Written evidence from National Children's
Bureau (COM 29)
1.0 SUMMARY
1.1 NCB welcomes the opportunity to provide
evidence to the Committee on health commissioning as it pertains
to children and young people. We urge the Committee to:
— challenge the government to ensure that
any changes to the structure and mechanisms underpinning health
service commissioning be implemented with a strong focus on improving
commissioning for children's health.
— recommend that a single body at the local
level—the health and well-being board—be responsible
for overseeing the commissioning of the majority of services for
children and young people, including health services.
— seek assurances from government that
health and well-being boards and their functions will be placed
on a statutory footing, with clear statutory responsibilities
for children's health and well-being.
— recommend that the Department of Health,
with the Department for Education, develop frameworks for providing
support on commissioning children's health services, as part of
its transition strategy.
— seek assurances from government that
GP commissioning consortia and the NHS Commissioning Board will
be subject to the Children Act 1989 duty to comply with requests
for support and services for children in need, currently placed
on Primary Care Trusts (PCTs) and Strategic Health Authorities
(SHAs).
— recommend that government put in place
measures to ensure that the implementation of its commissioning
proposals does not disadvantage looked after children.
— seek assurances from government that
it will transfer children's safeguarding and well-being duties,
currently placed on PCTs and SHAs, to the new commissioning bodies.
— seek commitment from government that
it will put in place mechanisms to ensure HealthWatch can effectively
engage children and young people, particularly the most vulnerable
and those with complex needs.
— recommend that government put in place
measures so that voluntary sector organisations delivering effective
health services are not disadvantaged by the proposed health reforms.
NCB would welcome the opportunity to provide
oral evidence to the Committee.
2.0 ABOUT NCB
2.1 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.
2.2 NCB's has a history of working to promote
the health of children and young people and to enable them to
influence the quality and choice of health services they receive.
As a Department of Health strategic partner, NCB's Voluntary Sector
Support (VSS) Programme provides information and practical support
to voluntary organisations providing health services to children
and young people. NCB has an established programme on health that
works across the range of settings where children and young people
live, learn and play, including schools, care, custody and supported
housing. Activities include the development of policy and practice,
improved partnership working and the participation of children
and young people themselves in order to improve their health outcomes
and service experiences.
3.0 CHILD HEALTH
AND THE
NHS WHITE PAPER
3.1 While the NHS White Paper set out significant
reforms to the commissioning and provision of NHS services, which
will undoubtedly have an impact on children and young people,
it included a surprising lack of clarity about the implications
for children and their families. The Department of Health's recent
publication, Achieving equity and excellence for children
(2010), has provided some insight. However, key questions still
remain:
— How will commissioning responsibilities
for children's health be divided between the NHS Commissioning
Board, GP consortia and the local authority-led "local health
and well-being board"?
— How will new commissioning bodies develop
and secure the knowledge and skills they need to commission for
child health effectively?
— How can we ensure the measures proposed
in the White Paper do not disadvantage those young people with
complex health needs, including disabled and looked after children
and young people and those in custody?
— How can we ensure a strong voice for
children and young people, and those who work with them, in the
commissioning process?
These questions will be explored in our submission.
3.2 For children and young people's health,
the status quo has not served us well. Despite areas of good practice,
there has been a lack of integration across service delivery and
a lack of accountability and transparency in the planning for
and delivery of child health services. Professor Sir Ian Kennedy's
review of children's NHS services1 identified a number of challenges,
including:
— Low priority afforded to children and
young people's care.
— GPs having insufficient training and
experience in paediatrics.
— Failures within the NHS to provide children
with a safe environment.
— A lack of coordination across children's
health services, and with other services, which can be particularly
difficult for those with complex needs.
3.3 We urge the Committee to challenge the
government to ensure that any changes to the structure and mechanisms
underpinning health service commissioning be implemented with
a strong focus on addressing these challenges and improving commissioning
for children's health.
4.0 COMMISSIONING
RESPONSIBILITY FOR
CHILDREN'S
HEALTH SERVICES
4.1 NCB believes that the maximum range
of services for children and young people—including the
majority of children's health services—should be coordinated
by a single body at the local level. Services should be commissioned
in a coordinated way to ensure they operate seamlessly across:
health, social care, education and other services; NHS and non-NHS
boundaries; and universal, targeted and specialist levels.
4.2 NCB believes that the local health and
well-being board, proposed in the Department of Health's NHS White
Paper2, would be best placed to take on this commissioning coordinating
role. With the participation of GP commissioning consortia, the
NHS Commissioning Board, local authorities and other partners,
the health and well-being board should have responsibility for
setting a local commissioning strategy across children's health,
education, social care and other services. NCB believes that such
an approach would help to secure seamless provision to children,
young people and families through effective partnership structures.
4.3 Effective interventions for children
and young people's health are often delivered through services
that are not health-specific. For example, the National Evaluation
of Sure Start found that a child with access to a Children's Centre
(formerly Sure Start Local Programmes) had more immunisations
and fewer accidents than young children living in other areas3.
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 issues4.
4.4 Having a single accountable body responsible
for children's education, childcare, recreation and health
services, bringing together the range of lead commissioners
for those services, would help ensure consistent approaches to
the commissioning and delivery of integrated, early intervention
services. It would also provide a framework through which a single
body can be held accountable to the public, through the local
authority, for ensuring that the Healthy Child Programme 0-19
is available to all children and young people.
4.5 In order to deliver for children's health
and well-being, the health and well-being board and its functions
must be placed on a statutory footing. Furthermore, government
must put in place mechanisms and incentives to ensure that the
local boards prioritise children's health and well-being. In such
a partnership there is always the danger that children's health
and well-being will be marginalised. This must be avoided.
4.6 We urge the Committee to recommend that:
— the local health and well-being board
be responsible for overseeing the commissioning of the all services
for children and young people, including health services;
— the health and well-being board and its
functions be placed on a statutory footing;
— government put in place incentives and
mechanisms to ensure that children's health and well-being is
prioritised within the health and well-being board; and
— consideration is given as to how to engage
children's services that commission health services directly,
such as early years settings and schools.
5.0 DEVELOPING
THE KNOWLEDGE
AND SKILLS
OF COMMISSIONERS—MANAGING
THE TRANSITION
5.1 If government does implement its proposal
to transfer responsibility for aspects of health commissioning
to GP consortia, with the NHS Commissioning Board leading national
and specialist commissioning, the transition must be well managed.
This is particularly important for children and young people's
health. Professor Sir Ian Kennedy's review of NHS services for
children found that many GPs lack knowledge and experience of
paediatrics1. Evidence also suggests that GPs are not sufficiently
aware of the range of services available to children and families.
For example, a survey of parents using children's centres found
that, although best practice would see health professionals signposting
parents to children's centres, only 4% were signposted by their
GP5.
5.2 In order to be effective, the work of
GP commissioning consortia, the NHS Commissioning Board and the
local health and well-being boards must be informed by:
— a thorough understanding of children's
health, including: the wider determinants of health; the impact
of broader children's services on health outcomes; and supporting
children with complex needs, such as disabled children, those
living in care and those with mental health problems; and
— the best available evidence of what works
to improve health outcomes, including examples of validated good
practice, provided to commissioners in an appropriate and accessible
format.
5.3 To achieve this, government must ensure
that a move away from centrally-directed targets and regional
advice and support, is accompanied by impetus and resources for
the development of sector-led models of support to commissioners.
This cannot be left to chance. We urge the Committee to recommend
that the Department of Health, with the Department for Education,
develop frameworks for providing support on commissioning children's
health services, as part of its transition strategy.
6.0 CHILDREN
AND YOUNG
PEOPLE WITH
COMPLEX NEEDS—LOOKED
AFTER CHILDREN
6.1 NCB has concerns about the impact of
proposed commissioning arrangements on children and young people
with complex and specific needs, for example disabled or looked
after children and young people and those in custody. Primary
Care Trusts and Strategic Health Authorities have a duty under
the Children Act 1989 to comply with requests from the local authority
to help them provide support and services to children in need6.
We urge the Committee to seek assurances from government that
GP Commissioning and the NHS Commissioning Board consortia will
be subject to:
— a duty to comply with requests from relevant
local authorities for support and services for children in need;
— public sector equality duties introduced
under the Equality Act 2010; and
— a requirement to conduct equality impact
assessments of their commissioning frameworks across all equality
streams, including disability and age.
6.2 Our work with looked after children,
through the Healthy Care Programme, and more recently Healthy
Outlooks7, revealed a severe lack of effective arrangements for
delivering care to this vulnerable group of children. Looked after
children are particularly vulnerable to health risks and problems
often due to their experience prior to entering care and the subsequent
challenges they face in the care system itself.
— 45% of looked after children and young
people aged five to 17 were assessed as having at least one mental
health disorder, compared to 10% of the general child and young
person population.8 They exhibit high rates of self-harm and high-risk
behaviour, particularly in secure accommodation.9
— Two thirds of all looked after children
were reported to have at least one physical health complaint—most
commonly eye and/or sight problems, speech and language problems,
difficulty in coordination and asthma. 10
— Some studies have shown higher levels
of substance misuse, including smoking, among looked after children
and young people, when compared to the non-care population, however
research in this area is limited. 11
6.3 While some health outcomes for looked
after children have improved in recent years, there have been
persistent difficulties, particularly in relation to partnership
working across health bodies and local authorities at the strategic
level, and arrangements for securing health services for children
placed out of authority12,13.
6.4 Looked after children and young people
are often highly mobile: nearly a third are placed outside their
local authority area, and over 10% experience three or more placement
moves in a single year14. This can often lead to confusion about
which local body in which areas has responsibility for commissioning
and delivering health services to these children. This is despite
the introduction of regulations15 which assign responsibility
for secondary health care to the PCT for the area where
the child originally lived. The introduction of GP commissioning
consortia will undoubtedly lead to changes to, and a possible
increase in, commissioning boundaries, which could cause greater
confusion and further disadvantage to children in care.
6.5 We urge the Committee to recommend that
government put in place measures to ensure that the implementation
of its commissioning proposals does not disadvantage looked after
children. Government should:
— clarify where responsibility for commissioning
health services for looked after children will sit. This includes
services to help them overcome barriers in accessing universal
services as well as targeted and specialist services;
— place a duty on the new GP commissioning
consortia to have regard to statutory guidance on promoting the
health of looked after children16. In 2009, the former Department
for Children, Schools and Families and the Department of Health
published revised guidance, and made it statutory for Primary
Care Trusts and Strategic Health Authorities for the first time
(under sections 10 and 11 of the Children Act 2004). The momentum
resulting from the publication and new status of that guidance
must not be lost;
— facilitate the provision of training
and support to GP commissioning consortia on the health needs
of looked after children, as an early priority, and clarify the
future of the roles of designated doctor and nurse; and
— clarify what arrangements local authorities
and commissioning bodies will be expected to establish for commissioning
services for looked after children and young people who are placed
outside their "home" authority or who move across health
commissioning boundaries.
7.0 LOCAL COOPERATION
AND SAFEGUARDING
GENERAL DUTIES
7.1 In carrying out their functions, including
those for commissioning, Primary Care Trusts and Strategic Health
Authorities are under a duty to have regard to the need to safeguard
and promote children's welfare, and to cooperate with the local
authority and local partners to promote children's well-being17.
PCTs and SHAs are also statutory members of Local Safeguarding
Children Boards (LSCBs) 18. In its recent publication on child
health, the Department of Health confirmed that it intends the
introduce new duties for GP commissioning consortia that "fully
replicate those that current apply to PCTs and SHAs under the
Children Act 2004"19.
7.2 We urge the Committee to seek assurances
from government that it will transfer children's safeguarding
and well-being duties, currently placed on PCTs and SHAs, to the
new commissioning bodies. Government should:
— place a duty on each GP commissioning
consortium to cooperate with all the local authorities it covers
to improve children's well-being;
— place a duty on the NHS Commissioning
Board to cooperate with all relevant partners to improve children's
well-being;
— place a duty on GP commissioniing consortia
and the NHS Commissioning Board to carry out its functions with
a view to safeguarding and promoting children's welfare; and
— require GP commissioning consortia to
be members of all relevant LSCBs operating in their commissioning
area.
8.0 A STRONG
VOICE FOR
CHILDREN AND
YOUNG PEOPLE
AND THOSE
WHO WORK
WITH THEM
8.1 NCB welcomes proposals in the NHS White
Paper to strengthen the voice of patients and the public in decisions
about health care commissioning and their own care, through national
and local HealthWatch. However, past experience shows that services
put in place to engage all members of the public will rarely
engage effectively with children and young people, unless there
is a specific requirement to do so. The experience of Patient
Advice and Liaison Services (PALS) and Local Involvement Networks
(LINks) suggests that children are often an after-thought.
8.2 It is vital, therefore, that as the
national and local HealthWatch plans are implemented, government
ensures that HealthWatch staff have the knowledge, capacity and
skills to engage children and young people, and that there are
strategies in place to do so. Staff will also need to understand
the value of working with both children and young people and their
parents and carers, recognising that listening to one perspective
does not conflict with listening to another. Furthermore, any
efforts to engage children and young people in the work of national
and local HealthWatch must include specific action to involve
those who are least likely to be engaged and those with complex
health needs. This involves additional and specific resources
and tools.
8.3 It is proposed by government that HealthWatch
support the involvement of patients in strategic decisions about
local services (currently the role of LINKs) and provide information
and advocacy to support patients to exercise choice and make complaints
(currently the role of PALS). However, NCB's work with LINks and
PALS suggests that they will need additional support, tools and
resources in order to effectively involve children and young people
in their work.
8.4 A current NCB project aims to build
the capacity of LINks to engage with voluntary organisations working
with children and young people. Early research has given a mixed
picture of the level of engagement of children and young people
within LINks.[48]
Those that failed to involve children and young people said this
was due to: a perception that this was not part of the LINks remit;
lack of capacity; and limited resources.
8.5 Research with PALS found that 75% were
not actively involving children and young people in their service,
because they did not have the necessary resources, skills and
support from managers20. Consultations with children and young
people reveal that most did not know what PALS are, but thought
it could be really useful, once the service was explained to them21.
Through our PALS project, NCB has provided training to 174 of
the approximately 500 PALS in the country, many of whom have since
reported increased involvement of children and young people. 22.
8.6 The effective engagement of children
and young people through HealthWatch can be achieved by building
on existing participation mechanisms and resources, such as: the
PALS and LINks projects referred to above, Participation Works23,
school councils and youth councils, children in care councils
and Parent Partnership Networks. There are also specific resources
to support children's engagement in commissioning, including How
to involve children and young people in commissioning, published
by Participation Works24.
8.7 Ensuring the engagement of local voluntary
and community sector (VCS) organisations within the work of HealthWatch
will also be key to securing commissioning decisions that reflect
the views and the needs of the most marginalised. VCS organisations
often work with the most excluded and vulnerable members of society,
those who are often reluctant to engage with statutory services.
Commissioners must be required to work in partnership with these
VCS organisation when assessing local need and engaging service
users/providers.
8.8 We urge the Committee to seek commitment
from government that it will:
— put in place mechanisms to ensure HealthWatch
receives support so that they are able effectively to engage children
and young people;
— provide incentives to ensure that HealthWatch
engages in effective outreach work to involve the most marginalised
groups of children and young people and those with complex needs;
— ensure GP commissioning consortia and
local health and well-being boards have the necessary support
and incentives to work with the voluntary sector to engage marginalised
service users; and
— help to develop the capacity of the voluntary
sector to bring their clients' voices to the commissioning process.
9.0 COMMISSIONING
THE VOLUNTARY
SECTOR
9.1 Voluntary and community sector organisations
are well placed to provide health services directly to children
and young people, particularly to those for whom access to mainstream
health services is a challenge. The voluntary organisations we
consulted expressed concerns about:
— the sector having a lack of capacity
or resources to demonstrate their impact, a real concern if we
are to move towards greater use of payment-by-results models.
Some voluntary organisations also struggle to access the patient
information held by commissioners, which they will need in order
to demonstrate service outcomes;
— GP commissioners having insufficient
appreciation of the importance of "soft" outcomes—such
as improved confidence and self-esteem—that are often the
focus of voluntary sector interventions; and
— the effect of proposals to make greater
use of payment-by-results on voluntary organisations where the
impact of their work may not be measurable for many years, especially
for those working with young children.
This could lead to voluntary organisations struggling
to compete with larger private providers, which may work less
effectively particularly with marginalised communities.
9.2 We urge the Committee to recommend that
government put in place measures so that voluntary sector organisations
delivering effective health services are not disadvantaged by
the proposed health reforms. This should include:
— assessing the potential impact of proposals
on the voluntary sector, and introducing measures to ensure that
voluntary organisations providing health services can compete
effectively;
— putting in place mechanisms to provide
health and well-being boards, GPs and the voluntary sector with
knowledge, support and incentives to ensure they engage with each
other as part of the needs assessment and commissioning process;
— addressing voluntary organisations' concerns
about access to patient information held by commissioners, as
part of the forthcoming NHS information strategy; and
— ensuring the NHS Commissioning Board,
when developing payment-by-results models, considers how it will
measure outcomes in a meaningful way where the real impact of
some interventions may not be apparent in the short-term.
October 2010
REFERENCES1 Sir
Ian Kennedy (2010) Getting it right for children and young
people: overcoming cultural barriers in the NHS so as to meet
their needs.
2 Department of Health (2010) Equity and excellence:
Liberating the NHS.
3 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.
4 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.
5 DCSF (2009) Sure Start children's centres—survey
of parents.
6 Section 27, Children Act 1989.
7 www.ncb.org.uk/healthyoutlooks. Health Outlooks
connects people who work with children and young people "most
in need" to networks which can support them.
8 Department for Education and Skills (2007)
Care Matters: Time for Change. Cm 7137.
9 Richardson, J and Joughin, C (2000) Mental
Health Needs of Looked After Children. London: Gaskell.
10 Meltzer and others (2003) The Mental Health
of Young People Looked After by Local Authorities in England.
London: The Stationery Office.
11 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. London: Department of Health.
12 Mooney, A, Statham J, Monck E, Chambers H
(2009) Promoting the Health of Looked After Children: a Study
to Inform Revision of the 2002 guidance Research Report DCSF-RR125
London: The Stationery Office.
13 Ofsted (2008) Safeguarding Children: The Third
joint Chief Inspectors' report on arrangements to safeguard children
www.safeguardingchildren.org.uk
14 Care Matters: Ministerial Stocktake report
2010.
15 The National Health Service (Functions of
Strategic Health Authorities and Primary Care Trusts and Administration
Arrangements) (England) (Amendment) Regulations 2007. SI 2007
No 559.
16 Department for Children, Schools and Families/Department
of Health (2009) Statutory Guidance on Promoting the Health and
Wellbeing of Looked After Children.
17 Section 10 and 11 of the Children Act 2004.
18 Section 13 of the Children Act 2004.
19 Department of Health (2010) Achieving equity
and excellence for children, para 4.27.
20 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 http://www.ncb.org.uk/default.aspx?page=605
21 Pobi S (2007) PALS: Getting it right for children
and young people—Consultations with children and young people
http://www.ncb.org.uk/default.aspx?page=605
22 The PALS resources are available at: http://www.ncb.org.uk/resources/free_resources/pals_project.aspx
23 www.participationworks.org.uk
24 www.participationworks.org.uk/resources/how-to-involve-children-and-young-people-in-commissioning
48 12% of LINks who responded to our survey said they
had not involved children and young people in their work via voluntary
organisations. The percentage of children and youth organisations
as a proportion of LINks' members ranged from 1 to 90%, with an
average of 30%. Back
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