Health and Social Care Bill

Memorandum submitted by the National Children’s Bureau (NCB) (HS 19)

1.0 Summary

1.1 NCB believes that the Health and Social Care Bill provides a real opportunity to improve integration across the broad range of services that promote children’s health and well-being. However, if this opportunity is missed, the result could be even greater fragmentation in the way that services are planned, commissioned and delivered, resulting in children, young people and families – and especially the most in need – facing greater barriers to accessing the services and support they need. During the passage of the Health and Social Care Bill, NCB will therefore be seeking to ensure that the government’s reforms deliver for children and young people, and especially the most vulnerable to poor outcomes and social exclusion.

1.2 NCB urges Committee members to:

a) ensure that Health and Well-being Board arrangements deliver for children and young people by:

o amending the Bill so that Health and Well-being Boards ‘must’ (rather than ‘may’) encourage integrated planning and delivery across health, social care and health-related services

o amending the Bill to require Health and Well-being Boards, when developing their joint strategic needs assessment and joint health and well-being strategy, to have specific regard to children, and in particular, vulnerable groups of children

o scrutinising government's plans for enabling Health and Well-being Boards to implement effective ways of planning services in an integrated manner for all children in their area.

b) ensure that the Bill supports the engagement of children and young people in decisions about local health services and their own health care, through explicit duties on HealthWatch England, Local Healthwatch, the NHS Commissioning Board and GP commissioning consortia.

c) scrutinise government's plans for ensuring that GP consortia base their commissioning decisions on a thorough understanding of the diverse needs of children and young people and on evidence of what works to promote their health and well-being

d) seek clarity as to how government will ensure there is clear accountability for promoting the health and well-being of looked after children and care leavers within the new planning and commissioning regime

e) investigate how government plans to enable the voluntary and community sector to contribute to the new health system.

2.0 Integrated local planning for children and young people’s health and well-being

2.1 NCB is pleased to see recognition in the Bill that services that are not part of the health service still have an important role to play in improving the health and well-being of individuals. This is particularly important for children and young people, for whom the most effective interventions are often those delivered through non-health settings and services. For example:

· schools: school health initiatives can have a positive impact on pupils' health and behaviour, and can be particularly effective in improving young people’s knowledge of health issues [1]

· children's centres: young children with access to a local children's centre are more likely to receive the appropriate immunisations and to have fewer accidents than those living in areas not served by a centre. [2]

Other non-health services which are key to children and young people's health and well-being include: further education colleges, youth justice services, housing and local planning.

2.2 Many of these services are particularly important for delivering health interventions to children with complex needs, such as disabled children and looked after children and care leavers, and to those who may be less likely to engage with universal health services, such as children and families living in poverty and young people involved in the youth justice system.

2.3 The Bill establishes local Health and Well-being Boards to promote co-ordinated planning and delivery across the NHS, social care and public health services (clause 179(1)). In addition, it states that these boards may encourage integrated working between the commissioners and providers of health and social care services and of ‘health-related’ services (those that are not part of the health service but impact upon the health of individuals) (clause 179(3) and (4)).

2.4 While we welcome this broader focus on ‘health-related’ services, we are concerned that the Bill is too weak to ensure that every child in every area benefits from education, health, social care, safeguarding and recreation services that are developed and commissioned in an integrated way.

2.5 NCB also welcomes the proposal to require councillors, local authorities, GP commissioners and local Healthwatch to work in partnership to develop a plan to improve the health and well-being of local people (the new joint health and well-being strategy), based on an assessment of local needs (the joint strategic needs assessment) (clause 180(1)) [3] . However, with such a broad remit, we are concerned that children and young people’s needs may get lost in the process, especially as they are less likely to be receiving services primarily through the health system. This is particularly significant in the context of government’s decision to remove the requirement on local authorities and their Children’s Trust partners to develop a specific plan for improving the well-being of children (the children and young people’s plan).

2.6 NCB urges the Committee to ensure that Health and Well-being Board arrangements deliver for children and young people by:

f) amending the Bill so that Health and Well-being Boards ‘must’ (rather than ‘may’) encourage integrated planning and delivery across health, social care and health-related services

g) amending the Bill to require Health and Well-being Boards, when developing their joint strategic needs assessment and joint health and well-being strategy, to have specific regard to children, and in particular, vulnerable groups of children

h) scrutinising government's plans for enabling Health and Well-being Boards to implement effective ways of planning services in an integrated manner for all children in their area.

3.0 Giving children and young people a voice within the health service

3.1 As a member of Participation Works [4] , NCB welcomes government’s ambition to ensure that, through Healthwatch England and Local Healthwatch, patients and the wider public have greater influence over decisions about their own healthcare and the development of health and social care services (clauses 166 to 169). However, any measures to achieve this ambition must include children and young people from the start. A move to truly shared decision-making between the public, patients, practitioners and commissioners will require long-term cultural change, on the part of both the public and professionals. Supporting the younger generation to make a contribution, and understand the value of engaging in decisions about health care and services, will be a key step in this process.

3.2 Through the work of NCB and its Participation Works partners, we know that children and young people want a say in decisions about their own healthcare and the development of local services [5] . However, the level and quality of their engagement in the health sector varies considerably across the country [6] .

· The percentage of children and youth organisations as a proportion of the membership of local involvement networks (LINks) – which government proposes to transform into Local Healthwatch – ranges from one to 90 per cent [7]

· In 2007, 75 per cent of patient advice and liaison services (PALS) (providing support to patients to make complaints and make choices about their care) were not actively involving children and young people in their service [8]

· Many LINks are not always clear that children and young people are part of their remit7

· Many LINks and PALS have struggled to develop the skills and access the tools needed to work with confidence with younger members of the public78

3.3 Government must make clear from the start that children and young people are central to the remit of Healthwatch England and Local Healthwatch, and enable these organisations to work with younger age groups in a meaningful way.

3.4 Certain groups of children and young people – including disabled children and young people, children in care and care leavers, those involved in the youth justice system and refugees and asylum seekers – have specific physical and mental health needs and face specific challenges in accessing services. However, too often their voices are not heard. Local Healthwatch will need additional capacity and skills to reach out to and engage these children and their families.

3.5 NCB endorses the evidence submitted to the Committee by Participation Works. We urge Committee to ensure that the Bill supports the engagement of children and young people in decisions about local health services and their own health care, through explicit duties on HealthWatch England, Local Healthwatch, the NHS Commissioning Board and GP commissioning consortia. We also urge Committee to seek clarity from government as to how it will enable Healthwatch and NHS commissioners to work effectively with younger members of the community.

4.0 Ensuring the new commissioners have a thorough understanding of the needs of children and young people

4.1 The Bill provides for new commissioning consortia (led by GPs) to commission the majority of NHS services (clause 6). NCB wants to ensure that those taking over NHS commissioning are able to do so on the basis of a sound understanding of children and young people’s needs. We are concerned that not all GPs have the depth of knowledge required to commission effectively for all children and young people. For example, they are unlikely to have a detailed understanding of the role and importance of wider children’s services in promoting health and the particular needs of disabled or looked after children. Our concerns reflect Sir Ian Kennedy’s review of children’s NHS services, which highlighted gaps in GPs’ paediatric training and experience [9] .

4.2 In order to commission effectively for children and young people, the work of GP commissioning consortia (including the pathfinders), and their Health and Well-being Board partners, must be informed by:

· a thorough understanding of child development and how to promote children’s health and well-being holistically

· knowledge of the specific needs of vulnerable groups (including disabled children, looked after children and care leavers, those involved in the youth justice system and refugees and asylum seekers)

· the best available evidence of what works to improve children’s physical, mental and emotional health and well-being.

4.3 NCB urges the Committee to scrutinise government's plans for ensuring that GP commissioning consortia base their commissioning decisions on a thorough understanding of the diverse needs of children and young people and on evidence of what works to promote their health and well-being.

5.0 Meeting the health needs of looked after children and care leavers

5.1 Looked after children are particularly vulnerable to health risks and problems, often due to their experiences prior to entering care and the subsequent challenges they face in the care system itself. While some of their health outcomes have improved in recent years, there have been persistent difficulties – particularly in relation to partnership working across health bodies and local authorities and arrangements for securing provision for children placed out of authority.

· 45 per cent of looked after children aged five to 17 were assessed as having at least one mental health disorder, compared to ten per cent of the general child population [10]

· Looked after children exhibit high rates of self-harm and high-risk behaviour, particularly when living in secure accommodation [11]

· Two-thirds of all looked after children were reported as having at least one physical health complaint – most commonly eye and/or sight problems, speech and language difficulties, coordination issues and asthma [12]

· Some studies have shown higher levels of substance misuse among looked after children, when compared to the non-care population. [13]

5.2 It is vital that these vulnerable children and young people are not further disadvantaged by the reforms contained in the Bill. The proliferation of health commissioning boundaries that may result from the replacement of Primary Care Trusts by GP consortia, and the need for local authorities to work with multiple consortia, is a particular concern for those in or leaving care.

5.3 NCB urges the Committee to seek clarity as to how government will ensure there is clear accountability for promoting the health and well-being of looked after children and care leavers within the new planning and commissioning regime.

6.0 Ensuring the voluntary sector promoting children’s health can flourish

6.1 As providers of health services to children, young people and families – and often to the most vulnerable – voluntary and community organisations (VCOs) are central to the successful implementation of government’s ambitions for population health and well-being outcomes to be delivered by the NHS, public health and their partners. They are particularly well-placed to support children and their carers to influence local service provision and decisions about their care, and to empower vulnerable and marginalised children and families to take-up universal and specialist services.

6.2 However, the VCOs NCB works with (through our membership and specialist networks) tell us that they will need help to thrive in the new health system, in particular to engage with the new commissioning arrangements and to compete to secure service contracts. There are already reports of VCOs losing public sector contracts or having their funding cut, as local authorities and Primary Care Trusts seek to reduce their spending. At the same time, these organisations are likely to face increasing demand for their services as statutory services are squeezed.

6.3 NCB urges the Committee to investigate how government plans to enable the voluntary and community sector to contribute to the new health system, and to maintain and build upon the huge contribution these organisations already make to promoting the health and well-being of vulnerable children, young people and families.

7.0 About NCB

7.1 NCB’s mission is to advance the well-being of all children and young people across every aspect of their lives. As the leading national charity which supports children, young people and families, and those who work with them, across England and Northern Ireland, we focus on identifying and communicating high impact, community and family-centred solutions. We work with organisations from across the voluntary, statutory and private sectors through our membership scheme, and through the sector-led specialist networks and partnership programmes that operate under our charitable status.

7.2 NCB has a history of working to promote health improvement among children and young people and enable them to influence the quality and choice of the health services they receive. As a Department of Health strategic partner, NCB runs the Voluntary Sector Support (VSS) Programme for voluntary organisations providing health services to children and young people.

February 2011


[1] Lister-Sharp D, Chapman S, Stewart-Brown S, Sowden A (1999) Health promoting schools and health promotion in schools: two systematic reviews Health Technology Assessment HTA NHS R&D HTA Programme

[2] The National Evaluation of Sure Start (NESS) (Institute for the Study of Children, Families and Social Issues, Birkbeck, University of London) (2008) The Impact of Sure Start Local Programmes on Three Year Olds and Their Families

[2]

[3] Clauses 176 and 177 of the Bill place duties on local authorities and each partners commissioning consortia to prepare a joint strategic needs assessment and joint health and well-being strategy. However, clause 180(1) states that these duties will be exercised by the health and well-being board.

[4] Participation Works is a partnership of six national children and young people's agencies that enables organisations to effectively involve children and young people in the development, delivery and evaluation of services that affect their lives.

[5] BYC (2010) Young people’s views on the Big Society: The Big Listen - we said

[6] Burke T (2010) Anyone listening? Evidence of children and young people’s participation in England

[7] Voluntary Sector Support (2010) LINks: getting it right for children and young people

[8] Pobi S (2007) PALS: Getting it right for children and young people – A report on the results from NCB’s PALS survey in July 2007

[9] Sir Ian Kennedy (2010) Getting it right for children and young people: overcoming cultural barriers in the NHS so as to meet their needs

[10] Department for Education and Skills (2007) Care Matters: Time for Change . Cm 7137.

[11] Richardson, J and Joughin, C (2000) Mental Health Needs of Looked After Children. London: Gaskell

[12] Meltzer and others (2003) The Mental Health of Young People Looked After by Local Authorities in England. London: The Stationery Office.

[13] Meltzer and others 2003 op. cit.; Williams, J and others (2001) ‘Case-control study of the health of those looked after by local authorities’, Archives of Disease in Childhood, 85, 280–85; Department of Health (1997) Substance Misuse and Young People.

[13] London: Department of Health.

[13]