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

HOUSE OF COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE THE

CHILDREN, SCHOOLS AND FAMILIES COMMITTEE

 

CHILD HEALTH STRATEGY

 

WEDNESDAY 20 MAY 2009

 

ED BALLS, ALAN JOHNSON, HEATHER GWYNNE and ANNE JACKSON

 

Evidence heard in Public

Questions 66 - 103

 

USE OF THE TRANSCRIPT

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Oral Evidence

Taken before the Children, Schools and Families Committee

on Wednesday 20 May 2009

Members present:

Mr. Barry Sheerman (Chairman)

Mr. John Heppell

Paul Holmes

Fiona Mactaggart

Mr. Andy Slaughter

Mr. Graham Stuart

Mr. Edward Timpson

Derek Twigg

 

Examination of Witnesses

Witnesses: Rt hon. Ed Balls MP, Secretary of State for Children, Schools and Families, Rt hon. Alan Johnson MP, Secretary of State for Health, Anne Jackson, Director of the Child Well-Being Group, Department for Children, Schools and Families and Heather Gwynne, Director of the Chief Nursing Officer's Directorate, Department of Health, gave evidence.

 

Q<66> <Chairman:> We now move into the next evidence session.

I was going to ask you, Secretaries of State, if you want your officials to sit with you, but they are sitting with you already, so we will regard that as a fait accompli, shall we?

<Ed Balls:> Yes, in order to show the seamless way that, while respecting the independence of the civil service and mutual roles, we all work as a team.

 

Q<67> <Chairman:> You are almost colour co-ordinated, except the Secretary of State for Health seems to be slightly out of line. Or is it you? [Laughter.] Right. Are we ready? I am sorry that there has been a delay and we have kept you waiting. I will have to use names, as we now have two Secretaries of State before us. We will address you as "Alan Johnson" and "Ed Balls". Is that all right?

<Ed Balls:> It is greatly preferable.

 

Q<68> <Chairman:> Right, let's get started. This is an extremely important session for this Committee. Given the wide remit of the Committee, it is difficult to not have some concerns and worries that there are parts of that remit regarding children to which you are really not paying sufficient attention to in terms of scrutiny. You will be well aware that, as members of the Committee go around the country and take evidence, very often we find that the Department of Health and the Department for Children, Schools and Families could work better together in a more co-ordinated way, so that at the point of delivery in our communities a better service-a joined-up, seamless service-can be delivered.

We feel strongly about that because we have just done a major inquiry into children in care and one of the issues that came back time and time again, particularly in terms of mental health challenges, was this lack of-we thought-access to high-quality care at the right time. For many of the children we met-and the evidence that we were given suggested that these were children who had been in dysfunctional families and had very often been abused-we found that it took a very long time to get any counselling and any professional support. That really did spark us to say that we ought to get both of you together to discuss what is going on.

Alan Johnson has only just joined us. Do you want to say anything to start off, Alan, or do you want to go straight into questions?

<Alan Johnson:> No, I am fine going straight into questions.

 

Q<69> <Chairman:> Okay, we will go straight into questions. Let us get started by saying to Alan Johnson-to give Ed Balls a little rest from the previous session-what do you think the real problems are in delivering a joined-up service at local level?

<Alan Johnson:> They are the problems you find in every attempt to join up government, both at national and at local level. People have their own grading structures and their own reporting systems and trying-whether it is through Every Child Matters, or whether it is through children's trusts-to ensure that you integrate that without disturbing the arrangements for local authorities and the NHS and primary care trusts and so on, is always difficult. In some areas they do it very, very well. In some areas, on a wider issue than just children's health, the PCT and the local authority work together. I quote Barnsley and Salford as examples, but there are examples all around the country. Others pay lip service to that principle, but don't actually do it, and it is something that I am very keen to break down-not just with Ed and the work that we have done together, but with Hazel Blears in the Department for Communities and Local Government as well. People talk about "our money" in terms of the health budget and the education budget, but it is actually taxpayers' money that should be devoted to joint objectives. Those are some of the problems about doing what everyone says they want to do, but people do it with varying levels of success.

 

Q<70> <Chairman:> As we were preparing for this session, it became clear from the material that we were looking at that Ed Balls, the Secretary of State for Children, Schools and Families, because he has direct communication to 20,000 schools and quite a direct line to elected local government, seems to have a much better ability and much more power to say, "Come on, these are the objectives we want and we need co-operation to achieve these objectives." It seems to me that you, Alan Johnson, have much more difficulty securing delivery at local level. How do we get over that? PCTs seem so remote and all the evidence I have read suggests that they don't prioritise children's issues enough.

<Alan Johnson:> Let me tell you about my experience of doing Ed's job previously. I found that there was a real issue about children's health when I was at Education: children's health was not high enough up the agenda of the NHS. Now, I tried to rectify that. We have the ability to be a benign dictatorship-nothing much has changed from Bevan's day in terms of the power of the Secretary of State in law, in the NHS. We have something called the operating framework, which used to be called the marching orders of the NHS. It goes out every year in November-December and it sets the trend. If you put something in the operating framework, it will get done.

I brought up children's health in my conversation with the chief executive of the NHS, who has spent 35 years in the NHS. He said that he has never had a Minister suggest that children's health should be part of the operating framework. It is now-it is tier 1. There are three tiers, and tier 1 is the one that says, "This must be done." That is a start to working together with Ed and his Department, whether it is on obesity, the Child Health Strategy, or the CAMHS review. We are saying, "Look, this is the example that we are setting nationally, and has to happen locally," and it does happen. If you put it in the operating framework, you will find that PCTs pay much more attention to it. They may have been late starters in terms of, perhaps, your perception of how far along they are, but they are doing this, particularly since the publication of the Child Health Strategy. I am encouraged by the fact that they are not just doing it, but recognising the need to do it.

One final point is that we don't really have the evidence yet that shows that investment in child health services produces better outcomes further down the route. Clinicians go by firm evidence, which is one of the reasons why the Yorkshire and Humber Public Health Observatory is being asked to do a job as a child health observatory to find the levers that show that there is a direct link between the work we do with children and the outcomes further down the track.

 

Q<71><Chairman:> Ed Balls, one of criticisms that we have read from the Health Committee is that there isn't enough evidence-based policy. A lot of policies have been running for 10 years with no real evaluation of whether they actually give value for money and increase the well-being of children.

<Ed Balls:> In the case of the CAMHS review, the work that we are doing on speech and language therapy and short breaks for disabled children requires very close co-operation in policy and delivery between the two Departments. Those reviews are quite evidence-based.

Can I also attempt to answer the question that you asked Alan about the difference between health and the children's services that I deal with? It has been hugely to the advantage of children around the country to have a Health Secretary who has come from doing my job and sees things from both sides. The absolute key to make this work is a culture of leadership and joint working at the level of the PCT chief executive, the local authority chief executive, the DCS, the police commander and the organisations below them, such as the schools, the GPs, hospitals and the children's services department. Around the country, we have brilliant examples of best practice and making it work. It is hard to get that culture right into different organisations. In other areas, you do not yet have the same degree of really committed local leadership.

The difference between our two Departments is that at Health, you probably have more powers to say, "This is what should be done," but it is not always clear-Alan has been clear about this-that sending an injunction from the centre is sufficient to deliver change, if what you actually want to do is empower local leadership. In the case of our Department, in the end, it works only if the schools and the individual social workers really want to do it. On the schools side, the winning of hearts and minds and empowering the local leadership is also important. What Alan has done is take that understanding of driving local leadership and decision making into the health and children's health area. That is why this is the best opportunity that we have ever had to take the best practice of local leadership and to try to make that universal across the country. This is a really significant moment for integrated children's service work at the local level.

 

Q<72> <Chairman:> Secretaries of State, I want to move on, and I realise that I have been terribly rude to Heather Gwynne and Ann Jackson in not welcoming them to the Committee. Someone has to ask what their jobs are. Heather, what do you in your Department?

<Heather Gwynne:> I am the director of the Chief Nursing Officer's Directorate, and have responsibility for children's health services as part of that.

<Anne Jackson:> I am the director of the Child Well-being Group at the DCSF, and I work with Heather across the range of children's health issues.

<Chairman:> Thank you, and you are very welcome. Andy, were you going to start?

<Mr. Slaughter:> I think my questions have been covered.

<Chairman:> Do you have anything to add?

<Mr. Slaughter:> I could, but we have limited time.

<Chairman:> We will move on to John, then.

 

Q<73> <Mr. Heppell:> The Child Health Strategy was delayed: it was supposed to be introduced in spring last year, but actually came out in February this year. I will ask this question in three parts as we don't have a great deal of time. Why was there such a delay in releasing the Child Health Strategy document? How do you intend to report on the strategy's progress? Thirdly, given that the document is supposed to be about communicating better with children and families, why has no child strategy been written specifically for young people, as well as the one that we currently have?

<Alan Johnson:> I don't know whether the delay was from spring last year to early this year-we certainly said that we would publish the strategy at the back end of 2008, but we didn't for various reasons. I can't take you through a blow-by-blow account of that, but you need to have Government agreement as to where you are in a group, you need to sort everything out with the Treasury and you need to have everything in place with affected Departments as well. Ed and I were keen to get it out as quickly as we could, but we understand how these things work-there were other policy announcements to be made-so for one reason or another, it went out later than we would have liked.

I think the acid test was the reaction to the strategy. People were concerned that they were never going to see the Child Health Strategy, and when the people who helped us draw it up-the voluntary sector, NGOs, people in local authorities and so on-saw what was in the strategy, they generally welcomed it and no one now talks about the delay in publishing it. I thought we had published a user-friendly version.

<Anne Jackson:> No.

<Alan Johnson:> Okay-we should have.

<Ed Balls:> The other thing to say is that the Child Health Strategy wasn't just that document. There were also a number of pieces of work that we were doing around the Bercow report and the response in terms of joint commissioning on speech and language therapy; our review of making PSHE, including sex and relationship education, compulsory in the curriculum; and free school meal pilots in some areas. All of those things came out of the work for this review, and in some ways it was actually better to put all the individual components in place before producing the final document.

At one point, we were thinking of doing this before we got to the end of the Macdonald review of the curriculum, but I think there would have been a real gap in the report. The fact is that, by being a little bit late with the final report, we were actually able to progress policy on CAMHS, language education in the curriculum and eating and obesity considerably further down the track than we expected at one point.

<Mr. Heppell:> I think Anne was trying to come in.

<Anne Jackson:> I was going to pick up on the point about monitoring progress simply to say that we have a joint programme board across the two Departments that looks at PSA 12 to improve children's health and well-being. We expect that board to take oversight and delivery of the strategy.

<Ed Balls:> Probably what we ought to do is a "one year on" progress report. Perhaps we will do a short version.

 

Q<74> <Mr. Heppell:> Presumably, that won't be late. [Laughter.] There is an awful lot of emphasis on children's entitlement to the health service being worked out and publicised locally. How much variation do you expect to see locally, and what sort of framework will it be set in? What sort of parameters will you allow?

<Alan Johnson:> Not an awful lot of variation. One of the issues here is a bit like adult social care-a large degree of licence is given to local authorities on this, just as there is to PCTs. Some 80% of our money now goes straight out to PCTs-it was only 70% a few years ago-and they get on with it. That is one of the points about the strategy-there needs to be consistency in different parts of the country, but some parts will be spearhead areas, which are generally recognised as the most deprived areas. For the purposes of the Department of Health, however, such areas have the worst health outcomes-they have very high levels of cardiovascular disease, of cancer, of smoking and so on, so given the health inequalities agenda, they would perhaps take a different approach from somewhere that doesn't have those problems in such depth and to such a profound extent. So there would be changes such as that and there would be changes in the school system, I guess. Some parts of the country would have a different type of arrangement for schools, whether selective education or-

 

Q<75> <Mr. Heppell:> Is this idea-what has been called the local offer-a new development in policy, or just a different way of communicating it?

<Ed Balls:> I think that it is more than that. We have now got to 3,000 Sure Start children's centres and we will get to 3,500 soon. Two days ago I was in a Sure Start in Tonge, Bolton, where as well as the nursery they have on-site midwives doing antenatal visits, and health visitors and family support workers working from the children's centre. That isn't happening everywhere yet, but increasingly we are putting the health provision within children's centres or right alongside them. The important thing about that children's centre was that the health visitors, the midwives and the children's centre together were now able to ensure that every parent across the area, which was a more disadvantaged community, would be guaranteed a number of contacts with the children's centre, including health contacts, over the first year of the child's life. That is really important because it ensures that children are not falling through the gap and that you are really getting out to every family. That is hard to do, but it is the best practice and is really delivering that first-year offer to parents and children in a much more effective way than we have ever been able to do before.

 

Q<76> <Mr. Heppell:> Moving to something different, the strategy points out the importance of GPs' involvement, especially on children's trust boards and so on, but it then goes on to say that the responsibility for that lies with local authorities. I just think to myself, "How do local authorities persuade GPs, who may feel that they don't want to sit in boring meetings for the sake of boring meetings or read great big lengthy minutes?" How are local authorities going to persuade GPs? Shouldn't there be something more direct-an appeal made directly to the GPs saying, "We expect you to do this."?

<Alan Johnson:> Heather can say something about the technical aspects. It is really important for GPs to engage in this way. GPs are the jewel in the crown of the NHS; they are access to primary care. But very often, and this is something that we have said to the BMA over and again, they are waiting for the problems to come to them. There are some exceptional GPs out there who have an entrepreneurial spirit and are going out to the problem and working with other agencies to resolve these issues. So, it is no good recognising, as we do, the crucial role of the GP and then saying that we are going to have all these partnerships and this integrated working that Ed spoke about but that the GP will get this second hand, because it is nothing to do with them as their time is too precious for them to go along to these meetings. I do not accept that at all. When we see GPs really grasping these issues of health inequalities, child health and obesity, and being part of the team that is focusing on them, as they should be through a primary care trust-a primary care trust is about primary care-I don't accept the argument that they are too busy to get engaged in this way.

<Heather Gwynne:> In terms of ensuring that the involvement happens, we are looking to primary care trusts as members of the children's trust boards to work with the local authority and ensure that the right GP membership is found. I think that we have said that we would expect, for example, the PCT professional executive committee, which exists in all cases, to be one good source of GPs. In the many areas where there is a strong GP commissioning group, again that would be a natural point with which to make a strong connection. We have been talking to the GP commissioning bodies nationally about that and will take it forward as trusts develop. So there is a number of obvious starting points that we will work with. Exactly who is best placed to do this and who will be the right leader will vary from area to area, but we are committed to looking at how that works and we will learn as we go on.

<Ed Balls:> As a way of making sure that the GP voice is heard, we hope there will be a lead GP with a speciality in children's health on the children's trust, who will hopefully corral some of their colleagues to participate as well. That is a step forward too.

 

Q<77> <Mr. Heppell:> One final question on children's mental health. The CAMHS review recommended setting up regional boards to support and challenge the roles of the Government officers and the strategic health authorities. Is there an acceptance that support for local services across all child health areas needs to be much more coherent?

<Alan Johnson:> I think there is an acceptance of that. We accepted all 20 recommendations of that review. It was an independent review, carried out by people whom Ed and I continually challenged, saying, "Look, make this as radical as you want to make it. Tell us what the issues are." They are all people who worked in children's mental health for years. They did point out that problem, hence that recommendation. By the end of the year, the support programme should be in place. I think you will see pronounced benefits from that.

<Ed Balls:> I have seen CAMHS in the area that I represent as an MP changing fast. Historically, there has been a bit of cultural divide between the clinical side engaging when there is clear evidence of symptoms, and head teachers wanting more emphasis on early intervention. My sense is that the CAMHS review is bringing those cultures together and making early action very much part of a more primary care-orientated approach from CAMHS. That is really welcome to schools. As I said, you now have CAMHS teams out there in schools, working on a daily basis with every school in the area, rather than at the end of a phone or a bit of a distance away, operating in a more traditional health kind of way. That is very positive.

<Chairman:> We are going to move on. Fiona, you want to ask about safeguarding.

 

Q<78> <Fiona Mactaggart:> I shall cheat and add a final question on the Child Health Strategy. One of the things that we heard from previous witnesses was that you can have the right strategy, but it really depends on investment on the ground for it to be developed, and that this area of investment has not got perhaps the salience of things like cancer targets and so on. Dr. Adams concluded that it is about the Government putting pressure on primary care trusts and strategic health authorities to invest-she said in the health visiting service and the health visiting team, because she was focusing on that at the time. What are you doing to make sure that happens, Secretary of State?

<Chairman:> Don't go into health visiting, Alan-that's the next section.

<Fiona Mactaggart:> I was merely using health visiting as an example. She talked about the Government applying pressure at the PCT level. The PCTs feel pressured on their targets for times and things like that. I don't think they feel sufficiently pressured on these issues.

<Alan Johnson:> This goes back to an answer I gave when you were out of the room-it's the operating framework. If you put it in the operating framework and you make it a priority there, it will happen. If you put it down as a tier 3 in the operating framework it means that you have discretion in this and that there are issues that you might want to tackle. If you put it in tier 1, they are the issues that you have to tackle. It has never been in tier 1 before and it is now.

 

Q<79> <Fiona Mactaggart:> Okay. My real concern and what I would like to focus on is the evidence from the Healthcare Commission, among others, that the safeguarding performance of the health service is not what we should expect. It suggested in the March 2009 report that significant weaknesses were still evident in relation to child protection training. We all felt in the accounts that we heard of the life of Baby P that health service personnel had been part of-there were others too-the failure there. Yet we really do depend on health service personnel in this area. What steps are being taken within the NHS to respond to these concerns about the relatively low priority and the lack of expertise in safeguarding in both GP and hospital services?

<Alan Johnson:> We have just had the report from the Care Quality Commission that looked at the four trusts involved in Baby P. First, they make the point that they have all come on leaps and bounds since the Baby P incident.

 

Q<80> <Fiona Mactaggart:> Not every trust is going to have such a desperate tragedy to act as a spur to coming on in leaps and bounds.

<Alan Johnson:> That is true, but you had Laming a few weeks ago, which made some very important points about health visitors that we will come on to. The Care Quality Commission specifically focused on the NHS failures. The child saw a paediatrician, most tragically, the day before he died-he had a broken spine and broken ribs, but it was not picked up. The mother took Baby P to A and E four times, and it was not picked up that he was on the child protection register. The health visitor went to see Baby P. Where was the NHS in all of this? The Care Quality Commission says that it has put an awful lot of investment and work into those four trusts, to make sure that those fundamental problems are resolved.

We need to do something much wider. GPs are an important issue, which comes back to the point that we made earlier-GPs are crucial in all of this. GPs need to be absolutely up to date with the latest information on how to identify such problems, even if there are no obvious signs in the early stages. How you get that early intervention is important. All the agencies involved recognise that you cannot put too much emphasis on ensuring that safeguarding becomes part of the everyday life of the NHS.

<Ed Balls:> There is a clear link to the structural changes. As well as the individual professional issues around training, health visitors and GPs, we also have the fact that we are making the Children's Trusts statutory, which means that when the safeguarding board says that there are issues around the co-ordination or the engagement of health for other professionals, it is the Children's Trusts' job together to get that sorted out at the local level. That local accountability, with the new public members that we are putting on, will be important. Also, the national unit that our new national adviser on safeguarding, Sir Roger Singleton, is leading, will be across government. There will be health expertise in that unit, with officials from Alan's Department. So, nationally and locally, we shall be able to press on that engagement. In the end, what matters is whether the GP or paediatrician comes to the case conference, in the individual case. That is something that is complex-it needs to be properly co-ordinated, it needs to happen-but really goes back to training and professionalism.

<Chairman:> We certainly feel, having extended our inquiry to cover some of the safeguarding issues, that this period when the child is relatively invisible-nought to three, before it gets into nursery-is so important. The GPs and health visitors-that team-are aware. But I am not going to ask a question-Edward, you are coming in.

 

Q<81> <Mr. Timpson:> Yes, on school nursing, and I am asking a question of the Secretary of State for Health. In the 2004 White Paper, "Choosing Health", a commitment was made to have at least one full-time, year-round qualified school nurse in each secondary school, also involving a cluster of primary schools around that secondary school. That was a commitment to be done by 2010, as I'm sure you know. We know that, four years on, September 2008 being the most up-to-date figures available, out of the 3,334 secondary schools, there are 1,447 qualified school nurses in position. From a report a few weeks ago, that equates to nearly 5,000 children per nurse. That is still very far short of the commitment made by the Government. What are you doing about it?

<Alan Johnson:> We are increasing the number of training places for school nurses. The Prime Minister, in his speech to the Royal College of Nursing on Monday 11 May, recommitted us to that objective from the 2004 White Paper. We mention it in the Child Health Strategy as well. We should be further on than we are. For various reasons, we are not at the right level that we should be in 2009. We have another year, and we are working at this very hard. I think that it will be difficult to hit it spot on, to be frank, but we can really ramp up the number of school nurses that we put in. You are right, it is one nurse not for every primary school, but for a cluster of primary schools around one secondary school.

 

Q<82> <Mr. Timpson:> I take it from your answer that you are still wanting to hold that commitment, but you have some reservations about whether it is achievable, given the current position, which I have just quoted to you.

<Alan Johnson:> Realistically, given the current position, it is going to take an awful lot to do it, but we have recommitted ourselves to it. The Prime Minister did that as recently as the week before last.

 

Q<83> <Mr. Timpson:> Asthma UK has commented that "the ambiguous recommendation for every area to have a School Health Team seems to be a real step back from the Government's previous pledge to resource comprehensive provision of school nurses by 2010." Is that something that you are struggling to agree with? What response would you have to Asthma UK?

<Alan Johnson:> You do need a team. You need to ensure that the school nurse is part of a team, the same as a health visitor is now part of a team. Once upon a time these were very isolated jobs. They were working in isolation. There is a much bigger focus now on a team. It comes back to your original question, Chairman, about how you integrate all the various elements of protecting children. Instead of having social workers over here doing their own thing, GPs over here, health visitors over here, the school nurse over here, they have to integrate. I stand second to no one in my admiration for Asthma UK but it isn't a matter of either/or. You can meet the school nurse target and also have them as part of the team.

 

Q<84> <Paul Holmes:> Personal, social and health education, PSHE, has become a statutory part of the curriculum. Apart from the issues of overloading the curriculum, which we always talk about, can I specifically ask how is that going to be delivered in an effective way? When I was a head of year 12 and 13, I ran a tutor group of nine different tutors. One of them might be very confident about doing sex and relationships education with 17 and 18-year-olds but another one might say, "There's no way I'm doing that," and the rest might do it in a very mediocre way. They are not trained. They are chemistry teachers, they are history teachers, they are maths teachers. They are not trained to teach sex education or relationship education. How are you going to get round that?

<Ed Balls:> The important thing-which the Macdonald review makes clear and we have accepted-is that it is not enough to say that is should be statutory; you have really got to make it happen. On the one hand, when it was not statutory, there were some schools that were not doing it or were doing it in a rather cursory way. Similarly, we must make sure that, once we make the expectation universal, it is done with quality. While saying that individual schools need to decide how to do this, we are not trying to be detailed in our prescription into the curriculum. It is also recommended in the review that part of initial teacher training should include training in PSHE and that we need a dedicated cohort of specialist teachers as part the work of the Training and Development Agency for Schools for initial teacher training. We also need to see whether we can have an enhancement option allowing for a possible PSHE specialisation as part of the masters in teaching and learning which we are progressively trying to roll out to include all teachers. We also need to see the ways in which we can do this as part of standard continuing professional development. There is no doubt that this is a challenge in terms of training and personal development of teachers but it is something we need to do over the next two or three years. It was a particular feature of the Macdonald review, whose recommendations in this area we have accepted.

 

Q<85> <Paul Holmes:> Some of the best education I saw was when you had health workers coming into school, for example, rather than just asking the chemistry teacher to do it. How do we link with the Department of Health? Can it afford to send specialists into schools anyway?

<Alan Johnson:> School health teams.

<Ed Balls:> I was looking at these figures. It was quite striking. Alan said it was a challenge to get to every school, but at the same time, the number of school nurses has gone up by 50% in four years, by over 1,000 more. The number of post-registration school nurses has gone up by 70%, which is almost 800 more. There has been massive investment in the NHS, delivered by the national insurance tax rise for the health service, which has delivered this big increase. The point of school nurses is to be part of the curriculum in the same way as within safer schools partnerships we now have police officers in the community participating in the teaching of citizenship in the curriculum. These two agendas integrate. We need to make sure that the health teams in the school, with the school nurses, are helping us to teach PSHE.

 

Q<86> <Paul Holmes:> In the context of a previous inquiry, this Committee heard from people from faith schools. When we were talking about delivering sex and relationship education-including issues of homosexuality, age and so on-they smiled and said, "Well, we're not going to do that." Are you happy with that?

<Ed Balls:> We have said that how individual schools choose to deliver sex and relationship education will be done within the context, values and ethos of the school as now. But at the same time that must be consistent with the core entitlement to that education. We need to ensure that schools and governing bodies understand fully their responsibilities-and young people too. We will not require every school to teach it in exactly the same way, but at the same time every child in every school will be entitled to proper, core sex and relationship education, unless, as in a minority of cases, parents exercise the opt-out, which Alasdair Macdonald recommends that we continue.

 

Q<87> <Chairman:> But you haven't answered the question, Secretary of State. Faith schools told us there is no way that they will teach it.

<Ed Balls:> Faith schools-in the case of Oona Stannard, for example-were part of the working group that the Schools Minister chaired and which made this recommendation. Those organisations have supported Alasdair Macdonald's review. Consistent with their ethos and the context of the school, they have a responsibility to teach citizenship and other parts of the curriculum, which will include sex and relationship education. It's really important that they do that well.

 

Q<88> <Paul Holmes:> But we heard from-again, we can send you the evidence from the particular report-heads of sixth forms and deputy heads of three different faiths. They all said, "We're not going to do that." They said it very nicely, but they said it none the less.

<Ed Balls:> Consistent with their ethos, it will be part of the national curriculum.

 

Q<89> <Paul Holmes:> So how will the Department decide that these taxpayer-funded schools are not delivering these strategies and do something about it?

<Ed Balls:> It is the responsibility of the governing body to ensure that they are doing it properly. Children, young people and parents will see the way in which it is occurring, as too will the inspectorate. I do not doubt that there will be some issues to deal with along the way, but we are making the right decision to ensure that all children have a proper understanding of these issues. It will help us to reduce teenage pregnancies, which is important for all children of all faiths.

 

Q<90> <Paul Holmes:> My local PCT, in Derbyshire, told me categorically that there is clear evidence that schools that don't do sex and relationship education have more teenage pregnancies and specifically said that faith schools are an example of that.

<Ed Balls:> That is why it is important that all schools, including faith schools, teach sex and relationship education.

 

Q<91> <Paul Holmes:> So you will expect Ofsted to pick up on that and report very clearly so that action will be taken against these taxpayer-funded schools?

<Ed Balls:> Of course.

 

Q<92> <Paul Holmes:> When the Health Committee looked at the national healthy schools programme, it said that it was a classic example of a big Government programme, in place for 10 years, but that there is no research base to say that it actually works. Research was due in spring. Has that happened?

<Anne Jackson:> We are getting an initial whiff of the first year of the research. It is a three-year research programme by the National Centre for Social Research. The early indications show that it is having an impact. It is welcomed by heads, and there are some slight positive correlations with academic outcomes in schools too. So we are very keen to pursue it.

<Ed Balls:> It is not published yet, and the truth is that it is not good enough. The Child Health Strategy sets out a substantial strengthening of the healthy schools programme and moves it away from schools simply showing that they have got the right processes in place-that is a good thing, because it is really good to ensure that you can do lots of things to ensure that children are healthy-and on to outcomes. We will now move to a more enhanced healthy schools programme where we will measure things on the basis of, for example, whether obesity is improving and healthy eating take-up rising. I think that we have learnt quite a lot from the first phase of the healthy schools programme. I have found schools very proud to show off the fact that they are healthy schools. However, we need to-Anne has been very clear about this-translate the obesity strategy into really measurable outcomes for children's health. That is what we will do in the next phase of the programme.

 

Q<93> <Paul Holmes:> And when is the report due?

<Ed Balls:> It says here, shortly. I haven't actually seen it yet, which is why I didn't immediately answer the question; but we will publish it shortly. Is shortly soon?

<Anne Jackson:> Yes.

 

Q<94> <Chairman:> This may be prejudice, but in the early years of the strategy I thought there was much more commitment from the private sector. You saw Tesco, Asda and the Co-op having children from schools in their stores to learn about healthy food and identify food that perhaps was new to them, and so on. That seems to have all dropped away. Is the private sector commitment waning?

<Alan Johnson:> No, quite the reverse. Asda and Tesco are part of the Change4Life campaign. Sainsbury's is kind of flitting around on the edge there. They are doing lots of things to help. Tesco, for instance, has a "Change4Life 4 Less" programme, where it points out that it is cheaper to buy fresh carrots and vegetables, and that ramps up over the coming year. Ed and I were listening to ideas about how the major supermarkets can help with healthy school lunches, and have a part of the supermarket dedicated to just going and getting a lunch pack, where parents find it much more convenient to find all the things. They are brilliant with ideas on this; they are very helpful.

<Ed Balls:> Also, there was the cook book for year 7 pupils that we published last year-over 500,000 copies went out last September-which we will repeat again this summer for year 7. We have had Aldi and Sainsbury's promoting the recipes on the websites in their stores, encouraging children to get their parents to buy the ingredients and have a go at cooking at home. The partnership is quite deep now, in our schools.

<Chairman:> That is good news. We don't want to miss out health visitors.

 

Q<95> <Mr. Stuart:> Can I seek both your reassurances on health visiting, particularly because of the backdrop? Over the last 10 or 12 years we have had big launches; we have been told that the Government are taking health visiting seriously; in 2004 the "A Healthy Child" programme said we were going to take on more health visitors and increase the number; now, following Lord Laming's report, we have the "Action on Health Visiting" programme. I believe there was going to be agreement on the programme on 5 May. Yet we find that health visitors are at the lowest level for 14 years. Lord Laming finds that case loads are far too high. One of the difficulties in our job, as a Committee, of holding you guys to account is how we can be assured that this time the Government are going to do what they have perfectly happily been prepared to provide statements and reassurances about before, and then, as far as I can see, signally failed to deliver. Do you think health visiting is important?

<Alan Johnson:> It is, it is crucial, but let us get this into context. The reason numbers of health visitors went down was the same as the reason the number of midwives went down: the birth rate was reducing. It reduced year on year in every developed country. There is a very clear ratio of numbers of health visitors and midwives to children. Now, the birth rate started to go up around three or four years ago and the statisticians told us it was a blip. They said, "It will just return to normal." The second year they said it was a blip. The third year we thought, "This is a bloody long blip." That is why we then started to concentrate on what we need in a completely different situation of a rising birth rate. That is point No. 1.

With midwives we have said very clearly that we think we need about 4,000 midwives, and we have recruited the first 1,000 in the first year. For health visitors we are not too sure about the numbers. I think in the Child Health Strategy we referred to a "substantial" number. I can't really put a figure on it. The reason for that is the second issue here, which goes back to something I was saying earlier. The profession has changed. There was a very important report commissioned by my predecessor in 2004-05 about the role of the health visitor. It used to be working in isolation as a kind of individual, when there was not a focus on community.

You are right about numbers of health visitors going down, and I have explained some of the reason for that, but the number of nurses working in the community has gone up by 37%. The report on the profession, by people in the profession, showed that health visitors had not had enough help and support to adapt to this new position; because really they are team leaders. Their skills are so vital, but the skills they need now are as the team leader, which was never part of their training in the past. So the profession itself, particularly through the Community Practitioners and Health Visitors Association, recognises all of that. We need more support for the profession to become more attuned to this world that it is operating in. We also need more health visitors and we need to define very clearly what their role is within a team. As I have said, my view is that they should be team leaders.

So, what we launched on 5 May was a very important summit of all the people representing health visitors, including the NHS, the strategic health authority and so on, with all of them saying, "Now we are really going to tackle this over the next six months". There will be another meeting in October. We are working with the representative organisations to define the role for health visitors and to find out what needs to be done to improve their training and support. We have a very low vacancy rate for health visitors-0.3%. So it is not a problem of attracting people into health visiting. That is a problem with midwifery, so there is a lot of return to practice with midwifery.

With health visiting, however, we have a low vacancy rate, so increasing the numbers is important, yes, because the birth rate is going up and they are crucial to dealing with that. Ensuring that they are used to their new role of working within a team and providing them with the support and development that they need is the total agenda. It is not as simple as just raising numbers, but raising numbers is a part of it.

 

Q<96> <Mr. Stuart:> That was a very persuasive answer, as ever. However, one of the questions was about holding you to account. You say that, in a sense, the role of health visitors is changing. Lord Laming was more straightforward. He said that a health visitor should deal with 300 families and 400 children, maximum. That should be the target case load. However, he said that 20%. of health visitors, which is an awful lot of health visitors, are dealing with 1,000 children. That doesn't quite accord with the picture that you just painted, when you said, "Oh, it's just that the birth rate went down and therefore naturally health visitor numbers went down." In at least a fifth of cases, it sounds like you have people with a completely unreasonable overload. Does this new team-working and the additional health nurses in the community mean that Lord Laming was wrong and that, in fact, that level of case load is perfectly adequate, or not?

<Alan Johnson:> No. I had this discussion with Lord Laming himself and he recognises how things are changing. A health visitor doesn't need to go to every single family. A health visitor, as a team leader, can ensure that all those other nurses are used. As I have said, there is a 37% increase in community nurses, who are qualified nurses working in the community, from PCTs, Sure Start centres, and so on. Those nurses can take the work load off the health visitors, so that the health visitors can concentrate their attention on the children and the families that they really need to get to. We will probably not have time to talk about the Family Nurse Partnership, but that has also been a crucial part of this strategy.

 

Q<97> <Chairman:> But there has been a lot of criticism that health visitors focus on more needy families and children in needy families. It is said that health visitors get burned out, like social workers, by only dealing with families under stress. Also, I said earlier that nought to three is a very difficult time to identify a child that is in danger. Health visitors used to be able to be the advance guard in picking up on problems. Is that diffusion of health visitors away from that general responsibility not dangerous for child safeguarding, Alan?

<Alan Johnson:> It depends what you mean by that. Every Sure Start centre will have a designated health visitor, as part of the Child Health Strategy. That is crucial, because Ed would be as frustrated as I was by the fact that that link was not always there, between education and the health service. The health visitor is crucial to maintaining that link.

Graham was asking me how we stay accountable for this area. This is the debate that people are having in the profession. This is the debate that kicked off before 5 May, but the 5 May summit brought all these issues to the fore.

Regarding accountability, by October we will have a clear idea, having consulted with the profession, about what the different roles will be. I would be very surprised if what comes out of that summit is "back to the future", because the document that Patricia Hewitt commissioned made the new role for health visitors very clear. It means that health visitors help to ensure that children do not fall through the cracks. It also means that health visitors are not overburdened. Lord Laming was absolutely right; some of these health visitors are overburdened with cases and there is not enough help from the team to support them.

 

Q<98> <Mr. Stuart:> But Lord Laming said that he was surprised and concerned about the lack of universality. You have said that you will use the teams, but what you also seem to have said is basically that the universal health visitor service will end. By having health visitors in a leadership role, you hope that the health visitors can use other professionals to deliver the same service. I guess that the question is this: can they do so? Do community nurses have the skill base? Will they be able to provide the same reassurance and pick up the issues that the Chairman has just mentioned? If you do not send a health visitor to every home, you have ended the universal health visitor service. You might be producing another universal community service, but you would have to persuade this Committee that that is the right way to go and that that team can deliver the service that you previously said was going to be delivered by more health visitors. In all the programmes to date-and we have not been told about 5 May-we were always told that you were going to deliver the service and you were going to recruit more, but you haven't. Now you are telling us that you may not.

<Ed Balls:> I feel as though this part of the conversation is entirely disconnected from our earlier conversation about how you delivered effective and integrated working between health, children's services and local government. As I explained earlier, Sure Start-the one I went to in Bolton-had an overall manager of the centre and, working within that centre, there were midwives, health visitors and family support workers who had a clear programme that ensured multiple contacts for every child and parent in the area. Some of those contacts would be triggered by the midwife. Some would be triggered by people coming into the children's centre, and some by the health visitors going out. The multiple contacts were being co-ordinated across the range of different services. The health visitors, who I am sure were probably stretched-and we would like to have more of them-were part of an integrated team. That must be a better way to do it, rather than saying we will have a group of health visitors here who go to every family and who will be separate from the midwives and the children's centre, because there is no effective integration. The other thing is that the wrong way to deliver on our desire to drive up the number of health visitors would be substantially to cut back the Sure Start children centres' budget. That would be totally self-defeating and counter-productive, and not something that we would ever contemplate.

<Alan Johnson:> May I make it clear that this is not the end of the health visitor? It is a health visiting programme, not a health visitor programme. The numbers will increase. We need more health visitors as part of the health visiting programme.

 

Q<99> <Mr. Stuart:> How do we know they will? We've been told that before, and the numbers went down.

<Alan Johnson:> You will see the numbers go up. We are recruiting and putting a lot of effort into that. This debate will define how they are used to best effect in the teams we have been talking about in a health visiting rather than health visitor programme.

 

Q<100> <Chairman:> Where would you prefer to see a health visitor based then?

<Alan Johnson:> There would be one based in every Sure Start centre. A named health visitor will be linked to every Sure Start centre. That is a big step forward.

 

Q<101> <Chairman:> Some PCTs do not agree on where they should be based. There is a big contest, with doctors having the health visitors based in their practice, but you will know that.

<Ed Balls:> I personally would rather they were in the children's centres.

<Chairman:> Fiona, a quick couple of questions on public health.

 

Q<102> <Fiona Mactaggart:> This morning, I was asked to comment on concerns expressed by services in Slough about their inability to cope with an explosion of problems with alcohol abuse among young people. This Committee has already received evidence from Simon Lenton of the Royal College of Paediatrics and Child Health who stated that the strategy would be strengthened if it confronted more boldly the major public health challenges, particularly alcohol abuse among young people. International surveys show that we are at the top of European countries for alcoholism among young people. A quarter of British students say that they have suffered an accident because of alcohol abuse. We have a real problem here, and I am not convinced that this aspect of the strategy has a high enough priority.

<Ed Balls:> There is the youth alcohol work that we have been doing and the work of the Chief Medical Officer. Through Safer Schools Partnerships and citizenship, we are making sure that we are getting discussion of alcohol into the school curriculum. We are trying really hard, but it is also about the lead that parents give in the home and the way in which they drink. Those are important parts of the campaign and the advertising that Alan has been doing through the Health Department. The facts show that the number of underage young people who are drinking has fallen in the last 10 years, so there are fewer young people drinking than there were 10 years ago, but those who are drinking are drinking substantially more. It is that concentrated consumption of alcohol by the minority that is a real concern for us.

One of the things I have been concerned about is that if you look at the current teenage pregnancy statistics you will see that there has been a rise in conceptions in the past year, but not a rise in births, so those are unplanned pregnancies. It worries me that there is a link to alcohol as well, so we have also been trying to ensure that our messaging to young people through advertising links the issue of responsibility about drinking with teenage pregnancy. There is a big and important education drive, but it also has to be about parental responsibility and parents understanding that the way they drink as adults affects the way children think about alcohol from quite an early age.

 

Q<103> <Fiona Mactaggart:> Secretary of State for Health, I do not disagree that there is a role for parents here, or that there is a role for schools, but one of the things you have recognised is that big public health challenges are often met by services other than the health service, which we must consider if we are actually looking to create a well community. The Education Secretary has pointed out that the increase in teenage conceptions might well be connected to alcohol abuse. One in 11 young people say they have had sex without a condom, and it is likely that that might well be connected to alcohol misuse.

We are not using tools other than education. I remember what I used to think about the kind of things my teachers said to me about alcohol, and I didn't really rate them as experts on those issues. I am not sure we are using all the tools at our disposal, such as price, peer information and more effective support. Is the health service taking the issue seriously, because it will lead to more attendances in A and E, let alone chronic ill health?

<Alan Johnson:> That is very true. The whole issue of alcohol, not just among the young, is a huge problem. If you look at all the graphs, you will see that cardiovascular disease is coming down, cancer is coming down by 2% a year and premature deaths are coming down. Practically any disease you look at is going down, but liver disease is going up. That is dreadfully worrying for the Department of Health, which is why there are various measures. The issue of pricing is not totally within our control, but we did commission the report by Sheffield University, and we are looking very carefully at whether, and to what degree, that would have an effect. In the 200-year history of the Chief Medical Officer, he or she has never produced a report on alcohol and young people, and there was tremendous confusion about it, because it was legal to give alcohol to children above the age of four, or was it five?

<Ed Balls:> Five.

<Alan Johnson:> So asking the CMO to produce a report on this to give parents some health and guidance was important.

On the cultural issue, in a recent speech I asked why youngsters who don't drink are treated as pariahs. Why in this country, I said, do people go out with the aim of getting drunk, whereas in other countries they go out for a drink as part of a social evening? There is a cultural issue here that we have to tackle as well, so we are absolutely aware of the public health message and of the need to use all the weapons at our disposal. We just have to be sure that they will have the desired effect before we use them.

We have told the alcohol industry that, with regard to the years of voluntary codes, they are now, to put it in context, drinking in the last chance saloon. That hasn't worked, and there is a really good debate going on about what the next steps should be. The Home Office legislation that has just been announced and put out to consultation is about ending these "women drink for nothing" or "drink all you want for a tenner" promotions, which also have to be tackled. It is a multifaceted and huge challenge. Ed is right: the statistics show that fewer young people are drinking, and that is an important message to emphasise, but those who are drinking are binge drinking, which is the big problem.

<Chairman:> I think that that is the end of the session. Thank you both for your attendance, and I am sorry we ran a little late, which was because we did a double session. I offer particular thanks to Ed Balls, because he had the two sessions joined up. Thank you, Heather and Anne, for your participation. It seems to me that there is pretty good co-ordination between you both, Ed and Alan. I hope that that is not only because Alan was in Ed's job previously, but because it is systemic.