Children's Health

HC Deb 25 March 1998 vol 309 cc415-34

[Relevant documents: Second Report from the Health Committee, Session 1996–97, on The Specific Health Needs of Children and Young People (HC 307-I); Third Report from the Health Committee, Session 1996–97, on Health Services for Children and Young People in the Community: Home and School (HC 314-I); Fourth Report from the Health Committee, Session 1996–97, on Child and Adolescent Mental Health Services (HC 26-I); Fifth Report from the Health Committee, Session 1996–97, on Hospital Services for Children and Young People (HC 128-I); The Government's Response to the above Reports, published as Cm 3793.]

Motion made, and Question proposed, That this House do now adjourn.— [Mr. Jon Owen Jones.]

9.35 am

Mr. David Hinchliffe (Wakefield)

I express my appreciation and that of members of the current Select Committee on Health for the opportunity to debate in detail the reports produced in the previous Parliament on children's health. I particularly thank those hon. Members who, like me, have been up all night for their presence at the debate. It is a tribute to their commitment to the issues that we shall be discussing.

I find myself in the unusual position of introducing a debate on four reports produced by a Committee of which I was neither the Chair nor a member. Therefore, my introduction will be somewhat general. However, I am delighted to see in the Chamber two Committee members from the previous Parliament: the former Chair, the hon. Member for Broxbourne (Mrs. Roe), and my hon. Friend the Member for Preston (Audrey Wise), who devotes great energy to this issue. I know that they will address in detail many of the points picked up by the Committee.

For the record, the Health Committee's inquiry ran from February 1996 until March 1997—just before the general election. It received some 500 submissions and conducted 19 oral evidence sessions. It is fair to say that it was a very thorough inquiry; the hon. Members involved deserve our congratulations on considering serious concerns in depth. The Committee issued four reports. The first two were published on 27 February 1997, and the final two were published on 18 and 26 March 1997. In an effort to conclude the inquiry, the Committee met 29 times in a four-month session shortly before the general election.

The reports from the 1996–97 Session covered a range of areas. The Committee's second report addressed the specific health needs of children and young persons; the third report dealt with home and school; the fourth report addressed mental health services; the fifth report considered hospital services. In introducing the debate, it is obviously important to stress that the contents of the reports refer to the policies of the previous Government. I pay tribute to Ministers in the new Government for the way in which they have picked up many issues raised by the Committee.

Last July, my hon. Friend the Member for Preston and I met the Minister of State, Baroness Jay, and had detailed discussions with her in the Department of Health. We are also grateful for the formal response that the Government gave in November to the recommendations in the reports.

As a background to the debate, I particularly welcome the efforts of the Select Committee in the previous Parliament. I welcome also the chance to discuss the contents of its reports. It has been my long-standing concern that Parliament rarely gives detailed consideration to child welfare and children's health. There are few debates on those subjects, so it is commendable that we have the chance this morning—I hope that we shall have more chances in due course—to examine an area that is much neglected.

It is said that children should be seen and not heard, and I believe that that saying typifies the attitudes to children's issues that have prevailed in this place—certainly during my time as a Member—until very recently. For generations, little consideration was given to the key concerns of children and young people.

One reason for that attitude is that, until recently, the overwhelming majority of Members of Parliament were male. Some of the male membership wrongly held the view that child care is a women's issue rather than an issue for men and women; but that attitude is changing. During my time in Parliament—and at 5 o'clock this morning, when we were discussing corporal punishment—I have been struck by the number of hon. Members, especially Conservative Members, who still place their children in private boarding schools. They probably have less contact with their children in term time and less knowledge of their children's concerns than I have. I am generalising. I accept that that does not apply to all Conservative Members, but a significant number of them have dispatched their children to school. Parenting at home has perhaps been second hand, because nannies have taken the bulk of the responsibility for the care of the children.

I welcome the radical changes that have occurred since the general election, such as the great increase, certainly on the Labour Benches, in the number of women Members of Parliament. The impact of that will be far greater consideration of wider issues of family policy, and of the health and well-being of children and young people.

Perhaps it is because I have reached middle age or beyond, but I also welcome the radical reduction in the average age of Members, which will afford us far more opportunities to discuss the concerns of children and young people. It is a particular delight that several of my female colleagues have just had or are expecting babies. That is healthy for Parliament, because their experiences of the health service and of caring for young children will be brought to bear in debates. In the past, opportunities to debate a huge area of policy have been missed because the vast majority of hon. Members, because of their age or background, had no direct experience of children's and young people's issues.

The changes have resulted in a radical sea change in attitudes. About 10 years ago, I was attempting to persuade the Whips Office that I needed time off to be present at the birth of my second child. There was a good deal of resistance, because the poll tax was coming through. I was told that there would be rebellions by Conservative Members, and that I had to be at the House. My daughter's arrival was delayed, and I was able to be present at the birth. My discussions with female colleagues who have recently been through those experiences suggest that there has been a radical change in the views of parliamentary business managers, which bodes well for future discussions about children and young people.

Members of the Select Committee will reinforce the fact that the overall picture of children's health and well-being is encouraging. The figures in the reports show falling mortality rates and marked improvements in the ability to treat children with diseases and to reduce the extent of those diseases in a range of ways. From our different perspectives, we all welcome those advances, which have been delivered relatively recently.

Nevertheless, the Select Committee has identified several key anxieties that relate to wider policy areas outside those for which my hon. Friend the Minister for Public Health is responsible. For example, the number of children who are killed and injured in road traffic accidents is alarming. That tragedy should be urgently addressed, and we must consider our personal transport habits. There has been a rapid increase in childhood asthma. I regularly visit schools in my constituency, and virtually every classroom has a supply of inhalers. It is tragic that such young children have been affected by problems that, in many areas, are directly related to traffic levels and pollution.

Transport policy must be reappraised radically if we are to have an effect on the health of young people, and I welcome the fact that the Government are soon to publish a White Paper on it. With regard to respiratory problems and asthma, I also welcome the steps that the Government are taking to reduce smoking. I look forward to the White Paper on smoking. As the Minister knows only too well, the Select Committee has produced but one report on tobacco so far in this Parliament. We feel strongly that urgent and radical steps must be taken to deal with the effect that passive smoking has on the lives of children and young people.

The Select Committee identified the mental health problems of children and young people as a key anxiety, and wider issues such as the increased incidence of family breakdown must be considered when addressing them. I urge my hon. Friend to discuss with her colleagues the apparent conflict between policies introduced by the previous Government, such as that between the Children Act 1989, which had cross-party support, and the operation of the Child Support Agency. The 1989 Act is underpinned by the welfare principle—the welfare of the child should prevail in relationships with the state and the natural family—but the CSA operates in such a way that children's welfare is the last thing to be considered. I see that too often in my constituency: CSA interventions often cause conflicts that damage children's welfare, and there is a knock-on effect on their well-being.

My personal anxiety about the mental health problems of children and young people is that we increasingly place far more pressures and stresses on them than we did when I was a youngster. Children do not have anywhere near as much freedom to enjoy childhood as I had. We make them grow up a great deal sooner, which is directly connected to the sad increase in mental health problems.

Eating disorders, especially among teenage girls, are a consequence of body image and the way in which the media reinforce what is expected of girls and, to a lesser extent, boys. The drug and alcohol culture has developed beyond that of the 1960s and 1970s, when I grew up.

The Select Committee rightly highlighted areas for specific action which my hon. Friend the Member for Preston and the hon. Member for Broxbourne will want to mention. It identified the lack of comparable data on children's health, which is discussed by the Acheson report on health inequalities. Although Government adult health figures can be compared, a comparison of children's health is not possible. I hope that the Government will rectify that through the health inequalities initiative on which Sir Donald Acheson will report.

The way in which children's services are fragmented over a range of professionals and agencies was emphasised. I had never heard of the children's community nurse service; as far as I know, it does not operate in my area. I was interested to discuss with my hon. Friend the Member for Preston the services that it offers. There are also health visitors, the school nursing service, social services and education services. The Committee is considering the divide between health and social services, and has rightly drawn attention to the fragmented provision and to how problems sometimes slip between the various agencies and professionals.

People in my area recently experienced the problem of the dreaded head lice, which caused great distress to many parents who look after their children and attend to their welfare. That problem arises throughout Britain, and it is difficult to decide who is responsible. Does responsibility lie with the school, the district nurse or the family? We need to consider carefully how to address this distressing, if not serious, problem.

It is obvious from the reports that, in the past, the health service has failed to recognise the separate needs of children. The report on hospital services emphasised that many hospitals do not take account of the specific needs and problems of children and young people.

I have my own interpretation of the Committee's conclusions, but other members of the Committee may take a different view. In my view, the Committee has clearly identified the need for much greater strategic vision in relation to provision for the health of children and young people. The Minister was a member of the Committee, and knows that there is a Cabinet Sub-Committee on Women's Issues. Perhaps we should consider a similar arrangement to oversee children's health and issues pertaining to them.

Perhaps the Minister will give us some information about collaboration between Departments. I served with the Minister, as a shadow Minister. She will remember that, at that time, we had a shadow Minister for children. There is a strong argument for a Minister with specific responsibility for children's issues who can span Departments and draw initiatives together.

Perhaps the Select Committee will consider the issue of a children's rights commission, which has been debated for a long time. It was raised in a recent inquiry into children who are being looked after. I welcome the Government's initiatives on children's health and their willingness to consider the issues that the Committee identified. I appreciate that wider policy changes, in particular the abolition of the internal market, will have a direct impact on the health of children. The expertise in commissioning children's services was discussed in the Select Committee.

I welcome the suggestions in the NHS White Paper on primary care, because they will certainly bring together community services that are currently fragmented. The Budget positively discriminates in favour of poorer families, and we know that there is a direct connection between poverty and the ill health not just of adults but of children.

The Committee's report on children who are being looked after was initiated in the previous Parliament and, because of its importance, was picked up by the new Committee. I hope that the House will debate that report soon. I also hope that this debate will be the first of many that will reflect a new political agenda for children and young people.

9.53 am

Mrs. Marion Roe (Broxbourne)

I am pleased to be called to speak in this important debate, and to have the opportunity to comment on the four reports on children's health; the inquiries took place when I was Chairman of the Select Committee on Health in the previous Parliament. I thank the hon. Member for Wakefield (Mr. Hinchliffe) for bringing those reports to the Chamber, and for his kind comments. I pay tribute to all my colleagues on that Committee for their constant support and commitment to our work.

It was the first time that the Select Committee had held an inquiry into services for children and young people. Twenty years had passed since the publication of the last comprehensive Government review of children's services—the Court report, "Fit for the Future"—and there had been no major parliamentary inquiry into the subject. That may surprise some people, because media hype about children easily lulls us into the trap of thinking that children, who comprise about a quarter of the population, receive excellent health provision that is specifically designed to meet their needs.

As the hon. Member for Wakefield has said, there is no doubt that the overall epidemiological picture is encouraging. Childhood mortality rates have been falling steadily for more than 100 years and are lower in the UK than in many comparable developed countries. There have also been significant improvements in the incidence and severity of childhood illnesses. However, areas of significant concern remain, and although the number of deaths and injuries from road traffic accidents have declined steeply in recent years, they remain high in absolute terms. There is considerable scope for further improvement, as there is for accidents generally.

There are still problems with respiratory and infectious diseases, and asthma, in particular, appears to have increased over recent decades, for reasons that are imperfectly understood. Mental health problems among children and adolescents may be increasing. Finally, there are the problems of success. Children who, in the past, would have died now survive with varying degrees of disability or need for care.

Unfortunately, the Committee's inquiry also identified areas of major concern and revealed that the specific needs of children were commonly ignored in the NHS. Our overall terms of reference were to consider The specific health needs of children and adolescents, and the extent to which those needs are adequately met by the National Health Service". We identified several major themes that were common whichever aspects of services for young people and children were studied. I hope that the new Committee will utilise the findings of the four reports to undertake further inquiries on individual aspects of care. I am pleased to note that the new Committee has resumed and completed the inquiry of major importance, "Children Looked After By Local Authorities". I look forward to seeing its report.

It is crucial that the inquiry's findings are not ignored because of the change of Parliament. As Chairman of the previous Committee, I urge the new Committee to be vigilant and to ensure that that does not happen. I hope that it will require the Department of Health to provide regular reports on its progress relating to the inquiry.

In their response issued in November, the Government Healthy children are much more likely to become healthy adults and we must make sure that we are investing in the future". They also agreed with the Committee that The health needs of children are significantly different from those of adults, that they are a particularly vulnerable group, and that the provision of effective health services for children depends upon a thorough understanding of their special needs. The Government's response states: The Department of Health will be discussing the future structure and development of health services for children with the service, the professions, users and their representatives. The Committee's reports will inform the debate about the specific policies of the new Government, and will help set the agenda for the future. Accordingly, we are not yet able to offer the Committee a substantive reply on many of their recommendations. Although I accept that any new Government have many issues with which to contend, I have seen little evidence of activity either specifically relating to our conclusions or recommendations, or in the involvement of professions, users and their representatives. It appears that the Department of Health has no intention of consulting anyone other than its own civil servants. That must be rectified. I for one do not intend to let all the work on the four reports following that first inquiry into children's services be ignored.

The Committee recognised and welcomed the undoubted improvements in some areas of children's health in recent decades, but that should not lead to complacency or to an under-estimation of the importance of a change in attitude, leading to child care that is more child centred. Many factors have contributed to those improvements: immunisation, health education, improved nutrition and housing are just a few. I welcome the Government's acknowledgment that the reports echoed the fundamental philosophy of their public health initiative and the fact that they are carrying forward the public health initiatives to which the previous Government gave such serious attention.

The rewards of good health care in childhood, especially health promotion and preventive interventions, are unique, because the benefits may last a lifetime and may be passed on to future generations. We all recognise that. Therefore, it seems incredible that health visiting and school nursing posts are being dramatically reduced. That group of health professionals has played such an important role in keeping children healthy.

The Committee received an enormous volume of evidence across a wide range of topics, but several themes were prominent in every aspect of health services for children and young people. The first theme we identified was that, at present, services for children do not always consider the specific needs of children. Too often, they are based on traditional customs and practices or on professional self-interest. Children's health services must be needs-led, not based on historical patterns or the self-interest of provider groups.

That was obvious in myriad examples, some practical and involving few, if any, additional resources, such as grouping children together in out-patient clinics, rather than mixing children and adults together. Another example was of information wholly designed for adults being sent to child patients. How can a mother feel confident that her small child's needs will be met when the information that is sent refers to refraining for a defined period from returning to work or resuming sexual intercourse? We would not appreciate information advising us that we should not attend nursery school or be permitted to play boisterous games such as football. Children have as much right as adults to receive information that is appropriate to their needs.

On a more serious note, it is worrying that many of our witnesses felt that, some six years after the purchaser-provider split, purchasers still did not have the necessary commitment to, or expertise in, purchasing services that focus on the specific needs of children. Department of Health policies relating to children's services rarely appeared to have been considered by the commissioners.

Some commissioners appeared to limit specific services for children to immunisation and health surveillance. The needs of children who were ill appeared to be completely subsumed within services for adults. We therefore recommended that hospital services for children should be purchased as part of an overall package of services for children. To rectify the problem, we also recommended that each purchasing authority should appoint a lead commissioner for child health services. The Government's response was: We agree that health authorities could benefit from having an individual who has a lead role in the commissioning of child health services". That lacks commitment. Again, children's specific needs are given less attention than those of adults.

A basic tenet of all Governments since 1959 has been that children should be nursed in children's wards among their own age group, with appropriate facilities for parents, play, leisure and educational activities, and that staff providing care should have undertaken specific training in children's needs, yet many witnesses gave examples of children being put in adult wards—even when there were empty beds in the children's ward— with no contact with specifically trained staff. That situation was often referred to as "surgeon's shoe leather syndrome." Some surgeons do not want to walk down the corridor to the children's ward from the adult ward in which the majority of their patients are placed.

That was clearly an example of the recurrent theme that services were too often based on traditional custom and practice or professional self-interest, and not in the best interests of the child. The Committee therefore recommended that the percentage of children admitted to adult wards should be included as a performance indicator in the Department of Health's annual hospital performance league tables. That would focus the minds of hospital managers, clinicians and purchasers on the importance of meeting that target. We also recommended that all the standards that are set out in the "Charter for Children and Young People" should be monitored.

I am sure that I was not the only member of the Committee to be staggered by the Government's response, which stated that their evidence was contrary to all that the Committee had received, as only 1.2 per cent. of children admissions are to a hospital without a children's ward. As a paediatric nurse said to me, the only reason for such a response is that the Department is being extremely economical with the truth, or deliberately obtuse, or it is completely ignorant of the reality of the situation in acute hospitals.

In reply to the Government's response to our reports, a Royal College of Nursing press release stated: We believe that the Government had simply failed to understand the situation. The problem is widespread in hospitals which do have children's wards and it is the reality which the Government has failed to address. The RCN's paediatric nurse managers forum has recently completed a survey of hospitals with a children's ward. It showed that the third commonest cause of concern of paediatric nurse managers was children in adult wards.

I was pleased to note in the Government's response that they were considering whether care of a child outside a children's ward should be a centrally returned quality indicator. I should be grateful if the Minister would inform me whether a decision has been made and, if so, what it is. If no decision has been made, when will it be made, and will she assure me that her decision will be announced in the House?

The care of children in accident and emergency departments provided evidence of similar lack of implementation of well-established good practice guidelines. More children attend A and E departments during a year than are admitted to hospital. Children comprise almost one third of A and E attendees. It is reasonable to expect that high priority should be given to children's needs in those departments. The Secretary of State for Health has properly drawn attention to the violence that is now common in A and E departments. What must it be like for young children to witness such events?

The 1996 Audit Commission report "By Accident or Design" showed that even separate waiting areas for children, recommended since 1959, were uncommon. The Department's response ignores our conclusions and recommendations. I specifically ask the Minister personally to consider children in A and E departments.

Another of the "cardinal principles" stemming from 1959 is that children should be admitted to hospital only if the care that they require cannot be provided as well at

home, in a day clinic or on a day basis in hospital. To facilitate that, community children's nursing services must be rapidly expanded.

The Committee was unanimous in its concern in discovering that in 1997, almost 40 years after the expansion of community children's nurses was recommended, only 50 per cent. of the country had such a service. Only 10 per cent. provided a 24-hour service. The Department of Health report on the evaluation of the pilot projects between 1992 and 1997, published last month, concluded that community children's nurses make a vast difference to these families. We would all agree that, whenever possible, children should be nursed at home. We were interested to learn how children's community nursing teams enable parents to care not only for children following a short acute illness or surgery, but for children who require long-term care due to major chronic illness and/or disability. That included children requiring special feeding techniques or ventilators to assist with their breathing.

Ms Julia Drown (South Swindon)

Will the hon. Lady give way?

Mrs. Roe

No. I have so much to cover and time is limited. The hon. Lady will forgive me, but I still have some important points to put on the record.

Only a few years ago, such children, if they had survived, would have spent their whole lives in an institutional setting. Now, if community children's nursing and appropriate social care are available, not only can such children live at home with their families, but they can participate in activities of the local community and be integrated back into school—some into mainstream schools.

We were most concerned to hear that, despite continual Government recommendations to expand services, the Department has paid so little attention to their provision. Our recommendations for the rapid expansion of community children's nursing services are clearly set out in our reports. For many years, such a nursing service has been available to all adults in their own homes. We consider that, as a matter of principle, sick children need and deserve no less. It is another example of the needs of children being given less consideration than those of adults.

We all recognise that children's health needs are different from those of adults. Children become more ill more quickly and more seriously than adults do, even those with the same condition. Safety margins are much narrower and, due to their stage of development, children have difficulty in telling us what is wrong, particularly when they are ill.

Like my fellow Select Committee members, I had always assumed that health professionals, particularly those for whom children are the focus of their work, would be required to have undertaken specific training. That is not so, yet staff caring for adults undertake long training focused on the needs of adults. How strange it is that children receive an inferior service.

Clinical effectiveness is of concern to us all, yet we received evidence from surgeons that a considerable number of operations are being performed on children unnecessarily. In 1996, the Royal College of Paediatrics and Child Health, in association with other royal colleges, issued a report entitled "Children's Surgical Services", which sets out the principles for those services. We recommended that the Department should issue explicit guidance to all those involved, reminding them of the good practice guidance and the need to monitor implementation.

While welcoming such reports from professional bodies, the Government's response is that they will consider how to encourage everyone to comply with them. That is not satisfactory. Successive Governments seem to spend considerable time "considering"; it is about time that action was required. I am waiting to see whether any action will be taken or whether such an announcement will prove to be no more than rhetoric.

An aspect of care that gave serious cause for concern—so we devoted an entire report to it—was child and adolescent mental health. Even the Department of Health witnesses agreed that current provision is inadequate in quality, quantity and geographical spread. In recent years, the House has rightly heard much about unsatisfactory mental health services, but our debates have been almost totally confined to services for adults.

Child and adolescent mental health services seem to feature at the bottom of the agenda in both mental health and child health services, and there is little public sympathy either for the children and young people concerned or for their parents.

Prevention is by far a cheaper option than treatment at a later date, when a plethora of problems have arisen, and health, social services, education and the youth justice system are involved. How many of those in prison, costing the country millions of pounds, would have become involved in criminal behaviour if their mental health difficulties had been addressed earlier? The paucity of services results in difficulty of access.

Successive Governments have devoted attention to the waiting time for surgery, but no such targets or the resources to meet them are available for child and mental health services. Only last week, the Select Committee's adviser informed me that his waiting list for an appointment is now 12 months. It is very difficult for those of us who have not had to experience the trauma associated with a mentally disturbed child or teenager to imagine what it must be like to have to wait at least 12 months for an appointment unless the child attempts suicide.

In common with consumer and professional groups, I was extremely disappointed that the Government response stated that they had no plans to set up a committee on children and young people. In Scotland and Wales, Ministers with responsibility for children review, develop and co-ordinate Government policy and strategy for children.

The House has a responsibility to represent all our constituents, particularly the most vulnerable. I was not fully conversant with how orientated our services are towards adults and so often ignore the needs of children, who represent 25 per cent. of the population and our future. Children are a vulnerable group. They have no political vote and cannot lobby Members of Parliament, yet they are not even to have parity with women by being given a Cabinet Sub-Committee. Surely that cannot be right.

The Government's response stated that they have a children's strategy group, which includes representatives of all the main Government Departments concerned with children, thus co-ordinating their activities. That does not convince me that fragmentation will be reduced. It was obvious from the evidence of Government witnesses that there was much about the services of which they appeared to have little knowledge and no mechanism for obtaining it. That is not good enough.

I remind the House that children are our future. The first inquiry into service for children and young people identified the serious lack of action by successive Governments on policies that were agreed by the House, consumers and voluntary bodies. It is about time that action rather than rhetoric was forthcoming. Why are our health services so focused on the needs of adults? Surely, as the 20th century nears its end, the needs of children should receive the same attention as those of adults. A notable achievement for the millennium would be in 2000 for the Secretary of State, backed by the facts, to confirm that all the principles of health care for children and young people had been implemented.

10.17 am

Audrey Wise (Preston)

I congratulate the hon. Member for Broxbourne (Mrs. Roe) on chairing the Select Committee during the inquiry. It was a long inquiry. My hon. Friend the Member for Wakefield (Mr. Hinchliffe) said that it started in February 1996. However, terms of reference and an appeal for evidence were published back in summer 1995, so we gave those in the field an ample opportunity to prepare evidence. The whole process has resulted in a substantial report of no less than eight volumes—four volumes of reports and four volumes of evidence to back up their conclusions.

One of the main and best characteristics of the work of the Select Committee is the publication of the evidence. I am pleased that, in their interim response, the Government have said that that substantial body of work would inform the debate. My only worry about the report is that it costs £131.60 to buy the whole of it, so I fear that its circulation is unlikely to be as wide as its contents merit. Like the hon. Member for Broxbourne, I have noted that the Government's response is an interim one; I must advise the Minister, in the friendliest possible way, that I have carefully annotated the Government's responses, paragraph by paragraph, and will seek out suitable opportunities to pursue each one. Never let anyone think that a promise by the Government to "consider" something will be allowed to die the death: it will not.

One of the good features of the new Government's policies on health is their emphasis on the baleful effect of inequality. The Committee said: We were surprised to hear from the Department of Health that there was no readily accessible data on variations in child health by region and social class. It is our understanding that there is a considerable body of evidence going back to Sir Douglas Black's report in 1980, 'Inequalities in Health', and before, which deals specifically with this topic. We welcome the Department of Health's announcement that further research into the nature and extent of variations will shortly be commissioned". The Government's response states: the Secretary of State for Health has asked Sir Donald Acheson to report to him on social, geographical, ethnic and sex inequalities of health … The health of children is likely to be a key component of this report. I am not sure that that sufficiently meets the case. I hope that the Government will convey to Sir Donald the firm idea that the health of children must be a key component of his report; otherwise, his report will not be the valuable document that we need.

The Committee looked first into whether children need any special attention. Are they not simply miniature adults? This view, although perhaps not entertained in theory, has been prevalent in practice. Thus, children being prepared for surgery are prepared just as though they are adults. That can be harmful, because, as we learned, children's physiology is different, and all their body processes work faster. In short, they are very different from adults. I will not dwell on all the differences, because the hon. Member for Broxbourne covered them competently.

Another difference between children and adults is that children must be considered in context. A doctor can treat an adult for a particular problem—we think ourselves quite lucky if the doctor treats us as a whole person. I do not mean any offence to the hon. Member for Isle of Wight (Dr. Brand), who is sitting directly opposite me—I hope that he will not take my strictures personally. As I was saying, we feel lucky if we are considered as a whole person rather than, say, a walking stomach.

With a child, it is not enough to say, "This is a whole person." One cannot sensibly deal with a child without dealing with that child's context—the family. Professionals dealing with children are dealing not just with individuals but with whole families. For this and many other reasons, children require a different service.

This fact seems to have been overlooked by Governments, planners and managers. We became aware that many of the professionals struggling to provide a good service feel undervalued. It is almost as though, because children are small, those caring for them, and their talents and expertise, are also thought of as small. That is a wrong point of view.

I was surprised to learn during our visit to Great Ormond street hospital that paediatrics is quite an unpopular specialty. Paediatricians often earn less than other doctors—they do not go in for private practice—and they work longer hours. In general, they are regarded somewhat as the Cinderellas of the profession.

As we continued our inquiry we discovered that there is a lamentable lack of properly qualified and trained children's nurses. Only 3 per cent. of nurses hold a children's nursing qualification. That results in a ratio of one nurse to 1,400 children, which is clearly ridiculous. Depending on where we mark the boundary between childhood and adulthood, children make up between one fifth and one quarter of the population. We do not say that between one fifth and one quarter of all nurses should be children's nurses, since children are generally reasonably healthy—but 3 per cent. is ludicrously low.

We also discovered that the guidance to the effect that there should always be two registered sick children's nurses in a children's ward during the whole 24-hour period is not observed; and whereas adults expect district nurses to treat them at home, there is no such adequate service for children. There have been district nurses for adults for about 100 years, and our report draws attention to the fact that children should be entitled to the same service. But 50 per cent. of the population have no access to properly organised, co-ordinated children's community nursing services, and only 10 per cent. have access to a 24-hour children's community nursing service. That is deplorable.

We found in the course of our inquiry that children's community nurses have additional duties; the recommendation made to us by the Royal College of Nursing about how many children's nurses are needed to provide a good community service was based on the notion that an important part of their work is training parents to do for their children what adults are not expected to do for other adults for whom they are caring. I refer, for instance, to passing nasal gastric tubes. Those of us on the Committee who are parents or grandparents found ourselves thinking about how we would have managed even if we had been lucky enough to have a trained children's nurse to show us the procedure. We were not especially enamoured of the prospect.

Our estimates of the necessary increase in the number of these nurses are based on the most conservative calculations.

Ms Drown

According to my reading of the report, the Committee found that areas with a children's community nursing service provided care that was not only better but more cost-effective. In three instances, the cost was between 11 and 43 per cent. of the cost of treating the children involved in hospital.

Audrey Wise

My hon. Friend is right, and the Government acknowledged that. I was therefore rather disappointed that, in their response to the report, they said—referring to improvements that might be made— This might include hospital at home schemes, community paediatric nursing and improved primary care services. There should be no "might" about community paediatric nursing.

The eight-volume report covered many issues. One was the patients charter as it applied to children. The charter states that parents may "expect" certain things, but we discovered, on examination, that that "expectation" could be deemed to be no more than a target—something very different from a right.

We investigated the response to respite care needs, and found it to be totally inadequate. We also investigated the need for proper equipment to be provided, and heard from witness after witness that it was also very inadequate. We heard repeatedly about the fragmentation of services, and about problems relating to the boundary between social services and education, and health services. I know that my hon. Friend the Minister is interested in that aspect. We certainly feel that it requires special attention, not only in relation to the elderly but in relation to children.

We found that parents were being told to take home and wash equipment labelled "For single use only". One mother who had to use a suction device to clear a child's airway was given a packet of six for a week, although she had to clear the child's airway 56 times in that week and the packet was labelled "Use once only". I hope that the Minister will take our recommendations in that regard seriously.

We considered the need for accident and emergency departments to be properly designed for children. We pointed out that, although children use accident and emergency services far more than in-patient services, some hospitals seem to ignore the fact.

We looked carefully at the whole range of children's problems and needs. My overriding impression was that, if I had to name the most important thread, it would be the nursing thread—the need for a seamless nursing service, with properly qualified nurses. Children's nurses receive excellent training, but unfortunately not all places are being taken up, because of the exigencies of training budgets.

I hope that my hon. Friend the Minister will consider all those points carefully. I promise her that I shall come back to her for regular updates on the Government's interim response.

10.33 am

Dr. Peter Brand (Isle of Wight)

I must declare an interest, especially for the benefit of the hon. Member for Preston (Audrey Wise). I was destined to become a paediatrician, but moved sideways to become a holistic family doctor in general practice.

The report is valuable, as today's speeches have been. I know that time is short, but I want to highlight two parts of the report that illustrate the lack of a national strategy, which has caused confusion in regard to the local delivery of services for children. One part deals with medical advice and treatment for children in schools, and is relevant to yesterday's prolonged debate.

In many areas, school nursing services have been cut to such an extent that they have become almost irrelevant, given the vast task that needs to be performed. That task involves surveillance, immunisation, the advising of parents, teachers and pupils, the identification of social care needs, all the work connected with child abuse, the identification of special educational needs, health promotion, the support of children when they first experience anxieties about sex and, indeed, the protection of children from the consequences of sexual activity.

I am disturbed by the fact that those services have been allowed to decline without consideration of children's needs. We seem to be considering which agency is responsible for a particular service rather than what a pupil requires. As has been explained, children with a vast range of medical needs now attend normal schools. It is unreasonable to expect a single nurse to meet those needs, especially one with a potential case load of between 2,500 and 5,000 patients spread over 15 schools.

There should be a much more flexible framework, allowing specialist community nurses who may be attached to hospital departments—and practice nurses, who are very experienced in the treatment of such conditions as epilepsy and asthma—to go into schools and advise not just teachers but children themselves.

Mr. Andrew Lansley (South Cambridgeshire)

In Cambridge and Huntingdon, in my constituency, there is a greater integration of the services provided by health visitors and school nurses, but that integration is in the context of what is euphemistically termed disinvestment. What that has actually meant is redundancies among health visitors and a reduction in services, which are focused only on children who are understood to be at risk. Because of that, we have lost the universal screening services that promote good health in children and help them to become healthy adults.

Dr. Brand

The hon. Gentleman makes a valuable point, which illustrates what I am about to say.

We need to use the specialist skills that are available to the community to help people in their homes and those visiting GPs, but also to help people in schools. Children are people, and they are entitled to all those specialist services. Not all services need to be delivered by specialist paediatric nurses. This is another example of the achievement that is possible for the NHS, provided that it encourages team work.

The second issue that I must mention is the provision of mental health services for children and adolescents. There seems to be almost universal confusion about the roles of education, social services and health departments. A cultural apartheid seems to apply to the various people who deliver mental health services to, in particular, children and adolescents. It is rare for educational psychologists to talk to clinical psychologists or psychiatrists, and social workers do not get much of a look in. That must be changed. It is not just the child who suffers in such circumstances.

A few years ago, the only place where I could send a psychiatrically disturbed 12-year-old lad was the local police station. The adult mental health facility would not take him, and he was too disturbed to be put in a paediatric ward in the local hospital. That is not satisfactory. It is a direct result of planning failure, which is itself due to the lack of a national strategy.

I welcome the spirit of the Government's response to the reports, but I am disappointed at the lack of detail. This debate is particularly valuable, in that it enables us to extract further details from the Minister about the direction in which she believes that these important services should go. It is not only the children who matter, but their parents, their carers, their teachers and the broader community.

10.39 am

Mr. Patrick Nicholls (Teignbridge)

I shall be as brief as possible, as not only do hon. Members want to hear from the Minister, but she will want to respond to the points that have been made.

The series of reports represents a formidable piece of work. When I first read my Whip, I thought that the debate would last for three hours, which I did not think would be long enough—one could not even read the reports in that time. When I realised that it would last for only an hour and a half, I knew that our work would be cut out.

The introduction to the second report sets the scene very well. It says: Childhood is a period of rapid and uneven development … Illness, disability and problems of mental health which develop during childhood may remain with an individual throughout life … Twenty years have passed since the publication of the last comprehensive Government review of children's health services, the Court Report … The Court Report contained over 200 recommendations". It also points out that the Department of Health said that it could not provide a check list showing whether those recommendations had been met, as there had been so many reorganisations in the national health service.

The Select Committee concludes that its consideration of reports dating back to 1959 reinforces our view, which has gained in strength as our inquiry has progressed, that the special needs of children are given insufficient priority by policy-makers, health service professionals and others who in one way or another have a responsibility for children's well-being. Changes in attitude, not merely in policy, are clearly needed. Although that is stated in the introduction to the inquiry, I think that it probably says it all.

Anyone listening to this debate—I take the point made by the hon. Member for Preston (Audrey Wise) that listening to it or reading it will be less expensive than buying the reports to read—will have realised that this is the House of Commons at its best. A report that was prepared under the previous Conservative Government has been introduced on the Floor of the House by the current Chairman of the Health Select Committee. Most of our work in the House is a seamless robe, which sometimes the public do not realise. I commend the hon. Member for Wakefield (Mr. Hinchliffe) for staying up—as I hope to do for the next few minutes—and I thank him for his kind words about the way in which the Select Committee carried out its work, including under the chairmanship of my hon. Friend the Member for Broxbourne (Mrs. Roe).

I mentioned that the reports represent the first major inquiry since the Court report. When they were issued, they were welcomed by one and all. Baroness Jay said of the Select Committee: We welcome their reports, which will make a substantial contribution to the debate on children's health. I make no criticism in saying that, although they are a substantial contribution, they must ultimately represent more than a contribution.

I have not totalled the number of specific recommendations in the reports, but even on a cursory count I reckon that there are at least 70—I could not begin to go through them all in the time I have. Indeed, it is always invidious on such occasions to highlight particular recommendations, but I shall point out the issues that struck me as relevant, in the knowledge that other hon. Members with greater experience of the Select Committee have highlighted the same recommendations.

The Select Committee said: health services for children and young people are not always designed to meet their needs, but may be based on traditional custom or on the convenience of the provider. They are not always delivered by appropriate staff. It also said that it endorses the 'cardinal principles' set out in Department of Health guidance on hospital care for children, but doubts the extent to which they are actual achievements, rather than aspirations. In particular, the principle that children should not be in hospital unless absolutely necessary cannot be met given the current inadequacy of community nursing care. It went on to say: many hospitals fail to meet the Department of Health standard of having at least two registered sick children's nurses on duty 24 hours a day … the Patient's Charter standard that children should be cared for in a children's ward under the care of a paediatric specialist is not being met; it is recommended that such information should be collected as part of hospital performance league tables to reinforce its importance. That point has rightly been made by a number of hon. Members.

Dr. Ian Gibson (Norwich, North)

Does the hon. Gentleman agree that children are subjected to a vast array of environmental hazards—such as ionising radiation—which may explain the increase in childhood leukaemias both in this country and in the United States? Would not reducing such hazards lead to a decrease in the number of illnesses to which young people, with their sensitive bodies, are subjected?

Mr. Nicholls

With a medically qualified doctor, the hon. Member for Isle of Wight (Dr. Brand), sitting to my left, and another, the hon. Member for Norwich, North (Dr. Gibson), sitting opposite, I shall have to be careful in passing judgment, but I think that that must be right. The hon. Member for Preston rightly said that childhood is dangerous; like the last days of one's life, it is a difficult time. I welcome the fact that we are moving away from the idea that children are mini-adults and can be treated as such. It is difficult to know where the dividing line falls, but children's experiences are clearly different.

The Government's detailed and thorough response to the reports was commendable. As has been said, the reports represent an agenda for action—we all share the duty to ensure that there is action. Again, time does not permit me to go through the details, but I shall mention some of the responses, both to commend the Government and to point out that further action will be necessary.

On page 13, the Government say: We do not believe that it is acceptable for children to be treated by inexperienced and inappropriately trained staff. We shall ensure that measures are taken to address this problem. This will include continued action to increase the numbers of relevantly trained staff. During the debate, hon. Members have stressed the importance of staff who are trained in the care and treatment of children. I believe that the Government's aspiration is laudable, and I hope that the Minister will find time to say something further about it.

In its extremely helpful briefing, the Royal College of Nursing highlights what the Government say on page 16 of their response. The Government state: We acknowledge the past shortages of qualified children's nurses have limited the opportunities for the health service to benefit from their skills. As the number of children's nurses increases, their skills can be utilised in many more areas of healthcare for children and young people. The Government's reaction is fine and right, but we need the Minister to explain how the number of children's nurses will increase.

On page 38, the Government say: As the Committee noted, there continues to be a need for more child trained nurses. The NHS Executive has asked education commissioners to ensure that sufficient children's nurse training commissions are placed to meet the recommendations of the Clothier enquiry (to have at least two Registered Sick Children's Nurses or equivalent, on duty 24 hours a day in all hospital children's departments and wards) and, in addition, that adequate provision has been made for the staffing requirements of paediatric intensive care units. Again, I commend the Government for their response, which was exactly right, but we need to have some idea of how they believe that they can take that process forward.

In preparing my thoughts for the debate, it seemed to me that three common themes ran through the reports. First, there is reference to the fragmentation, and lack of child-centredness, in the delivery of many child services. Secondly, there is a failure to follow existing good practice guidance. Thirdly, there is training, training and training, a point that has been made throughout the debate.

What is interesting about the reports—I say this as a compliment, not as a criticism—is not so much that they break new ground as that they remind us of how much there is that has yet to be implemented. It is significant that the Court report was issued in 1976 and that other official Committee reports go back to 1959 because it illustrates how Governments and Select Committee reports have so often failed to pick up and run with the excellent work done. I referred to the Department of Health's response that it could not comment on whether the Court report had been dealt with, because rules had changed and the matter was difficult.

New Governments have an opportunity. This Government are not quite bright and spanking new—if I may pinch a theme of an earlier debate in which the hon. Member for Wakefield and I were involved—but they are pretty new. We are also fortunate that the Minister for Public Health's commitment to the health and welfare of children is thoroughly accepted and appreciated on both sides of the House. There is an opportunity for a new Government to ensure that the sins of the past are not repeated. I would like to think that constructive suggestions by Opposition Members on how recommendations may be taken forward and the brooding and extremely experienced presence of the hon. Member for Preston, combined with what the Minister will bring to the matter, will ensure that the reports' recommendations will not suffer the same fate as the Court report, and that, in 20 years' time, they will be seen as an agenda that was taken forward.

10.50 am

The Minister for Public Health (Ms Tessa Jowell)

I join others in paying tribute to the hon. Member for Broxbourne (Mrs. Roe) for her stewardship of the Select Committee on Health and her contribution to the debate. I also pay tribute to my hon. Friend the Member for Wakefield (Mr. Hinchliffe), and particularly to my hon. Friend the Member for Preston (Audrey Wise).

All speeches in this very important debate have made it clear that the Select Committee's conclusions and the Government's response to them are in the light of the development and implementation of children's services under the previous Government. Although my hon. Friend the Member for Preston referred to the Government's response as interim, I hope that members of the Committee will not be holding their breath over the publication of the next stage of the Government's response.

I should make it absolutely clear first that I would expect nothing less from my hon. Friend the Member for Preston than her persistence and vigilant scrutiny of Government action in the light of the reports' many recommendations, and secondly, that the Government are as one with the Select Committee in its determination to meet the many shortcomings in the service that the reports identified. I hope that there can be a spirit of partnership and common purpose as we take action in areas where the need for it has been so clearly identified.

It is important to reflect on the difference between the approach adopted by this Government and that adopted by the previous one. Several hon. Members have made clear the devastating impact of inequalities in health on children's opportunities. Inequalities are evident in almost every aspect of young children's lives. Health services for very young children are so important because they can act as an instrument to combat inequality and to promote greater fairness and opportunity for all children. That is so when judged by any measure.

Let us consider accident rates. The child who is born into a family of social class 4 or 5 is five times more likely to die in an accident before the age of 15 than a child from social class 1 or 2. Stark regional variations can be linked to poverty, unemployment, pollution and lack of educational achievement. Enormous regional variations occur in the incidence of tooth decay, which is very important to the developmental health of children. As our public health Green Paper makes clear in considering the likelihood of survival of children in the first year of their life, the most telling indicator is the country of birth of their mother.

Tackling inequality sits at the centre of the Government's approach to dealing with the problems that the Select Committee raised, as does our commitment to insisting on consistency of quality. The Select Committee was rightly critical of the preoccupation with numbers rather than the consideration of quality of interventions.

We are absolutely at one with the Select Committee and several speeches in the debate about the extent to which the impact of good work and services can be sabotaged by fragmentation. It is an enormous challenge for health, social and education services to move to treat the child as a whole person in context, as part of their wider family. That is the challenge for the Government, local government and local health services.

In the context of Sir Donald Acheson's report on health and equality, to which several hon. Members referred, it is important to understand that not all children who appear to suffer the same social and economic hardship necessarily suffer the same degree of ill health as a result. We need to understand much more about the protective factors that can act. That has been a major preoccupation of the review of services for children under the age of eight, which I have chaired as part of the Government's comprehensive spending review.

We intend to build on the very important contribution of prevention in our investment in the health of children, reiterating and underlining the importance of immunisation. I draw to hon. Members' attention yesterday's very important statement from the Medical Research Council and the Chief Medical Officer about the desirability of the measles, mumps and rubella vaccination to protect children against what were previously killer diseases.

Yes, we are absolutely committed to strengthening the role of health visitors and the important contribution of school nurses, but it is important that their role develops as part of the strengthening process, at a pace that reflects the change in the nature of services, the importance of overcoming fragmentation and the importance of applying evidence of what works.

Yes, we are determined to overcome the unacceptable degree of local variation and inequality in access to services. That is why the national health service White Paper stressed the importance of national frameworks. Yes, we see the development of healthy schools, harnessing the resources of health and education, as a very important contribution to overcoming fragmentation and the treatment of the child as a whole person.

I shall pass quickly through the specific points raised in the debate. On proposals for a Minister for children as a way of overcoming fragmentation, I draw hon. Members' attention to my remarks about the efforts to scrutinise across government the effectiveness of spending on children, reflecting the importance of how we put in place structures that address the whole child.

We are dissatisfied with the data on the level of community nursing available to children and on establishing the extent to which children are being treated as if they were adults requiring adult services. That is unacceptable. We recognise that that is particularly a cause for concern in relation to adolescents, which is why £2 million of the mental health specific grant will be dedicated to the development of child and adolescent mental health services. We are certainly open to the case for a lead purchaser for children. Target setting in relation to mental health is very much a preoccupation of the current consultation on the public health Green Paper.

My hon. Friend the Member for Preston made an important point about ensuring that equipment in hospitals is used only once, but clinical advice suggests that specific guidance may be provided on equipment used at home.

We are concerned about the shortage of children's nurses, as we recognise the important point that children are not merely small adults: their needs are very specific.

I hope that I have made absolutely clear the Government's commitment to acting on the recommendations of this important report. We see this is as the beginning, not the end, of the process, and we recognise that we must invest now for the future health of our children.