Health and Social Care Bill

Memorandum submitted by the Royal College for Paediatrics and Child Health (HS 58)

Health and Social Care Bill



The Royal College of Paediatrics and Child Health is the leading authority on healthcare services for children and young people. We welcome the principles behind the Bill of clinician led commissioning, reducing inequalities, greater information about services and the focus on outcomes.

But we have concerns around the detail of the new structures and foresee care for infants, children and young people becoming fragmented. Child protection arrangements and responsibilities in the light of changes on commissioning are not clear. We are pressing for increased authority of health and wellbeing boards to ensure that commissioning of services for children reflects the interaction in their lives of both health and local council services.

The 11.78 million children in England comprise over 22% of the population and it is essential that the changes envisaged to the NHS and public health result in improvements to their health and wellbeing rather than worsening outcomes and increased complexity of provision.

Children and families must receive the right health care swiftly, linking effectively with other local services so all children get the best start in life.

We are pressing for changes and amendments to the Bill to strengthen its coverage and close loopholes to ensure that the vision of better healthcare and less bureaucracy can be realised for children and young people as well for as the adult population.

Key messages

There are three core themes in the Bill where the College will press for greater consideration of the implications for children’s services.

Maintaining continuity and quality of care for children and young people with complex needs across health, education and social care.

For those children with rare or complex needs [1] , the proposals expose potential difficulties in maintaining continuity and integration of care, where a number of agencies and services are involved. Specifically :

· The removal of boundary restrictions for GPs and absence of a cotermn o sity requirement between consortia and authorities is likely to result in complicated cross-charging arrangements for children requiring complex packages of care, with less opportunity for clinical, therapy and social care staff to build constructive professional teams around the child and family.

· Any delay s in developing an alternative secure system of information sharing poses a risk to those c hildren who have a range of professionals involved in their care, across several provider organisations. It is not clear where the "lead professional" oversight of the child’s package of care will lie; if it is with the GP we assert that patient information systems within individual practices may be insufficiently developed to deal with the complex contractual arrangements required to meet the health and social care needs of infants, children and young people

· It is not yet clear how the outcomes and incentive arrangements will be implemented . We believe controls are needed to ensure that those whose condition does not fall into the 150 for which quality standards are being developed do not receive poorer care.

· We need stronger assurances that Health and Well Being Boards will work closely with GP Commissioning Consortia, specialist professionals and the wider local community, with a specific statutory remit to commission services together to raise standards of care for all children based on need and impact. Whilst recognising the strengthening of requirements on commissioning consortia to take account of the joint strategy, the governance remains underpowered with respect to commissioning across health/social care boundaries.

· We recommend establishing a mechanism for reporting on effective joint working and monitoring outcomes for all children across services ( linking health, public health , education and social care) , particularly in relation to incentive payments for commissioning .

· The market concept where any willing provider can be commissioned for specific services may improve service responsiveness in some areas, but will undoubtedly lead to a fragmentation of staff culture, competition between providers across a pathway of care, gaps in provision and information flows and a lack of integration and co-ordination of appointments. This will result in poorer quality of care and inequity of provision for children together with significant increase in bureaucracy to commission and performance manage effectively.

· The Committee is urged to ensure that modelling takes place within the pathfinder consortia of pathways of care for disabled children and those with complex health and social care needs so that effective safeguarding can be designed without compromising the principles of the reforms

· The impact of low-volume/high cost continuing care packages for children with the most complex needs could drain an individual commissioner’s budget and there should be a risk-pooling system to support these awards

The changes may weaken child protection arrangements in a more fragmented and less experienced commissioning environment.

· Professor Eileen Munro is reviewing the practice and behaviour s of social work and acknowledges the importance of needs analysis and early intervention across partner agencies. The proposed changes however could significantly weaken the accountability and effectiveness of the multidisciplinary contribution and of healthcare’s contribution in particular to the safety of children.

· The crucial role of clinicians, in child protection, whether as the health visitor, the family GP or the paediatrician, together with the key roles of Named and Designated health professionals must be acknowledged in the Bill and subsequent regulations to ensure that the responsibilities transferred from PCTs are not diluted in the new structures, where expertise may be lacking or resources stretched.

· It is crucial that existing networks of experienced health child protection professionals are maintained and strengthened, to provide expertise, supervision and support to consortia and public health teams and their designated nurse and doctors.

· The links between health and with other agencies (Children’s social care, the police and the judiciary) needs much greater recognition and clarity over responsibilities during transition and once the new reforms are in place. Specifically the Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategy must include core sections on child protection arrangements across organisations and pathways of services, with contributions from expert designated clinicians.

· Overarching responsibility for child protection rightly lies with the Local Authority, with the LSCB bringing partners together to agree and monitor shared plans, training and knowledge. Already LSCBs find that the number of different representative organisations in "health" including acute trusts, mental health, community providers, PCT commissioners and CAMHs can be hard to marshal effectively and this apparent lack of cohesion must be addressed through clear duties on Commissioning Consortia, monitored effectively by the NHS Commissioning Board

· Under the proposals, commissioning consortia may span more than one Authority , and there will probably be two or more consorti a in each LSCB catchment area. Managing LSCB business with this plurality of health organisations, including implementing LSCB-wide procedures, delivering joint training and building strong and trusting relationships between GPs and the relevant social care teams w ill be an increased challenge, and there is a much greater potential for children at risk to be missed, or confusion over responsibility to occur. RCPCH is pressing for detailed modelling and practical exploration with Local Authorities and LSCBs as to what arrangements can mitigate this risk.

· Designated doctors and nurses currently provide an oversight and expert function within the PCT commissioner and to the (coterminous) LSCB Board , ensuring that provider-unit clinicians are properly supported in child protection practice, and that commissioning contracts, information sharing, training, supervision and learning properly protect children, young people and families using services. These clinicians contribute extensively in many a reas to the work of LSCBs and sub committees, bringing a health perspective to local authority planning and training. Whilst the Bill states that the responsibilities will transfer to consortia, the re is uncertainty as to whether the role will be supported and how links with the LSCB and authority will be maintained. There must be a clear duty on Commissioning Consortia to include advice from designated nurses and doctors within their commissioning plans.

· The Directors of Public Health have in their new remit responsibility for domestic violence, linking police education and social care services together. This remit does not mention child protection yet there is overwhelming evidence of the link between family violence and child abuse and responsibilities should be stronger . Consideration should be given to s hifting commissioning of the designated nurse and doctor role to the Public Health department, and strengthening its jurisdiction so that commissioning consortia must take account of requirements .This could significantly fortify local arrangements , maintain authority-based team connections and trusting relationships and ensure that children within a local area have a consistent and effective framework of protection.

· Responsibility for effective joint commissioning for the health and wellbeing of children who are looked after and/or placed away form home requires clarification within the new arrangements, as expertise within commissioning consortia is likely to be diluted in transition from PCT commissioners .

The implications of choice and keeping a national, networked service .

· Whilst welcoming the principles of choice and competition to drive up quality we seek additional security within the system to protect children’s services. Market-based competition in health however without expert collaborative commissioning will undermine links between professionals, leach expertise, reduce service availability and increase waits and there must be safeguards in the Bill to ensure that services for children, which may not be lucrative enough for competitive market improvement, do not suffer.

· Whilst provision of information and advice direct from providers in a plural system can improve choice and quality of care, navigation through the options for vulnerable patients and carers will require careful commissioner support, to ensure that children receive the care they need and appropriate safeguards are in place. There are examples within the current "Choose and Book" system of parents failing to make appointments for their children, or failing to attend with consequent deterioration of the child’s condition. Increased competition amongst provider services will require clear contractual safeguarding within commissioning to ensure children’s rights are protected.

· Ensuring that children receive the best quality evidence based care requires the introduction or maintenance of clinical networks, for example for paediatric specialties. It is not clear in the Bill how these networks will be sustained in an open market to ensure appropriate investment in secondary and tertiary services, which may require co - located ancillary services. The College has published clear service standards for paediatric care and the bill requires strengthening to ensure that expert clinical advice is taken into account by the National Commissioning Board, Commissioning Consortia and Monitor.,

· Where services cannot be provided within the market system more clarity in needed on the process of "designated" services and how this process may affect c hildren’s healthcare which may not be a lucrative investment for independent providers. Depending upon the strength of the designated service arrangements, there is a risk that assertive providers will convince commissioners they can "cherry pick" the most lucrative services. This could leave vulnerable families with more complex journeys, poorer levels of care and the consequent risk of children missing appointments and suffering poorer health outcomes

· We have concerns about the risk to availability and quality of medical training placements within small independent providers – this is already proving a concern within acute mental health and plastic surgery services

· Splitting the commissioning of the healthy start programme between consortia up to aged 5 years, and with local authorities through health and wellbeing boards once children have started school offers a potential risk to continuity and family support if health visiting and school nursing are insufficiently linked. There are no elements within the Bill that support mental health and emotional well-being interventions for young children and adolescents - two crucial points where input can demonstrably improve outcomes.


The Royal College of Paediatrics and Child Health has significant concerns over elements of the bill, and the speed and risk of implementation for children’s services. We seek reassurance and the opportunity to work closely with Ministers, parliamentarians and Public Bill team to develop arrangements which ensure that care for all infants, children and young people is of the highest quality, efficiently provided and tailored to their needs.

February 2011

[1] For example, children with Downs ’ syndrome or cerebral palsy need input from a range of health services (such as paediatricians, physiotherapists, speech therapists, geneticists, and sometimes a children's heart or glands specialist) which families usually receive from one health centre or hospital, as well as educational, social care and family

[1] support provided by public and third sector services.