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Today, on my arrival in the House after the weekend, I saw a letter from the NSPCC, which emphasises some of the points that the noble Baroness made. Perhaps with the leave of the House I may quote from the letter. In doing so, I join the noble Baroness in expressing appreciation to all the officials and staff who have enabled us to complete
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“45 per cent of looked after children and young people aged five to 17 are assessed as having an emotional or mental health disorder, compared to 10 per cent of the general child and young person population ... Looked after children and young people exhibit high rates of self-harm and high-risk behaviour, particularly in secure accommodation ... and some studies have shown higher levels of substance misuse ... Two-thirds of all looked after children are 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.
These figures demonstrate not only the significant physical, emotional and mental health needs of children in care, but also the extent of need that remains unmet”.
I shall quote just once more from the letter:
“Furthermore, 63 per cent ... of children are taken into care for reasons of abuse or neglect. The negative consequences for their health and development, both in the short and the long term, are well documented. As the Royal College of Paediatrics and Child Health has clearly stated: ‘[T]aking into account the serious consequences abuse has on the child, the necessity of the intervention and psychotherapeutic treatment is obvious.
Undetected and untreated abuse and neglect yield devastating results for both the individual and the community ... immediate reporting, intervention and treatment of abused and neglected children is an essential priority of public and social policy’”.
When those carrying front-line responsibility on behalf of society as a whole say these things to us, we must respond, and I am sure that my noble friend will do so when he comes to reply.
Baroness Massey of Darwen: My Lords, I shall comment very briefly on the health assessment needs of children in care. I want to talk mainly about partnerships. I realise that there are a number of tools but the Minister commented on those in Committee, so I will not go into them.
Ofsted has identified the ongoing monitoring and assessment of the physical and mental health needs of vulnerable groups, including looked-after children, as a weakness within children’s services partnerships. There is enormous inconsistency. One local authority reports 100 per cent of children in care receiving an initial health assessment, while the poorest performing authority reports only 48 per cent. Multi-agency working between local authorities, healthcare bodies and others is essential in improving outcomes for children. In some PCTs, there seems to be little clarity about who has responsibility for the health needs of children in care. The Government have already proposed to make guidance statutory for PCTs and that is welcome, but will they guarantee co-operation between local authorities and PCTs, will assessments be carried out by suitably trained and qualified practitioners, and will regulations set out how joint arrangements will be made, recorded and reviewed?
The new NHS operating framework for England states that PCTs are expected to,
- “ensure that children and young people’s health and well-being needs are assessed and that action to address these is included in PCT plans”.
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This is most welcome, but what priority is given to emotional and mental health needs when we see as priorities obesity, smoking and teenage pregnancy? Those are all understandable and important but so is physical, emotional and mental health, particularly for vulnerable children and young people.
Some things need to be stated very precisely in legislation and guidance, and I think that this area of the health of looked-after children is one of those. I am grateful to the noble Baroness, Lady Meacher, for introducing the amendment. This matter cannot be dealt with satisfactorily unless there is good assessment of need in the first place. This particular group of children—not large—could be helped so much by having its exact needs assessed so that appropriate treatment and care can be provided, rather than that being done on assumptions or their needs being neglected. I look forward to the Minister’s response.
Baroness Sharp of Guildford: My Lords, there are 60,000 looked-after children in this country: 63 per cent of them were placed in care for reasons of abuse or neglect; an equivalent two-thirds had some kind of physical health problem; and, as the noble Baroness, Lady Meacher, pointed out, 45 per cent of them had mental health problems. Section 10 of the Children Act 2004 places a duty on local health bodies—the PCTs—to improve the health and well-being of these children. They are statutory partners within the children’s trusts with a responsibility to co-operate with local authorities. It is clear that that is not working and that the health needs of such children are not being met. Some local authorities have looked-after children nurses, but one gathers that some do not have looked-after children nurses at all and often those nurses cover two or three PCT areas. There is a desperate shortage of such nurses and a desperate need for more.
Not only are health needs not met for these children, but they are not even identified. The proposals put forward by the noble Baroness, Lady Meacher, in these amendments seek to strengthen the Children Act in this respect. When we talked about this in Grand Committee, the Minister promised that there would be revised guidance so that there would be a statutory duty for the health commissioning bodies as well as the local authorities to act in this way. Will that be strong enough? We know perfectly well that guidance is something that PCTs only have to have regard to. There is a very strong case for having a piece of legislation that says that they must co-operate.
I want to finish by quoting from a transcript of an interview with a consultant psychiatrist from the child and adolescent mental health services. It says:
“Provision is very patchy. One of the difficulties relates to the split in funding streams over the last couple of years—half to the health route and half to the social services route. This was based on the government’s idea of joint thinking which works well in theory but has been atrocious in practice. This has resulted in Health Services and Social Services not discussing the needs of young people and just setting up very ad hoc patchy services”.
In other words, each has taken their share of the money and not done what they are supposed to do.
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Lord Ramsbotham: My Lords, in supporting my noble friend Lady Meacher in her amendment, I declare an interest as an adviser to the Sainsbury Centre for Mental Health. At this moment the Sainsbury Centre is focusing on the mental health needs of those in custody. Emerging from that is the fact that the figures mentioned by the noble Baroness of those suffering from these problems while in care are far worse for those in custody. Therefore, I appeal to the Minister, in considering the very great importance of proper assessment and therapeutic treatment, to remember that custody offers not just an opportunity to do those things, but a requirement to carry on with whatever may have been achieved during custody. While acknowledging that forensic mental health services are not nearly as good as they could be, one should take the opportunity gained to assess someone during their time in custody, and it is essential that that is not lost when the person returns to the care from which they came.
Baroness Howe of Idlicote: My Lords, I support these amendments. We have heard all the facts and figures and they are all horrendous. As my noble friend Lord Ramsbotham has just said, they are far worse for those who end up in prison than for those in care. I am impressed by the range of bodies—the Local Government Association, the NSPCC, a whole range of children’s bodies and the associate directors of children’s services—that are all coming to the same conclusion. As the noble Baroness, Lady Sharp, has just said, the physical, mental and emotional needs of these children are not just not identified, they are not being met. It is clearly time that rather more attention was paid to this side of things. I congratulate my noble friend Lady Meacher on her amendments, and wholly support them.
Baroness Morris of Bolton: My Lords, we fully support the spirit of Amendments Nos. 32 and 33. I was prevented from speaking to the earlier amendments of the noble Baroness, Lady Meacher, on this issue because of the ticking of the clock in Grand Committee and a fierce glare from the noble Baroness, Lady Crawley.
Healthcare assessments, though already obligated to occur every 12 months for children in continuous care, often do not. Information from the Chartered Institute of Public Finance and Accountancy, as the noble Baroness, Lady Massey of Darwen, said, shows that in Sandwell Metropolitan Borough Council, for example, only 48 per cent of children received a health assessment of some kind. Yet, at the other end of the scale, Trafford was able to provide assessments for all of the children in care in its area. The discrepancy goes to show that, although efforts have been made, not enough is being done. What these statistics do not reveal is what kind of assessment is being given. We agree that it is extremely important that assessments focus not only on the physical health of a child but also on their mental health. Thus we strongly support the intention of the amendment.
Amendment No. 33 fits with our position on early intervention: anything that can be done to prevent
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Lord Adonis: My Lords, we are all agreed that it is vital that we improve the health of looked-after children. We also agree that doing this requires us to improve both the proportion of looked-after children who receive health assessments—both initial and ongoing assessments—covering their physical, emotional and mental heath and the quality and timeliness of these assessments.
To reinforce the existing legislative framework, we will put revised guidance on promoting the health of looked-after children on a statutory footing for health bodies as well as local authorities, using the powers in Sections 10 and 11 of the Children Act 2004. The revised guidance will be statutory for primary care trusts, strategic health authorities, NHS trusts, NHS foundation trusts and local authorities.
I shall respond specifically to the questions posed by the noble Baroness, Lady Meacher, as to what this revised guidance will cover. It will cover health assessments for looked-after children, including their physical, mental and emotional health; health plans, including the implementation of these plans through the provision of appropriate health care; the involvement of qualified medical practitioners in health assessments and health reviews; the timescales in which the initial health assessment and reviews must be completed, a particular point that the noble Baroness raised; health promotion; the provision of targeted child and adolescent mental health services for looked-after children, which we know are important for improving their mental health; and the roles and responsibilities of health bodies and local authorities, including, to respond to the point of the noble Baroness, Lady Sharp, how they should work together to improve the health of looked-after children. I hope that that addresses the noble Baroness’s concerns relating to the timeliness of health assessments and reviews, the qualifications of those carrying out the reviews and the involvement of health services.
The noble Baroness also raised the issue of whether health bodies will have only to “have regard” to this guidance. I can assure her that this does not mean it is in any way optional. Health bodies, when exercising any discretion, and particularly when making decisions about delivery of services, will have to take proper account of the guidance and follow it unless they have good reasons not to do so. Failure to have proper regard to statutory guidance would be a ground for impugning a health body’s decision and challenging it thereafter. In the Court of Appeal case of the London Borough of Newham v Khatun and others, Lord Justice Laws said that,
- “an authority is not entitled to depart from guidance given in a circular issued by central government, to which it is obliged by statute to have regard, merely because it disagrees with it”.
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- “what is conventional law, namely that respondents to such a circular must (a) take it into account and (b) if they decide to depart from it, give clear reasons for doing so”.
There are strong duties on health bodies in respect of the guidance that I have set out.
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The revised guidance will be complemented by the new joint strategic needs assessment, the new NHS operating framework for 2008-09 and the national indicator set for local government. For the first time, the NHS operating framework includes keeping children well, improving overall health and reducing health inequalities as one of five priorities for the NHS. The JSNA forms the basis of local authority and PCT commissioning. Statutory guidance on the joint strategic needs assessment states explicitly that it should take particular account of the needs of vulnerable groups such as looked-after children. In addition, from April, the NIS forms will form the basis of all local area agreements and the new local government comprehensive area assessment. They will include indicators on the emotional health of looked-after children, placement stability and the timeliness of care reviews as well as indicators on the education of looked-after children, the proportion of care leavers in education, employment or training at 19 and adoption.
Improvements to the health of looked-after children will be monitored through our existing data collection systems, the new indicator on the emotional health of looked-after children and the Ofsted-led programme of inspection of services and outcomes for looked-after children. My officials are currently discussing this programme of inspection with Ofsted. I hope that that meets the concern of the noble Baroness in respect of monitoring.
Finally, on Amendment No. 33, the noble Baroness is right to raise the issue of ensuring that we use the most effective interventions in our work with the most vulnerable children and families. The Care Matters White Paper makes several references to the use of the term “evidence-based interventions” both for families where children are on the edge of care and for carers for looked-after children. The broad definition of such an intervention is that it has been the subject of reliable evaluation, preferably using a randomised control trial. As part of our wider parenting strategy, we are piloting nurse-family partnerships, which are aimed at vulnerable new mothers, and family intervention projects, which are comparing the use of Webster-Stratton and triple P programmes.
I particularly draw attention to the plans set out in Chapter 2—on page 37—for multisystemic therapy. MST has a strong evidence base in the US and my department is funding 10 pilot sites jointly with the Department of Health. In addition, the Department for Children, Schools and Families intends to support a single pilot of a new MST programme, which has a focus on child abuse and neglect rather than anti-social behaviour, as part of a wider international pilot. We take the noble Baroness’s points about evidence-based interventions very seriously in our work with vulnerable children and young people.
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Baroness Meacher: My Lords, I thank the Minister for that detailed reply. I got a bit lost in the middle and will look carefully tomorrow at what he said. For example, he referred to guidance making reference to the timeframe within which these assessments will take place. I am not sure what that means. I was hoping that there might be some specific time within which these assessments would be undertaken. I do not know whether he can provide any further detail on that between now and Third Reading. However, I am happy to beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendments Nos. 33 to 40 not moved.]
Clause 37 [Orders, regulations and guidance]:
Lord Adonis moved Amendment No. 41:
On Question, amendment agreed to.
Lord Adonis moved Amendments Nos. 42 and 43:
On Question, amendments agreed to.
Lord Adonis moved Amendments Nos. 45 and 46:
(a) paragraph 4 of Schedule 2 (which comes into force in accordance with subsection (8)); and(b) section 39 and Schedule 3 (which come into force in accordance with subsections (2) and (3)).”On Question, amendments agreed to.
Schedule 1 [Children looked after by local authorities: supplementary and consequential provisions]:
Lord Adonis moved Amendments Nos. 47 to 52:
“ In section 17(5)(a) of the 1989 Act (facilitation of provision by others of services local authority provide under provisions of Part 3 of that Act)—
(2) In subsection (1)(aa), for “an appropriate children’s home” substitute “a children’s home in respect of which a person is registered under Part 2 of the Care Standards Act 2000”.
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“(3A) Regulations under subsection (2) or (3) may in particular make provision which (with any necessary modifications) is similar to that which may be made under section 22C by virtue of any of paragraphs 12B, 12E and 12F of Schedule 2.”
6A In section 26 of the Children (Scotland) Act 1995 (manner in which accommodation is to be provided) for subsection (2)(b)(i) substitute—
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