HC 1048-III Health CommitteeWritten evidence from National Children’s Bureau (PH 75)


As children develop their health and wellbeing is influenced by a broad range of factors and the contribution made by a range of services has a long term impact. We are therefore particularly keen to see the Marmot Review’s call for action across all social determinants of health implemented.

We urge the committee to consider how this broad agenda for public health can be better supported by the proposed public health structures and funding mechanism for public health, as we believe they should go further.

Education, early years services, leisure, housing and transport policy have a significant impact on the health of children and young people. As the relevant services are largely planned and commissioned at a local level, the committee should consider how such services can have a closer relationship with the local authority’s public health functions and the operation of the health and wellbeing board.

In addition to locally managed services, national issues such as fuel poverty and the benefits system also impact on children and young people’s health. We urge the committee to consider how Public Health England will need to work across government including with the Department for Work and Pensions the Department for Energy and Climate Change and the Department for the Environment and Rural Affairs.

We welcome the recognition in the draft public health outcomes framework of the importance of children’s health, wellbeing and development. We urge the committee to consider how the experience of children and young people can be accurately captured and acted on and how accountability for broader public health outcomes can be secured.

About National Children’s Bureau (NCB)

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.

1. Local arrangements: Scope

1.1 While Healthy Lives, Healthy People acknowledges the role of other a range of children’s services such as schools in public health we believe that the overall strategy still underestimates the full range and extent of the impact of such services on child health and the consequent need for them to work closely together.

1.2 Schools have a key role to play in promoting better public health for children and young people and this should be reflected in the remit and planning functions of health and wellbeing boards. As a universal service with which children and young people will have significant contact, they are well placed to identify health related problems in this part of the population and to disseminate and sign post to public health information. Engagement with other services will also enable schools to better coordinate on broader support for children and young people.

1.3 Making information and support available to young people at the right age will be crucial and have an impact on their health for the rest of their lives. Changing Behaviour, Improving Outcomes highlights the high numbers of children and young people of secondary school age experiencing tobacco, alcohol and sex for the first time, yet detailed discussion of the role of the school in informing healthy behaviours is notably absent from this strategy paper.

1.4 Young people that attended our consultation event suggested that specific actions in schools such as more discussion of healthy eating in PSHE would be helpful but also that, due to concerns about confidentiality and a desire to talk to someone who can communicate well with young people, they would want the to access public health advice from sources beyond their GP, schools and school nurses. In addition to the welcome involvement of specialist organisations such as Terrance Higgins Trust and The African HIV policy network nationally in providing alternative sources of information, the efforts of schools will need to be coordinated locally with those of other agencies to ensure that all children and young people get advice and support they need.

1.5 The way a school operates itself will also have an impact on health, and the engagement of schools with other local services will help them to tackle issues such as bullying and ensure that children with specific health needs can have those needs met in their chosen school setting. The Marmot Review also presented evidence of the strong influence on cognitive development on a persons broader and long-term health.

1.6 The contribution of early years services to public health should mean that they are placed more centrally and are an obvious partner for other services represented on health and wellbeing boards. As identified in the Marmot Review, what a child experiences during the early years lays down a foundation for the whole of their life. A child’s physical, social, and cognitive development during the early years strongly influences their school-readiness and educational attainment, economic participation and health. Sure Start has the opportunity to play an unrivalled role in setting the conditions for life-long healthy living. Reductions in funding, however, may limit centres’ ability to deliver health improvement among young children and families. The current proposals would mean that sure start centres do not benefit from the ring-fenced public health grant as they are funded through the non-ringfenced early intervention grant and other local government funding streams, which are reducing in size.

1.7 Active play is widely recommended as an important element in combating childhood obesity, a complex issue where, according to the government’s engagement paper Achieving equity and excellence for children (DH, September 2010), “many agencies and groups have a role to play to deliver change, and in supporting preventative child social care”. Great Britain is below the OECD average for levels of physical activity and recent years have seen a significant increase in the number of overweight children, with well-documented implications for long-term health and financial impact on health services. Children who do 15 minutes of exercise a day reduce their chances of being obese by 50%. Research by University College London found that outdoor and unstructured play is one of the best forms of exercise for children, being more effective than many structured sporting activities. This shows how play can have a major role in reducing obesity and its financial burden on health services.

1.8 Support for school sports is welcome. However, if physical activity is equated only with competitive sport, it will be difficult to engage many children and young people whose interests lie elsewhere. Provision of wider opportunities for physical activity and play will need to be a focus of public health interventions. Young people at our consultation event made suggestions for encouraging exercise which included: Creating a directory of local information for young people where they can access exercises and outdoor activities; Free swimming and other activities. Such actions would require partnership working leisure services, directors of public health and health and wellbeing boards.

1.9 Transport will need to be appropriately planned and coordinated for children to be able to access all of the above services and feel the associated benefits to their health. Young people at our consultation event suggested free bus service to leisure centres for young people should be a part of an effective exercise campaign.

1.10 The availability of good quality housing is also key determinant of children’s health so the local planning and management of housing will be very relevant to the public health functions of local authorities and health and wellbeing boards. A study carried out by Shelter in 2006 suggested that children in bad housing conditions are more likely to have mental health problems, such as anxiety and depression, to contract meningitis, have respiratory problems, experience long-term ill health and disability, experience slow physical growth and have delayed cognitive development.

1.11 Owing to the impact the impact these issues have on child health and development we urge the committee to consider how education, early years, leisure, transport and housing can be closely coordinated with the work of the health and wellbeing board and director of public health locally.

1.12 While we welcome government’s commitment to provide “sufficient flexibility in the legislative framework for health and well-being boards to go beyond their minimum statutory duties to promote joining-up of a much broader range of local services for the benefit of their local populations’ health and well-being” we think the government needs to go further. An explicit duty on health and well-being boards to set and oversee a local commissioning strategy across all children’s services, covering the NHS, public health, education, social care and youth, early years and other relevant services may form part of a more effective approach. Boards with such a role would substantially improve efficiency, reducing the likelihood of gaps and duplications arising from multiple commissioners. We urge the committee to consider this as a possible solution.

2. Local arrangements: The health and wellbeing Board arranging certain services relevant to public health

2.1 There are good reasons for commissioning in certain areas to be conducted at the level of health and wellbeing boards, rather than at that of GP commissioning consortia level. Placing commissioning for CAMHS services in tiers 1 and 2 (and some of tier 3) with HWB Boards would allow commissioning of services over a wider area than that covered by individual GP consortia and also, crucially, permit closer integration with preventative services. Preventative mental health care that has long been neglected and so presents an area in which a properly positioned public health strategy might hope to make real advances.

2.2 The Healthy Child 0-5 Programme may be another example of a service that should be commissioned locally with health and wellbeing boards having regard to NHS Commissioning Board requirements. This would enable consistency and joined-up commissioning for children and families across the 4–6 divide but with appropriate direction from the Department for Health and/or the NHS Commissioning Board would also allow for national co-ordination of the Government’s Health Visitor programme. We urge the committee to consider how the role of health and wellbeing boards may be developed to oversee the commissioning of services that have overriding relevance to public health.

2.3 It is of concern that there has been very limited reference to children’s safeguarding in the setting out of reforms and more clarification is required regarding lines of accountability and how it could work in the new system. Through their legal responsibilities and representation on local safeguarding children’s boards, PCTs have taken a lead on safeguarding in the NHS, with SHAs also playing role. While it is welcome that the relevant duties regarding the establishment of safeguarding children boards will be transferred to the successor agencies, it is not clear how this will work in practice. Flexibility in boundaries of GP consortia and in the NHS commissioning board’s regional presence may make it harder coordinate safeguarding efforts and ensure that any commissioning of relevant services is undertaken across the appropriate geographical area. We urge the committee to consider how responsibility for safeguarding with in the NHS may be better coordinated and the role of the health and wellbeing board in securing this.

3. The Role of Public Health England

3.1 The remit of Public Health England should reflect the full range of policy areas that impact significantly on children and young people’s health. We urge the committee to consider how this can be secured.

3.2 A public health input to the Department for Work and Pensions would be valuable to inform the development of the welfare system that plays its part in promoting the health and wellbeing of children and young people. The Marmot Review highlighted a number of issues that suggest this may be necessary. Firstly, that progress on reducing child poverty has been stalled since 2005. Secondly, unemployment can trigger distress, anxiety and depression. Many psychosocial stressors contribute to poor health not only among the unemployed themselves, but also among their partners and children. And thirdly there is evidence that income has a direct impact on parenting and on children’s health and well-being. For example, according to Gregg et al, “Holding constant other types of parental capital, income is strongly associated with types of maternal psychological functioning that promote self esteem, positive behaviour and better physical health in children.”

3.3 Fuel poverty is also well known as a health risk for children and the Marmot Review identifies it as such. The Marmot Review team published a report on the impact of fuel poverty, which points out that:

More than 1 in 4 adolescents living in a cold house are at risk of multiple mental health problems, compared to 1 in 20 teens who’ve always lived in warm homes.

Cold, poorly heated homes have a significant impact on children’s health, affecting infant’s weight gain and development and increasing the frequency and severity of asthmatic symptoms.

Living in a cold home negatively affects children’s educational achievement, emotional well-being and resilience, which can worsen their life chances and increase health inequalities. Public Health England may also need to work closely with the department of energy and climate change as well as with DWP and DCLG to tackle this issue.

3.4 The recently published Natural Environment White Paper makes welcome reference to the children and young people’s relationship with their natural environment and the importance of green spaces for mental and physical health. Public Health England will need to work closely with the Department for the Environment and Rural Affairs to ensure these policy are developed and implemented in a joined up way for the benefit of children and young peoples health.

4. The Public Health Outcomes Framework

4.1 The draft public health outcomes framework has a much needed focus on the wellbeing of children and young people, including a number of specific measures. This is justified given the huge impact that experiences during childhood and adolescence can have on long term health an wellbeing, which has recently been documented in reviews by Michael Marmot, Frank Field and others. We urge the committee to consider how this may be implemented effectively, with particular regard to the following issues.

4.2 Development of measures to record self reported wellbeing will need to capture the views and experience of children and young people. Article 12 of the United Nations Convention on Rights of the Child requires that children are able to express their views on issues that affect them and that these views are given due weight. As children and young people will have a different perspective, responding to different language and different view on what is important for a happy an healthy life, the development of a series of separate age-appropriate mechanisms would help to achieve this.

4.3 It will be vital to involve children and young people in the development of these measures as well as all other aspects of public health reform. There is extensive experience of developing the engagement of children and young people to be harnessed from the children voluntary and community sector including members of Participation Works.

4.4 The proposed scope of domain 2 of the outcomes framework (“Tackling the wider determinants of ill health”) is notable in that it reflects the more wide ranging approach to public health which we have called for above. It also bears resemblance to the 5 outcomes that young people at our consolation event suggested should be included in the frame work. These were: Ensuring everyone can live in a healthy clean environment; Better accessibility of services for everyone; Better health education; Better education; Working together—make sure everything works together to make the NHS more efficient. We particularly welcome the inclusion of child poverty, school readiness, housing overcrowding and fuel poverty. It will be vital that all the required work to develop effective measures for these outcomes are carried out.

4.5 In order to make governmental accountability to be as clear as possible for the outcomes in domain 2 it may be appropriate to further pin down specific departmental responsibility. This is particularly relevant for outcomes that relate to education such as truancy and NEET rates. Due to the expansion of the academies programme the department for education is effectively the commissioner of education for an increasing proportion of children and young people in England. It may therefore be more meaningful for the Department for Education (rather than the NHS or local authorities) take lead responsibility for these outcomes.

June 2011

Prepared 28th November 2011