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It is quite interesting to look back over history. In the 1970s, the recession gave rise to the Black report on health inequalities, and in the 1980s—to which I refer reluctantly, given how many Members of this House were busily engaged in Government then—a report produced for Mrs Thatcher’s Cabinet, which was leaked, proposed drastic increases in user charges in the NHS and a reversion to health insurance funding for healthcare. Mrs Thatcher rejected that publicly, and saw the value of making continued investment in the NHS.

In a recent edition of the Health Service Journal, the noted economist Professor Alan Maynard gave cause for some hope when he said that in periods where more money is available the NHS has tended to be taken by surprise, causing inefficiency, while when there is less money around the NHS becomes more resourceful, not least because it has to work to clear priorities. Over the coming year, it will be the job of responsible politicians to work with the professions and say what those clear priorities are. Today, I want to set out the view from these Benches: that it should be the job of politicians to ensure that the NHS does not make the mistake of going for quick wins, but continues to invest in underfunded areas—public health and social care—in order that we can prevent some of the causes of ill-health, and tackle others.

The Pre-Budget Report, which was in effect a Budget Statement, set out the Government’s case. They intend immediately to take £5 billion from public service provision, and to achieve greater savings from 2011—the point at which the NHS budget was already going to cease to grow. It is likely that there will be cuts to the NHS of between £1.35 billion and £2.5 billion, and

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there is already widespread comment that the Treasury has identified the NHS commissioning budget as a ripe candidate for those cuts. Could the Minister say whether the department and the Treasury intend that savings should be achieved in the commissioning process, rather as local authorities have done in social care, or intend to achieve those savings by cutting levels of service?

I also think that the question of how tariffs work within the NHS, which we have discussed many times in this House, will come back with a vengeance. It cannot continue to be the case that some independent providers and trusts build up large surpluses on the basis of the existing tariff system, when there will have to be greater efficiencies elsewhere in the service. I, too, read the Healthcare Commission report with great interest and took two particular points from it, which lead us back to the decisions that need to be made about where NHS expenditure should not be cut. I refer to the continued lack of robust information on how well community services are performing, and on how acute and out-of-hours services integrate with other organisations to ensure that urgent care pathways work both for staff and patients.

Connecting for Health is an obvious and easy target, because it is a massive budget which has overrun. I caution the Government not to make a knee-jerk response by cutting that budget, but rather to conduct an urgent review of the parts of the NHS IT system which have worked well and those which can be speeded up and worked on in the next two years. It is vital that the NHS has an IT system which enables staff to do their jobs and enables patients to have a better service, but generates the data necessary for everyone to make informed decisions about treatments and operating systems.

I wish to make another suggestion. We have talked in this House a great deal about mental health since the passage of the legislation. The Healthcare Commission noted in its report that access to talking therapies is being increased, but still needs to be improved, and that there are still major gaps between the quality and safety of community mental health services in particular. One does not have to be particularly gifted with foresight to know that the mental health of a nation is likely to suffer in a recession. Therefore, I suggest to the Government that they continue to look at that.

It is debateable as to whether the NHS Constitution is a constitution at all. I simply observe that all the pieces of landmark legislation, such as the National Assistance Act 1948, the Children Act 1989, the Mental Health Act 1983, and policy statements such as the Seebohm report in 1965 and the Griffiths report in 1983, were interventions that brought about tangible improvements for patients and social care users. I am not convinced that the NHS Constitution is a document of that magnitude or import, as it was aptly described by the noble Earl, Lord Howe. However, in so far as it clarifies and codifies the rights of patients, he is right, it will have our support.

The other matter which is looming, but has not been the subject of discussion so far, is the adult social care Green Paper. The truth is that we have a social

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care system that has been chronically underfunded in comparison to need for some considerable time. Since this Government came to power, it has been well known that there needs to be a settlement between individuals and the state about how we will fund social care, particularly that of older people.

I would simply say to the Government again that their own adviser, Sir Derek Wanless, in 2002 set out in detail that for every pound spent on social care, there is at least an equivalent saving to the NHS. It would be terribly tempting in times of economic hardship to make cost savings in social care. Were we to do that, the health impact would be immense.

I wish to make three points about matters that we think should be the subject of continued investment to meet health needs. First, preventive health services such as sexual health clinics are important, as people in times of austerity have a tendency to behave in rather unsafe ways, and that increases the burden of disease. Secondly, I flag up to the Government the point made by Jamie Oliver in his recent presentation to the Health Select Committee in its inquiry on health inequalities that there is a need for co-investment in culinary skills, because a generation of people have lost the knowledge and the art of cooking, and of cooking well on a budget. Not only will that work to further the Government’s set goals for tackling obesity, but it will ensure that children do not suffer by eating bad food. Finally, although it is outwith the subjects of today’s debate, there is a significant health challenge as regards the crisis in social housing, and I hope that government departments will work together to address it.

Boom and bust is not good for an economy and it is certainly not good for the National Health Service. There is much to do and a very short time in which to do it. I hope that by the end of today we will manage to achieve a consensus on where the funding priorities should be and that we will enable the Government to avoid some of the false economies that they might be tempted to make.

12.30 pm

The Earl of Listowel: My Lords, I, too, am grateful for this opportunity to debate the Queen’s Speech, and I am honoured to follow the Front-Bench speakers. I say to the Minister that I was particularly pleased to hear that the Government are giving further attention to tobacco. When the noble Lord, Lord Hunt of Kings Heath, took important measures on tobacco through this House, we were reminded that if a mother smokes at the wrong time, a baby can experience a lower birth weight and his IQ can be impaired for the rest of his life. We also know of the impact of smoking on the respiratory health of children, so I welcome the further attention in this area and I know that the House will give it careful consideration.

I also welcome what the Minister said regarding the small but important point of giving teachers more time for planning. I am heartened to hear from many people, and to see from the statistics, that teaching is becoming an increasingly attractive profession and is gaining a higher and higher status. It gives me great hope for the future that we are now valuing teachers as we always should have done.

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I also wish to refer briefly to what the noble Earl, Lord Howe, said regarding the inattention and lack of priority given to the quality of patient care. It reminded me of research comparing children’s homes in this country with those in Denmark and Germany. Using a vignette, staff were asked about their priorities. In this country, if a child in a children’s home cries in his bedroom at night, the staff’s first priority is to follow procedures. That is no reflection on the staff; it is just where we have got to by giving insufficient attention and support to this sector over a long period. On the Continent, the response would be to care for the child by giving him a hug, and carers would not feel inhibited about doing that.

In the short time available, I want to concentrate on the children’s workforce, which is so important in implementing all the legislation that the Government have brought forward in recent years, particularly on the theme of partnership, with Every Child Matters and Care Matters. The Government’s strap-line for this is: working in partnership to improve outcomes for children. I emphasise how important a strong, professional identity is in the workforce in achieving an effective partnership. It is something that we have worked for and wished for over many years, but again and again we see partnership working, the sharing of information and working together for outcomes fall down in various places.

I was encouraged to hear that at the weekend the Secretary of State, Mr Balls, said that he now wants to give social work the same attention that the Government have successfully given to teachers and that he wants to raise its status in the same way. I was also very pleased to hear Mr Sheerman, the chair of the Select Committee in the other place on children, schools and families, talking to a group on early-years childcare and enthusing about the continental model of pedagogy, which is a specialism with a heavy emphasis on child development, on hearing the voice of the child and on developing vocational skills to engage with children. It seems to be very successful on the Continent and I am glad that the Government are looking at it.

Perhaps I may briefly illustrate what I mean by partnership and by strong professional identities, both of which are important. Some years ago, I visited a hostel in King’s Cross for 18 to 23 year-old drug addicts. On a Friday afternoon, I spoke to a mental health nurse, Gabriella Maceirras. She and two other mental health nurses had been appointed to that setting nine or 10 months earlier, and she explained to me how her two colleagues had burnt out in that period. No thought had been given to what support they might need in working in that environment—their need for supervision and mental health services support. She described how she had to mother all these desperately needy young people who were queuing up outside her door but how she was simply not supported. She also said that she felt she was working blind in that area because of the lack of support and a lack of access to mental health services.

On a more positive note, I had another experience at about the same time when I visited a hostel for young rough sleepers in Olympia in west London. People working with them on the streets were saying

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that when they sent young people to this setting they stayed there, unlike in other settings. They did not leave and go back on to the streets, and therefore I was very interested in this service. I met two of the young people: a young woman who had scars on both wrists from self-harm, and a young Irish man who had been in the country for perhaps a couple of years but had been on the streets on and off throughout that period. Both were settling down in this establishment. The manager of the hostel said that she put this success down to the very close partnership with a child and adolescent psychotherapist, who visited the setting once a week. He gave the manager an hour and a half of his time and worked with the staff group for an hour and a half to examine their relationships with the young people and to give them the confidence to do their job well and sustain those relationships.

This large organisation was providing support for the most challenging young homeless people but what struck me most was that, when I looked at the statistics, I could see that it had the lowest sickness absence rate. Therefore, if staff are well supported and work in partnership with professionals and with a strong professional identity, they can be far more effective and enjoy their work, even in challenging circumstances. However, such models are very fragile. A year or two later, that service was lost, as it no longer had support from CAMHS. People are very good at looking at the cost of things but not at judging their value. Quality—a matter referred to repeatedly by the Minister—is very important but it has been overlooked in this area.

Over a number of years, I have sought to encourage, and make universal, the notion of partnership with children’s homes. In his report on children’s homes, Choosing with Care, the noble Lord, Lord Warner, said that, when giving evidence to him, psychiatrists said that on the Continent it is the norm for such homes to have a regular, ongoing relationship with a mental health professional at a psychiatric level—that is, a high-level mental health practitioner. The staff get to know him and he deals with the staff rather than with the young people. That is normal, and in children’s homes on the Continent, the level of mental health disorders in young people is far lower than is the case here. In this country, staff are left to deal with a very high level of mental health disorders—the ONS identifies 68 per cent of children in children’s homes as having such a disorder—often without important, high-quality support.

Over the years, I found that a piecemeal approach was taken and often the quality of the input was not as high as it should have been. The reason for that was the low status of staff in children’s homes, their lack of a conceptual understanding of what is necessary in their relationships with the children, their lack of understanding of child development and their lack of confidence, which made it very difficult for them to engage with mental health professionals and to recognise their need for that support.

I move on to the subject of social work. The degree course introduced five years ago is very welcome but there is still an awful lot of work to be done in developing the social work profession. Recently, a social worker told me that his son was accepted on a

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social work course with an offer of just two D grades at A-level. We want people with strong interpersonal skills and a good experience of social work, but we also need people who are thoroughly able to make good, clear judgments in difficult situations and who can analyse complex situations. After all, some of these people have to decide whether a child should be taken out of its family and placed in foster care, or whatever, which may have an impact on the rest of that child’s life. We need to address that issue.

Professionals working in partnership with social workers tell me that their experience is variable. Social work has become a somewhat unattractive profession for various reasons over the years. I am grateful to the Government for looking at this issue. The Teacher Development Agency has been effective in ensuring that the right calibre of student gets on courses, that courses are of the right quality and that recruitment campaigns are effective. That would be a very welcome model in this area. Even if one is successful in that, the point made by the noble Baroness, Lady Barker, about boom and bust was important. History seems to suggest that many people of great acumen have entered social work but the constant cutting of resources and lack of certainty about the future has driven them out. It is no good addressing just this side of the issue; there needs to be continuity of resources.

I shall refer briefly to health visitors, a profession that has been around for 150 years and which has a strong professional identity. In recent years it has lost its statutory protection; there has been a dilution of health visitors now working with nurses. They have a specialist skill in working with families in the early years but their numbers have reduced by 10 per cent in recent years. When the family nurse partnership, an interesting model used to target certain very vulnerable families, used health visitors to train in this model of working there was a 50 per cent improvement in outcomes. It pays to have high-level professionals in the field. Will the Minister say what guidance is being given to primary care trusts to give more priority to health visiting? Is he considering whether their professional identity might again be protected in statute?

I have gone beyond my time. There is so much to say about the workforce. Commissioning is vital and attention must be given to children’s homes. Unfortunately in the current economic climate the best quality children’s homes, where there is a true partnership with mental health which is more costly, are closing. We are being left with the poorer quality ones. Children’s homes are an important aspect of provision. Foster care is very important, as is adoption, but for some children a residential children’s home is the right place. We cannot afford to let that slip so I hope more attention will be given to that area. I look forward to working on the legislation on children in the forthcoming months.

12.43 pm

Baroness Massey of Darwen: My Lords, it is a great pleasure to follow the noble Earl, Lord Listowel. He so rightly points out the importance of the workforce involved with children in developing better measures for children.

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I welcome many measures in the gracious Speech, set out so eloquently by my noble friend. I shall focus my remarks today on children, and will refer to the children’s skills and learning Bill and the child poverty Bill. I assume that there is still an intention to halve child poverty by 2010 and eradicate it by 2020. We shall want to know how it will be measured and to look at how indicators on health inequalities, education and employment will impact on that. Child health is vital and I look forward to the child health strategy which I assume will be published soon. Perhaps the Minister can tell me when.

I should declare an interest as the chair of the All-Party Parliamentary Group on Children and chair of the National Treatment Agency for Substance Misuse. All children need protection, love and support. Their abilities need to be encouraged and they need to be listened to, enabling them to develop their self esteem. Sadly this does not happen to some of the 12 million children in England today. The Government have done much, and will do more, on child poverty, deprivation and support for families. The development of Sure Start, with currently 2,500 centres catering for 2 million children, is a good example. The Children’s Commissioner for England, Sir Al Aynsley-Green, said at a recent meeting, which some noble Lords attended, that more has been done for children in the past 10 years than in the previous 50. Initiatives continue but some things are still going wrong, as recent incidents and reports point out.

The UK commissioners’ report to the UN Committee on the Rights of the Child lists things that are good about being a child in England and some of the bad things, based on evidence from children and other sources. It says that increasing importance is given to children by the Government through increased investment. The majority of children say that they are happy, and most say that their health is good. They are ambitious, increasingly well educated and feel safe. Most feel engaged, motivated and that they are making a positive contribution.

On the other hand, bad things about being a child in England include the punitive approach to children, with the criminal justice system being used too readily. There are inequalities in income and health, asylum-seeking children experience breaches of their rights and child poverty is still high. Large numbers of children are affected by domestic violence and abuse. Children in care have poor outcomes and they are concerned about violence and weapons in their area. They drink more, engage in early sex, and child obesity has risen by 50 per cent in the past 10 years. They feel pressured by school exams and commercial marketing. I hope that any initiative related to children will take this evidence into account.

I shall address some concerns to do with child welfare and its paramount position as stated in the UN convention. There are 60,000 children looked after by local authorities—55 per 10,000 under 18s. Of those, 12 per cent achieved five A to C grades at GCSE compared to 59 per cent of all children. Apart from academic underachievement, there are other deprivations and risks to these children. There are nearly 3,000 children in custody, with 217 in secure children’s homes,

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247 in secure training centres and 2,349 in prison. They are overwhelmingly boys. They return to custody over and over again, sometimes because they cannot bear the thought of being outside and unprotected.

Urgent action is needed and I welcome the commitment to improve these outcomes. Many dedicated children’s charities will be working with the Standing Committee for Youth Justice on the Education and Skills Bill to meet the education needs of these young people before, during and after sentencing. The transfer of responsibility from the education and training of young offenders in juvenile custody to local authorities will be a welcome measure.

The Bill will also transfer funding and responsibility for delivering 16-18 education and training to local authorities and will create a Young People’s Learning Agency. The Bill intends to improve behaviour and attendance at pupil referral units and other alternative provision. There will be a statutory basis for the apprenticeship programme, creating a new national apprenticeships service. I hope that that will include young people with disabilities and learning difficulties.

The children, skills and learning Bill will seek to strengthen the statutory framework by legislating for children’s trust boards to be set up across the country. The proposals in the youth crime action plan to place YOT management boards on the same statutory footing should also be considered. So much has been done to improve outcomes related to Every Child Mattersbut, as I said before, much needs to be done.

I was concerned recently by the UNICEF report in which we came 21st out of 24 developed countries on child well-being. A Barnardo’s report recently stated that many adults consider young people to be feral—a dreadful word—and dangerous. That is a terrible perception of young people. I wonder whose fault that is. Two other reports make depressing reading. One says that 50 per cent of 4 and 5 year-olds in some parts of the country cannot speak in sentences when they start school. A newspaper headline on this read:

“State urged to help deprived children to communicate”,

to tackle the cycle of deprivation that has its roots in inadequate parenting. These children are also reported as needing lessons in empathy and self-control. Such concerns are not new; they go back many years. I believe it was Sir Keith Joseph who spoke about the cycle of deprivation. It is not enough to say that there has always been mistreatment and neglect of children. We need to do more about it.

A report on child maltreatment in the Lancet, drawing on evidence from affluent countries, concluded that one in 10 children in the UK suffers physical, sexual or emotional abuse and neglect, yet only 1 per cent is referred to child protection services. We know that children who are mistreated are more likely to get involved in crime, do badly at school, use alcohol or drugs, attempt suicide, indulge in early sexual activity and suffer depression.

Following the appalling case of Baby P, the Government are committed to strengthening the serious case review. It is not enough to blame hard-pressed social workers. The NSPCC is calling on the Government to invest in building the skills of professionals working with children at risk. Such professionals, it is pointed

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out, need sufficient training, experience and courage to tackle parents and carers effectively. They need to have time to spend with families and to talk to children themselves. They need support for their investigations. They need to be paid what they deserve. The welfare of the child is paramount, and we should have the courage to maintain that.

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