within the organisations. DCSF feels more able, because of its history, for the Secretary of State every now and again to issue a letter to local authorities saying, "I really want you to do X and Y." That does not happen in the Department of Health because that all runs through the NHS Chief Executive. It is a cultural difference in the two organisations. It is not for me to say which is the better, but they are different, and therefore trying to identify combined work between them is challenging.

We have all been promised, and are expecting, a joint letter signed by the two Secretaries of State following the publication of the Child Health Strategy to help PCTs and, indeed, local authorities to understand what that really means for the services they should be commissioning right now for the next year. But the letter has not yet come out, six weeks after the strategy has been published, because the language the two Government Departments traditionally use is different. The question is, should it be signed by the Secretary of State on one hand and Chief Executive of the NHS on another? That is not how the Government do things. We still have a few things to sort out.

<Fiona Mactaggart:> I do not want to ask anything else after that. I think that is profoundly depressing.

 

Q<28> <Mr. Timpson:> The Child Health Strategy is very strong on enhancing the role of children's centres, as part of the delivery of the Healthy Child Programme. Within that, there was talk of having a named health visitor for every children's centre and making them the focus of delivering the Healthy Child Programme through the children's centres. Is that how the role of a health visitor should be developed in the children's centre? Cheryll is the obvious person to answer that.

As a supplementary, is there a danger that, by prioritising or focusing the health visitor's work in the children's centre in that capacity, they may get isolated from their other roles-for instance, collaborating with GPs and actually getting out into family homes and working with families in that environment?

<Dr. Adams:> I think that there are strengths and that we always have to be aware of risks. There is a real strength in the children's centre becoming the focus for children and families. It is somewhere where services can be individually focused for communities. For instance, if you have an area of high ethnic mix, you can have the right types of service within the children's centre to address the needs of particular communities. That is very important. It is also absolutely essential that the health visitor has a very strong working relationship with the members of the children's centre team.

At the moment, we are in a situation where health visitors used to be based with GPs. Only about 40% are now based with GPs, and about 50% have been moved into neighbourhood areas and into geographical areas. Only about 8% are currently based with children's centres. We need health visitors either based with GPs or in children's centres, because those are the two relationships that are critical to children's outcomes.

I think that it is a very positive step forward from the Children's Health Strategy that there should be a strong linkage. We are obviously, as an organisation, looking at what that should look like. We have been talking to our members who work with children's centres about what it should look like and what the health visitor could do. You could look at it at different levels. They could obviously deliver services within the children's centres, if there is capacity to do that, and that must be useful. They could also work with the leader of the children's centre and with the staff within the children's centre and train them and skill them up to be able to deliver certain interventions. So you have a pathway approach working across health through the local authority. That would seem to make a lot of sense as well.

In terms of exactly what that role needs to look like, I do not think that we quite know the answer yet, but I do not think that it is about every health visitor. I think that it is about a named health visitor having that link with the children's centre and developing a role with them that is sensitive to the needs of that particular centre. It needs to be flexible; it probably needs one day a week; and it probably needs some time freed up, so that time is actually put into the children's centre for its benefit. It is also important to pick up that the evaluation of Sure Start demonstrated that, where there was health input, there tended to be better outcomes for families. The reason for that is that, traditionally, health visitors work at the level of the individual-in the family, in the community. They take-I am told that you should not use this word today-a holistic approach. But is very important that you do not just focus on the child and that you think about what is going on around that child, in terms of its family and the wider family, but also the community. That is when you start to get the right outcomes for particular groups of children.

 

Q<29> <Mr. Timpson:> When I recently visited health visitors in my constituency, their biggest complaint-there were a number of them-was the high case load that they have and therefore the inability to really get into a family and get to know what the problems are. What we are talking about here sounds great in principle, but unless we have sufficient health visitors out there so that you can have a dedicated health visitor working in a children's centre, it is not going to work. Do I take it from your reply that the prerequisite is that we need to have proper recruitment, training and commissioning within PCTs towards the work of health visitors, to ensure that what is going to be a good model works on the ground for children?

<Dr. Adams:> Absolutely. There has been sign up for that from the two Secretaries of State within the children's strategy, but it needs to be moved forward quickly. There is commitment from the Department of Health to do that, but we need to attract the right recruits into health visiting. There is now a possibility to look at alternative routes into health visiting, such as a fast track through nursing. There are also a lot of young graduates-such as psychology graduates-coming out who could offer a lot to health visiting. The traditional route is through nursing, but nursing could be cut back to the key elements, and then you could have the additional public health-visiting trainee to get these people working at the right level into the community. We are obviously already looking at this. Health visiting would then need to go back into statute, so that there could be new entry gates into it. But it needs to happen; otherwise it is quite a long training.

There are other issues around health visiting. In a sense, health visiting has been downgraded in terms of its professional status and pay, so it has become less attractive to nurses. Those coming forward are not necessarily able to meet the criteria to train to be a health visitor. Unfortunately, there are lots of problems in the profession at the moment and we have, once again, to incentivise people to want to become health visitors and to make it an attractive profession, which is valued. Then we will know that it can deliver the outcomes. We now have the evidence base-we are clear about what needs to be done and where things can start to go wrong for children-so we need to get the services delivered.

Health visitors need that clinical control, so that they can work with a skill-mix team. They know when to bring other people in-whether it is a speech therapist or a community nursery nurse who can do much more intensive work with families than they would be able to do. But we have got to get back to the position that we were in 15 or 20 years ago. One does not generally tend to look back to history; but in this instance, there has been a deskilling and devaluing of the profession. The profession can deliver the early interventions in those first two or three years of life. As Simon said, it is a pathway, and it is other people who will deliver different paths at different times.

 

Q<30> <Chairman:> Are our health visitors any good now then?

<Dr. Adams:> There are some fantastic health visitors, I can assure you.

<Chairman:> But you said that they have been deskilled and run down.

<Dr. Adams:> There has been poor investment in training. We have had an evidence base that has gone up.

 

Q<31> <Chairman:> That is what you just said. Are they any good if they are not well trained?

<Dr. Adams:> Yes they are, because they make the effort to get hold of the training that they need, but it needs to be at a national level. There need to be very clear training programmes.

 

Q<32> <Chairman:> How long does it take to train a health visitor?

<Dr. Adams:> A year on top of nurse training.

 

Q<33> <Chairman:> Why does a health visitor have to be trained as a nurse?

<Dr. Adams:> It is not so much the nurse training, but parts of the health training are used all the time. Health visitors are giving advice about immunisation, skin issues, growth and development.

 

Q<34> <Chairman:> How long does nurse training take?

<Dr. Adams:> Three years.

<Chairman:> Three years, and then another year on top.

<Dr. Adams:> No, because it needs a certain maturity to go into health visiting. You can have that maturity quite young, but if you think of the job that the health visitor is doing, she is working with every single family in this country.

<Chairman:> Social workers work with the most challenging families, and they do not get a long period of luxurious experience and maturity.

<Dr. Adams:> That is being questioned in the Laming review. They do need more consolidation.

<Chairman:> We realise that they need more, but you seem to be wanting to cosset health visitors.

<Dr. Adams:> No, I am not wanting to cosset at all.

 

Q<35><Chairman:> So have we got a well-trained health visitor profession or not?

<Dr. Adams:> We have inadequate numbers within the health visiting profession.

 

Q<36> <Chairman:> What if you cut down the training to two years overall and had many more of them there?

<Dr. Adams:> They would not deliver the outcomes.

 

Q<37> <Chairman:> Why not?

<Dr. Adams:> Because they would not have the resources to call on. If you think about how a health visitor is working-

<Chairman:> I bet if I asked my vice-chancellor at Huddersfield University to design me a modern health visitor course run over two years intensively-part nursing, part the health visitor thing-he could deliver it.

<Dr. Adams:> They could do it in four years.

 

Q<38><Chairman:> Why can you not do it in two years? Why is there this historic, mediaeval attitude, where everything in medicine has to be as long as it possibly can?

<Dr. Adams:> I am personally all in favour of cutting down where you can cut down. You can talk about education and you can talk about training, and the health visitor needs the education to be able to have the critical skills to be able to assess need in the wider sense.

 

Q<39><Chairman:> But you would not go for shorter training and more of them?

<Dr. Adams:> If it could deliver the right outcomes then obviously, yes, I would. But if you talked to our educationists, which we are doing quite a lot at the moment, because we have to find a solution to this problem-obviously, it is important to us that we do-the view is that, no, you cannot. Unless you have proper, academic underpinning, we are not going to be able to deliver the types of outcomes and leadership-

 

Q<40><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 though 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.

 

Q<41><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.

 

Q<42> <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.

 

Q<43> <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 equalities 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 risk 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.

 

Q<44> <Mr. Chaytor:> Would this strategy be strengthened if it confronted those issues as well?

<Dr. Adams:> Yes.

 

Q<45> <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.

 

Q<46> <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.

 

Q<47> <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.

 

Q<48> <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.

 

Q<49> <Mr. Chaytor:> Cheryll, you touched on PHSE. 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 PHSE. From our point of view, there are some wonderful examples of PHSE being delivered in the partnership approach, with PHSE specialist trained teachers acting not only as the deliverers but the commissioners of other people to deliver PHSE 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 PHSE, 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 PHSE offer, both in school and out.

 

Q<50> <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.

 

Q<51> <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.

 

Q<52> <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.

 

Q<53> <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.

 

Q<54> <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 work force 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.

 

Q<55> <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.

 

Q<56> <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.

 

Q<57> <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.

 

Q<58> <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.

 

Q<59> <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.

 

Q<60> <Chairman:> A lot of people would ask how, given that we have poured more money into the health service than in the history of our country, children's health is now in such a parlous situation. You would have thought that all this money flowing through would have got to the parts that we needed it to get to a long time ago. Are there any countries that do it better than us that the Committee ought to look to?

<Dr. Adams:> Scandinavia obviously does very well. Scandinavia has robust health visiting services

<Fiona Blacke:> With a 40% tax rate.

 

Q<61> <Chairman:> It is more about proper-sized countries such as Germany, France and Italy-proper countries, like ours. Are they better or do they have the same problems?

<Fiona Blacke:> I was in the Netherlands last week and they have been quite smug to date, in that many of the health issues-teenage alcohol and drug abuse-were things that they had not encountered to the extent that we had. Now they are facing the same kind of problems. I do not think that we are alone in Europe in struggling.

<Chairman:> Sorry, it is just that we, as Members, have to talk to our constituents and they will be saying to us, "All of this taxpayers' money is floating in the health service, what the hell has been done with it?"

 

Q<62> <Mr. Heppell:> In some respects, it goes on to my next point. I thought that there had been a focus on things such as teenage pregnancy for a long time. Figures were going down. It is a particular problem in my city, Nottingham. All of a sudden, the figures have gone up again. When you compare us to other countries in terms of young people's drug and alcohol misuse, it is not good. I wonder what is wrong with the system that we have got. What is the best way to get a message across to young people about the identified public health issues that we all know about-sexual health, obesity, substance misuse. Is there a better way to get the message across?

<Fiona Blacke:> I want to make two general points to start with. One is that it is very interesting to note that as a society we spend less time with our adolescents as parents and families than any other country in Europe. Our teenagers tend to live in peer groups much more than they do anywhere else in Europe and that has a significant impact on a lot of the things that they do. The second is that you might say that teenage pregnancy statistics are as much a relationship to cultural issues and the level of aspiration and expectation that young women in particular have about being successful in education and employment, as they are to the level of knowledge and understanding of contraception. It may be a coincidence that we are facing a fairly significant economic recession related to teenage pregnancy figures going up. I would not want to comment on that. That is a broad punt.

The other thing-and it has maybe come through in this-is that the way in which you change people's behaviours around health is by empowering them with information and letting them make choices. That is what we need to do better. Because some of our most vulnerable young people have least access to education in its formal sense, sometimes they are the ones who have least access to information and the fewest opportunities to develop skills and the social and emotional resilience to make decisions appropriately.

<Dr. Lenton:> Children in the UK have poorer health outcomes than in most rich countries throughout Europe. There is a real issue there. Yes, there has been more money going into the health service. It has not always flowed into children's services because a lot of the targets that have been set are around elective surgery and access to adult services. Therefore, it has not necessarily flowed into children's services. But even if it had, I am not sure that children's health services can address some of these very large societal problems that need a different approach. Although giving children a voice and choice is important, some of the public health interventions have to be on a society-wide basis. We all know that health and wealth go together and, yes, some health outcomes are going to get worse in an economic recession but I think we have to look at the way money flows in the country because that does determine where areas of inequalities lie. We also need to look at the relationship adult society has with its children and youth society, because it is substantially different from other countries. Almost all of the research says that social capital-this interconnectedness between people-is really important for health outcomes. Somehow children are becoming marginalised from their parents and that has a significant impact on their health. It would be fair to say that we do not fully understand how that impacts on health. We are aware that it does have an impact but we are certainly not in a position to be clear about what needs to be done to change that.

<Paul Ennals:> Today is the 10th anniversary of the pledge to end child poverty. The strongest single correlation that goes across countries is that between child poverty rates and child health outcomes for disadvantage. If we had made greater progress in meeting that ambitious target 10 years ago, we would have made greater progress on the key topic issues that you have identified for this question. It is, I am afraid, as simple as that. That is not the only thing but it is the biggest single underlying issue that we could have done in the past 10 years to tackle it.

<Chairman:> But there has been progress.

<Paul Ennals:> There has, which is why there has also been progress on most of the indicators that we are concerned about-just not on as many as we wanted, and we still have not caught up with Germany and France in many cases.

 

Q<63> <Chairman:> So the heart of the problem, as you were saying just now, Simon, is bad parenting-bad parenting and dysfunctional parents.

<Dr. Lenton:> Clearly, dysfunctional parenting has an adverse outcome on children's health and well-being but I do not think we can blame the poor health outcomes within the UK on poor parenting. Clearly the majority of children do not experience poor parenting.

<Chairman:> But a significant minority do.

<Dr. Lenton:> A significant minority do. I understand that your Committee has explored the whole area of safeguarding vulnerable children. I am sure you are very aware of the issues that those children face.

<Chairman:> Last point, John.

 

Q<64> <Mr. Heppell:> I agree more with Dr. Lenton than yourself. I don't want to transfer the correlation between poverty and bad outcomes in health to mean that being poor makes you a bad parent. I don't believe it.

The final thing I want to talk about is children with additional health needs. How well do schools deal with that? We hear anecdotal stories-some quite horrific-about how children with long-term and acute conditions get discriminated against in schools. Recently, I heard about a woman with HIV who found it very difficult to get her child into a school. It was partly that she tried to get her entered and they said, "Oh well, we would have to inform all the parents that your daughter is coming to this school, because this is a child whom we would have to make special arrangements for if she was doing swimming and PE with other children." It was just a complete nonsense in terms of real medicine, but it sends signals to you and you say, "Well, what sort of training or expertise do schools have in terms of dealing with such children?"

<Chairman:> My role is to stir the questions up, so I know that John knows that I do not believe the question that I put to you, so I just needed to wheel that out. You have got a chance to quickly run across and come back on John, because I know another member of the Committee has got to leave and that would mean that we have to end the session. Start with Fiona and work backwards.

<Fiona Blacke:> In response to John? I do not know that I am qualified.

<Dr. Lenton:> I lead a children's palliative care team where I work in Bath, which has made substantial difference to that particular group of children's lives. These are children with life-limiting or life-threatening conditions. It hinges around, first of all, an appropriate assessment of the family and then access to appropriate support services. So that initial assessment, once a diagnosis has been made, is incredibly important. What is then important is continuity and co-ordination of care throughout that child's life, and the service is called the Lifetime Service because it tries to encapsulate that concept.

At the moment, those children's palliative care services that have been developed over the last, say, eight years, following the New Opportunities Fund funding that pump-primed the development of many community children's nursing teams across the country-the principles behind those teams now need to be applied to a wider range of children: in other words, children with complex continuing health care needs and children with complex disabilities with a variety of sorts that can be everything from cerebral palsy through to autistic spectrum disorder through to HIV.

Essentially what I am talking about is a community-based team that can give advice to children's centres and schools, and can support children in those environments-not just looking at the child's conditions, but the impact of those conditions on the child, and the consequences for the family and the places where those children are. That is emerging best practice. It is emerging. The £340 million announced in the Child Health Strategy will enable further roll-out of that, but those principles-or concepts of care-have worked very well for the group of children with life-threatening conditions.

 

Q<65> <Chairman:> Last word, Paul. Why did you shake your head when I started talking then?

<Paul Ennals:> To say that I did not mean to-

<Dr. Adams:> Well I was just going to say, again, that this is where a trade school nurse can be advocate for the child and the family within a school in a situation where a child has special needs, and that there is quite a lot of good practice around that.

<Chairman:> I am sorry but we are going to have to end on that note. We have learnt a lot. The learning curve has been really steep, you probably noticed, but that does not mean to say, to contradict Graham, that we do not have the competencies. We are quite good at this and we will prevail. Will you stay in touch with the Committee so that we can ask some other questions that, perhaps, we did not ask? If you think of anything that you did not tell the Committee, that we should be informed of, come back to us. But as you know, this is pretty uncharted territory and we want to make a good job of it. Thank you.