§ 5.38 p.m.
§ Lord LOVELL-DAVIS rose to call attention to the Court Committee's Report on Child Health Services (Cmnd. 6684 and 6684—I); and to move for Papers. The noble Lord said: My Lords, I have been asked to remind noble Lords taking part in this debate that it is a short debate, limited to two-and-a-half hours, and as there are 11 speakers, as well as the Minister, my noble friend Lord Wells-Pestell, to deliver the Government's view, it may be best to limit our remarks. Although this is a substantial and very important subject, worthy I think of a full debate, I shall do my utmost to set a good example in brevity in my opening speech.1606
My Lords, it is often said that our children represent our greatest investment in the future. So far as mankind is concerned, they are the future and it is the investment we make in them—what we contribute to their early, formative years—which can ultimately make or break mankind. So it was a commendable and far-sighted decision on the part of a former Secretary of State at the Department of Health and Social Services, Sir Keith Joseph, to set up in 1973 a Committee under the chairmanship of Professor Donald Court to review, for the first time ever, child health services in this country. Following the change of Government in 1974, it received wholehearted support from his successors, Mrs. Castle and Mr. Ennals. After three years of intensive and painstaking work, the committee—in which I should declare an interest as my wife was a member—presented its report in December under the title Fit for the Future. It is a very comprehensive and remarkable piece of work and it stands as a tribute to the committee, whose members gave so much time and effort to its preparation. I cannot improve on the words of an excellent digest of the report published as a 15p supplement to the Journal of Education, which praised the committee for performing its task, it said, with
consummate skill—and with a kind of sensitivity that is so often lacking in official reports.
§ It is a great honour for me to have the chance of making the report the subject of this debate in your Lordships' House. Here I should like to make a special plea to my noble friend Lord Wells-Pestell and his right honourable friend the Secretary of State. The cost of the two volumes which make up the report, £10.50, is a lot of money to those who would find it of greatest use. Could not a shorter version, including the Introduction and the principal recommendations, be produced for sale at a much lower price? I realise that what was, in effect, the Press release is being circulated, but that is not quite the same thing.
§ The measure of Britain's investment in its children's health, our contribution to the future, is set out early in the report. Twenty years ago we could take pride in having one of the lowest rates of infant mortality in the world. Today, we have fallen behind many of the countries we used to lead, and the number of our 1607 children who die in the first year of life is equal to all the deaths in the succeeding 24 years. Of those who survive, one in seven is likely to have a handicapping condition sufficient to be a cause of educational concern. So uneven are our child health services that twice as many children of unskilled workers die in the first month of life as those of professional workers—and, what is even worse, the class gap in this respect is widening. There are wide variations in services from region to region.
§ Many physically and mentally handicapped children are not identified as such until it is too late to recover lost ground. Many also spend unnecessary years in hospital, restricted in their movement, with little or no proper therapy, sometimes bathed and prepared for bed in the middle of the afternoon—and with their teeth rotting. For dental caries is an uncontrolled endemic disease in childhood, and 71 per cent. of our children at five years of age have decayed teeth. By the age of 15, 33 per cent. have already lost one or more teeth. And the total failure when health, social and education services fail to act individually, much less collectively, is reflected in the killing of helpless children such as Maria Colwell. The figures quoted in the report suggest that about 5,000 children every year face this degree of risk, of whom 1,000 will be seriously injured and nearly 100 will die.
§ My Lords, I could go on adding to this appalling record, but I shall sum up our investment in our children's future simply by pointing to the fact that in 1973 we devoted 9 per cent. of the National Health budget to the 24 per cent.—nearly one quarter—of our population under 19 years of age. By 1974, there had arisen a further compelling practical reason for the Committee to report as quickly as possible. For by then the 1973 National Health Service Reorganisation Act had begun to take effect—a reorganisation which now, three years later, has been described by the very consultants who helped design the new structure as a failure which has simply led to "a proliferation of paper and a massive bureaucratic problem". Under this Act, the local authority services were transferred to autonomous health authorities, in an effort to overcome the separation between 1608 hospitals, general practice and the preventive services. These were the services providing care for babies and toddlers, the school health services, health visitors—all those areas of care and preventive medicine of vital importance to mothers and children.
§ But the divisions persist: there is still overlap, lack of communication and confusion. The service for children is not a unified service. The preventive services are still set apart from the acute services, and there is a danger that our strong tradition of preventive medicine will decline at the very time when we are beginning to want more emphasis on prevention than on cure. We cannot go on treading a path over the sort of crazy paving our child health services have become—too many of our children will trip over it. There has to be a different way.
§ I am, as it were, chorus to this short debate, but since other noble Lords, far better qualified than I am, wish to speak, I shall make no attempt to cover the whole report. Instead, I propose to look at the broad lines of the organisation of services which is proposed in the report. Descriptions of services often start with definitions of professions and hierarchies, but I am going to look at the proposals from the point of view of the child and family. This, I believe, is the point of view the Committee have tried to keep uppermost in their thinking. A new baby in a family will need at least two kinds of professional health care: on the one hand, an easily accessible source of medical advice if the child is sick, and some kind of continuing professional care which will watch development, carry out preventive procedures such as inoculations, and advise the parents on the problems which arise during the normal growth of any child.
§ These two types of care—one for crises and the other for on-going surveillance of the child's health—have usually been provided by general practitioners (with, of course, the possibility of referral to a specialist) and by clinic doctors and health visitors. Now, while this division into treatment and preventive services may be understandable in the way our child and maternal health services have developed historically, and there may have been good professional reasons for the separation, to the ordinary user of health services the scene has been 1609 confusing and communication between the two has generally been very poor. We all know, those of us who have used the services, that often the school doctor or the clinic doctor is so separated from the general practitioner that they seem to inhabit different worlds, with occasional pieces of paper passing between them. How much more satisfactory for the child and his parents if the doctor he sees when he is ill is also well-informed about his growth and development both in and out of school, because a child's health is not divided into unrelated arbitrary compartments.
§ The Court Committee believed very strongly that an integrated source of medical advice would improve the care of children, and they looked at three possible ways of providing this. One was to encourage better communication between the three services—general practice, clinics and hospitals: a proposal which would avoid upheaval in an already disturbed service. The Committee rejected this idea as not being radical enough to improve the care given to our children; they felt that things would probably just go on as before.
§ Another idea they considered was that of a service provided for children only, with doctors of first contact and a specialist back-up, trained to deal exclusively with children. This would be a paediatric service in parallel with the service provided for adults. This, too, was rejected on the grounds that it would cause wasteful duplication and would initially be more expensive, and also because a child's health has to be considered in the context of the family. And it was this belief that a child's health should not be considered in isolation from its family which led the Committee to recommend the third possibility, that the first line of care should be provided by general practice and health visitors. From these two sources families will get advice, support, care and treatment for children, both at home and at school. There are good reasons, too, for looking to general practice—for a start, because of the trend towards group practice. Then there has been the emergence of the primary health care team, where doctors, health visitors and social workers work together. And, lastly, there is the developing concept of general practitioners having a special interest in a particular facet of health care.1610
§ I have mentioned the confusing pattern of services which families have had to face. The other, and possibly more serious, problem has been the lack of training in child care. The paediatrician in this country is a hospital-based specialist: there has never been any requirement that doctors dealing with children at the primary care stage—that is to say, general practitioners and clinic doctors—should have any specialist training for their work. Given the present state of knowledge about the management of acute illness in childhood and the preventive aspects of child care, the Committee considered the gap between the existing state of knowledge and its application was too great to be tolerated. Their proposals, then, depend on the training of all doctors dealing with children, and they have recommended the concept of a general practitioner with a special interest in children becoming more formalised, both in training and in organisation. This doctor would be general practitioner paediatrician.
§ This, then, is the main recommendation of the report and one on which the Government must decide with all speed because a decision is urgently needed to end the uncertainty surrounding the future of the pre-school and school health services and the position of the doctors working in them. We have a fine tradition of preventive medicine; it must not decline simply because of uncertainty. Much will depend on whether general practitioners themselves accept the ideas put forward. I recognise that it is a challenge, but it is one I hope they will take up. The report recommends a review of progress after a period of five years, which is a long time in the life of a child.
§ The concept of specialisation—the general practitioner paediatrician—is one which the Committee would also like to see in the health visitor service; the child health visitor would care for the children of the practice as a member of the primary care team. The role of the health visitor, providing a service devoted to the prevention of illness and the support of families, has always been of great importance to families in this country. It has also in the past been the service which went out to find children in need, and the Committee feel that this aspect of the health visitor's work should be strengthened.1611
§ Not all families understand or appreciate the value of a visit to the clinic. The story of the Christmas card sent to the welfare ladies but addressed to the "warfare ladies" may indicate a greater state of alienation than actually exists, but the fact remains that the service has to be provided in terms which are acceptable to its clients. No matter how good a primary care team is, it will be of value only if the children are brought into contact with it. At the moment a substantial proportion of children, possibly 10 per cent., slip through the net and are never seen by a doctor except when an emergency takes them to hospital. The Committee want to see a service which reaches out to find its clients.
§ I have been talking about the situation when the child is growing up in reasonable health and is developing normally; but, of course, a large number of our children have some kind of handicap. No separate service has ever existed for them and their needs have always been met by a mixture of general practitioners and hospital specialists, and by the facilities for special education which local authorities provide. Parents of handicapped children do not see their children's needs as being separated into education, health and welfare; but those are the services they are offered— and often very little communication exists between them. The Committee's proposal for a district handicap team, where all the caring professions combine to offer a service to a family, reflects their belief—and my own feelings, too—that more co-operation between professionals would result in a better service for children.
§ One member of this district handicap team would be a consultant community paediatrician, who would have responsibility for special schools in the district. This concept, of a specialist who does not restrict himself to the hospital but is part of the community and provides advice at the point where it is needed, is an essential element in the organisational proposals. I, for one, welcome the idea which recurs constantly in the report, that health care should be provided at the point where the patient needs it.
§ I come to the last point I want to make about the report. Central to the thinking of the Court Committee is the belief that children have special needs which they 1612 cannot articulate for themselves, and society, therefore, has a duty to ensure that these needs are identified and cogently represented. The members of the Committee asked themselves this question: "Who speaks for children?" No very satisfactory answer was forthcoming. There are certainly many bodies concerned with different aspects of children's interests and needs, but for three years this Committee have been working to consider the whole child.
§ On the Committee were representatives of the medical and nursing professions, of social work and education, and of parents themselves; and they finally asked themselves whether a body with a similar breadth and depth of experience should not continue to examine and represent the needs of children—educational and social, as well as medical and nursing needs. "Whose job," they asked, "will it be to see that any of our recommendations that are accepted will be carried out? Not just as elegantly-worded circulars of advice and direction, but actually in surgeries and clinics, hospitals, schools and homes—and in the spirit we intended?" There seemed to be no group they could turn to to take on this task.
§ Aware of the danger of proliferating national councils, the Committee looked at means of creating a powerful national group speaking for children within the existing framework of advisory bodies. The result is their recommendation that a joint committee for children should be formed. Such a committee—a joint subcommittee, in fact, of the Personal Social Services Council and the Central Health Services Council—would constitute a unique bringing together of figures of outstanding ability with the purpose of providing a national forum where the quality and development of services for children would be kept under continuing review. This is an excellent idea, and the Joint Committee for Children is one recommendation that I feel the Secretary of State should accept and implement as a matter of urgency. At a time of economic retrenchment, not all demands can be met; advocacy is vital—and who is speaking for children? My Lords, I beg to move for Papers.
§ 5.56 p.m.
§ Lord REDESDALE
My Lords, I wish, first, to thank, as I am sure other noble 1613 Lords will, the noble Lord, Lord Lovell-Davis, for giving us this opportunity to discuss the Court Report. I wish, secondly, to congratulate Professor Court and his Committee on preparing and producing such a superb report, and I shall talk more about that later. I suppose I should declare an interest; as the noble Lord, Lord Wells-Pestell, knows only too well from previous debates about children, I have referred before to my own seven children and two foster-children, which gives me perhaps a disproportionate interest in the case and I must be careful not to talk in proportion to my interest in terms of time, otherwise in this mini-debate game of beating the clock I shall fall foul of the speakers who come after me.
I should like at the start to say that we on these Benches are rather proud to be associated with the report in that Sir Keith Joseph, as Lord Lovell-Davis said, instituted the Committee back in 1973, the opportunity being provided by the National Health Service Reorganisation Act 1973. The problem obviously existed then which prompted Sir Keith to put the Committee in hand, and the problem, as it appears from the report, is vast and obviously justifies his care at that stage. Talking of care, it is obvious that we all, in all parts of the House, care very deeply on this subject. I know the interest of Lord Wells-Pestell from the past in talking about these issues and that of Lord Lovell-Davis, and the fact that his wife took part in the Committee means that she should share in the praise of the report.
It is a superb report; in fact it is a superb consultative document, based on what one can only describe as a veritable inflation index to a fortune of information, so much so that some of us who have had to try to read through it are almost frightened by the total amount of information that is available, and this gives us much to work on in future. It shows up some very frightening facts, some of which Lord Lovell-Davis mentioned in depth.
Two points come right out at the start, putting them slightly differently. One is that 3,000 babies die needlessly each year. That sounds a cold statistic, but imagine if a hospital went up in flames and 3,000 babies died on one occasion: the outcry 1614 would be stupendous. However, because it happens over a year and because the causes are diffuse, it does not have the same publicity as would a single holocaust. Nevertheless, it exists and the report has thrown it up. It has also thrown up the fact that we are falling behind in real terms. The infant mortality rate is dropping but it is not doing so nearly as quickly as in other countries. We have been overtaken by such countries as France. Clearly, something has to be done about that.
Another area which I know only too well is the subject which hides under the rather innocuous title of "non-accidental injuries". One of my foster children was a battered baby and one can see the effect in terms of vision and paralysis that one blow can cause. As the noble Lord said, 5,000 are affected, and 1,000 of those have serious injuries, not to mention the 100 or probably more who actually die. Those cases do achieve the publicity of a Maria Colwell. Something has to be done. There is no simple answer; there are so many factors that affect that particular area.
The report also covers every other aspect of the child's health throughout its life. It does not deal just with those who die or who are handicapped. I feel that it does its job so well that it is pointless for us to discuss in detail each individual point. However, I should like to touch on some. Because I have an interest in autism, I immediately looked at that part of the report. I wanted to see what was said about handicap. Again, as with every other part of the report, I was most impressed with its findings and recommendations in terms of the handicap team and on other points.
The report lays enormous stress on prevention as well as on cure. It goes into great depth as regards a rationalisation, in terms of creating the child health visitor instead of having two separate sectors of health visiting and of treatment. This would seem eminently sensible, as also is the general practitioner paediatrician scheme. The CHVs are, as it shows in the report, a rather interesting development from the original concept of Florence Nightingale in 1867 of the "health missioner". I found this fascinating, for the report goes into the history as well as the present situation and does it in such a way that it is quite obvious that it has 1615 been written with enormous care and understanding. In fact, I think it one of the most human reports I have read in a long time.
The report also made a point about personal responsibility and it is that area which it highlights because it is so practical. The problems of area and class have already been raised and it is quite clear that in one of these areas—infant mortality—deaths could be reduced greatly if education were increased. But let us remember some of the problems that exist at the moment. Anybody who has had anything to do with pre- and post-natal clinics will know that they are hard to operate in terms of staff and that the mothers who come, and who may often be working or have other children, are hard pressed for time. They cannot afford a lot of time and when a mother goes to a clinic like this she tends to have to sit and wait too long. It is not surprising that the attendance at such clinics is not as great as it should be and that therefore the level of education is not as high as one would wish. It is understandable, but I believe that the scheme will have to be changed so that, as the report recommends, the system can be tailored to fit the needs of mothers who have other children or other responsibilities. In that way the mothers can be brought into the clinics so that they and any children that they have in the future can benefit.
The other evening at dinner, I sat between two distinguished members of the medical profession. On one side of me was Sir Wilfred Sheldon who was responsible for the 1967 report. An aspect of the Sheldon Report which is touched on in the Court Report is that, under the former committee's terms of reference, it was prevented from considering schools. The present report had a much wider brief and it is extremely sensible that this should have been the case because if we are to have a service it should be comprehensive and integrated. While talking to Sir Wilfred, he pointed out that on my other side sat Dr. MacDonald Critchley, who is just writing a book on dyslexia. He had written it in a week, which impressed me greatly. The point that Sir Wilfred made was that there are a vast number of aspects of child care. For instance, he did not know about the book which 1616 Dr. MacDonald Critchley was writing, which emphasised the point that a great many people are involved. Sir Wilfred pointed out that, supposing one had a college of child development, a horrifying number of people would have to be brought in. This service brings in a vast number of people.
Very briefly, because I see that the clock is starting to beat me, I should like to say that the Joint Committee for Children is an excellent recommendation, though I feel that, as it is proposed, it may not have quite the strength necessary to implement the scheme. I know that some people talk about a Minister for Children; I think that that is going far too far, but I feel the Joint Committee may not be quite strong enough to get its views across as it is simply a sub-committee.
So as not to cheat and take more than my fair share of time, I shall conclude by considering what is to be done. Chapter 22 lays out the priorities and expresses it rather delightfully under the heading, "High priority recommendations without major resource implications". Those must be words which will be attractive to any Government. Clearly, the Government will have had little time fully to consider such a major report and I believe that it is unfair to expect instant action. However, I believe that all of us wish to see something implemented and to see a plan which will go on over the next 10 to 15 years, so that, as resources become available, we actually achieve something. On that basis, the major implications are capable of implementation fairly quickly. I am glad to see that the DHSS has called for comments from all interested parties by 1st June. That is a good step and will take matters on their way, and I hope that we shall get a White Paper on this subject when the whole matter has been studied.
In conclusion, I feel that the National Health Service as a whole requires a fairly strong dose of rationalisation. I think that it may perhaps be in danger of a coronary caused by its arteries being blocked by too much bureaucracy. Let us learn from this report and let us hope that when its recommendations are implemented it is done in as streamlined and as logical a way as possible, with the element of bureacracy kept to a minimum so that the system works as effectively as it can.
§ 6.10 p.m.
§ Lord AMULREE
My Lords, I should like to join the noble Lord, Lord Redesdale in thanking the noble Lord, Lord Lovell-Davis, for introducing the Court Report for our attention now, because, although it is a rather lengthy report, it is one of the most readable that I have seen for a very long time and I have taken a great deal of interest in it. The other great virtue of the report arises from its comparison with other reports affecting the National Health Service, which have been implemented on the spot. I am thinking, for example, of the Salmon Report on nursing, which has done a great deal of damage to the nursing profession, and the Seebohm Report on the social worker service, which I believe to have done some good but a great deal of harm to the personal social worker services; whereas the reorganisation of the National Health Service several years ago has been admitted, even by its supporters (the American firm) as being a mistake.
The Court Report deals with many matters about child health, with which I think one can be in general agreement. But one matter which I am not entirely sure about is the paediatric general practitioner. I know that this has been the dream of the paediatricians for a very long time, but because paediatricians dream of it it does not necessarily mean that they are correct. At present there is ' only a relatively small proportion (17 per cent.) of general practitioners working in group practices which would be big enough to employ a paediatrician of this type, whereas a further 20 per cent, work by themselves.
Generally, in the past, where there has been a "biggish" group of practitioners practising together each of them has developed a special interest. I am sure that it has been found that among big practices there is generally one practitioner who has taken a special interest in paediatrics and the care of children, and he would be called in by his colleagues if something particularly difficult arises to see whether or not there is need to bring in a consultant. Most of these people who are interested in the care of children have probably had some experience in working in a hospital in post-registration, which Professor Court suggests they should do before they take up this work.
1618 But I think that one must be rather careful about the way in which general practitioners are used if we are to continue to have them. It is a great advantage if a young person, a child, who comes under the care of a practice so long as he remains in that part of the country (of course it is a different matter if he moves away) should be seen by the same general practitioner from—I was going to say birth to death, but that is taking a rather firm view about the matter. But certainly he should be seen by the same general practitioner over a very long period.
At the same time I think there is advantage in general practitioners taking care of the whole family and not concentrating on a particular member of the family, such as a child up to the age of 14. I agree with the noble Lord, Lord Lovell-Davis, and what is mentioned in the report to the effect that the infantile mortality rate in this country is not as good as it was, as compared with other countries in the civilised world. But I think that general mortality among children under 14 has fallen steadily over the last 70 years, and I hope that we shall be able to pick up on the infantile mortality rate what we appear to have lost.
Professor Court says that the number of extra doctors required for the implementation of his recommendation is under 2,000. I call 2,000 quite a big number and they are going to be very expensive, but the money side of it does not really come in now. I was very pleased that the Committee repeats several times that they want to create a preventive service and that is really what we want to concentrate our attention upon. There are one or two concrete suggestions that they make which I think every thinking doctor would welcome. One is the increase in the number of speech therapists. These people can do an enormous amount of good for children, and their numbers are very under strength at present. It is important, I believe, that there should be a careful system of records worked out which will not be too complicated to operate. Even good general practitioners become rather tired of keeping too many records and they do not all have the secretarial help which is required. Where careful records have been kept, one has seen that they can be easily placed in the years to come, and they form a very good 1619 background to knowledge of a patient who was first seen when young; this knowledge can be used in considering how the patient is to develop when he grows older.
I do not want to say much more, but I believe that there have been several advances in the care of children over the past few years. One of the most important was the setting up of the Attendance Allowance Board, of which I had the privilege to be chairman for a period of six years, whereby it was possible for a family with a child who is handicapped, either physically or mentally, to receive a weekly sum of money tax free, to help to take care of that child and so keep him in their home. I am sure that most children should be kept in their own homes, and the fewer that have to be put into care or custody with either the local authority or the health authority, the better it is for everyone.
Another matter where I believe there is a great deal of promise in the future is in genetic counselling, and by that I mean carefully inquiring into the incidence of certain congenital killing, incurable and long-suffering diseases, such as the various dystrophies which in the course of a year kill a significant number of children or young people. If this could be developed—and it would not be very expensive—it might be possible to reduce very considerably the incidence of these diseases, which are very distressing both to the parents and the children involved. As they begin to grow up such children find that they cannot do what other children can do, and this certainly raises difficulties. My Lords, I do not want to say any more, other than to thank the noble Lord, Lord Lovell-Davis, once more for bringing this matter forward, and to thank Professor Court for having produced such an extremely good report.
§ Lord WINTERBOTTOM
My Lords, before the noble Countess, Lady Loudoun, speaks, I should like to point out to your Lordships, with respect, that a fair ration for each speech is 10 minutes.
§ 6.19 p.m.
The Countess of LOUDOUN
My Lords, I, too, welcome this report which is so informative that I wonder whether we can do it justice in a mini-debate. I 1620 shall confine myself to a few remarks on the services for emotionally disturbed and mentally handicapped children. The report proposes that of the 6,000 mentally handicapped children at present languishing in hospitals, at least half should be accommodated in local authority hostels. These children are not ill. They are not now seen as medical cases, and it is generally accepted that they can be helped. Surely this recommendation should have top priority, and pressure must be put on local authorities to stop using mental handicap hospitals as dumping grounds for children for whom they have failed to provide care in the community. But to bring these children out the parents will need the full support of all the back-up services.
Over the last few years we have gained a great deal of knowledge of how parents can be made to help, and, using new techniques, progress can be made; but this knowledge needs to be spread much more widely. Here I should like to mention Honeylands, a project in Devon, and the consultant paediatrician there, Dr. Brimblecombe—a truly remarkable man. Honeylands provides a day and short-stay residential care for severely handicapped children, and I think that the two things which impressed me most about this project were, first, that training the parent to look after her handicapped child often started from as early as a few weeks after birth, or at least as soon as the handicap was diagnosed. The other thing which was outstanding was the co-operation between everyone involved, at all levels.
Also, by taking in children for short stays this project enables parents and families to get a rest, after which they are able to continue, thus obviating the need for permanent residential care. As I have said, this is a joint project, and the Area Health Authority provides help with travelling to the unit, without which some parents would be unable to take advantage of the facilities at Honeylands. As paragraph 14.54 of the report states, it is the Committee's view that:each health, education and social service authority should assume responsibility for ensuring that transport, if necessary, is provided for handicapped children and their parents when attending their services".I was pleased to see that the first recommendation in the specific chapter on handicap is that the Area Health Authorities should undertake their own surveys of 1621 handicapped children to obtain appropriate data on which to base services to meet local needs. This seems to me to be most important if wastage of precious facilities is to be avoided. There is disquiet in some quarters over the manner in which various aids are supplied to children, and I hope the DHSS will look into this. To quote the report:It is a short-sighted policy, after money and effort has been spent on treatment and social education, to fail to equip a handicapped child so that he may fully exploit his limited opportunities".Children's health needs to be looked at in the much broader context of society's problems. I think it comes over very clearly in the report that there is a necessity for community services and multi-disciplinary teamwork. Too often there are fundamental and divisive differences in attitudes and methods of work among the various professional groups. There must be liaison and active co-operation between the health and social services in all areas, not just in a few as at present. This could be done without too much expense and without too much upheaval. The last thing anyone wants is any more major change in the National Health Service. There are numerous variations from one area to another, and although Government policy is clearly laid down there seems to be no specific way in which we can get it implemented. The run-down of the large subnormality hospitals continues, but there is no clear evidence that the money thus saved is being put back into the community services, which would surely be the obvious thing to do with this whole new thinking on community care.
I should like to end with a quote from the report on the Court Committee's own picture of subnormality hospitals. They say:We have seen for ourselves how hollow the lives of these children can be. Early to bed and early to rise, with few toys and little education, and nothing to do at week-ends, their quality of life and standard of care are all too often subordinate to regimes and staffing dictated by the organisation of a large institution.We have also seen the caring devotion of staff struggling with professional isolation, as well as lack of facilities. The primary responsibility lies, not with them, but with an insensitive society which chooses to ignore the problem".
§ 6.25 p.m.
§ Lord VAIZEY
My Lords, I am indebted, with the rest of your Lordships' 1622 House, to my noble friend for raising this important report at this early date in your Lordships' House. The recommendations of the report will of course take many years to implement, and it is not necessary to expect a full reply from the Government at this early stage. My noble friend has fully explained the need for a new medical care system. I interpret the report as arguing that if their very bold proposal, placing enormous reliance upon the general practitioner, is not successful, then there really is no alternative to the creation of a full-scale paediatric service.
My purpose, however, in rising today is to draw attention to what I think is in the long run the most important part of the report; namely, the first chapter. In my judgment, this chapter may well be the most important single social document which has appeared for many years, because it describes in graphic detail the changing pattern of family life, which affects not only child health but also education and, indeed, the whole functioning of our modern society, not only as it affects the social services but as it affects the pattern of work as well. In this brief debate, necessarily, we have to be selective in what we say and speak very quickly, as I regret I am now doing, and I am therefore seeking the opportunity to highlight for your Lordships (for it is an extremely long report) certain points which I think should be taken into consideration by everybody active in public life when considering the various steps which have to be taken in public policy in relation to children.
The report points out that the fall in the birthrate is of fundamental importance in understanding what is happening in modern society, and that this fall in the birthrate is in some respects a manifestation of the growing importance which is attached to the life of the individual child. People have fewer children, but they respect them more. I am sorry; the noble Lord, Lord Redesdale, is giving me a nasty look. A hundred years ago a substantial proportion of the large number of children born to each family died young. Now, I am glad to say, child death is a rare occurrence, though the report points out, as noble Lords have also pointed out, that much child death and handicap could be elimiated by adequate health services. The report 1623 confirms the quite extraordinary difference in the experience of children born into homes where the parents follow professional occupations and the experience of children born into homes where the parents are manual workers. It is two-and-a-half times more likely that children of the latter group will die than children of the former, professional group. This reinforces the view which has come from the great educational reports in the past 25 years of the extreme differentiation which still persists in our egalitarian society. It persists, my Lords, in all countries, from Sweden to France, from America to Poland. It is a very difficult, perhaps an insoluble, problem.
The report draws attention to the fact that marriage has never been so popular as it is now. People are marrying much younger than they used to, and many more people are marrying. For example, the proportion of women aged 45 to 49 who have never married was 17 per cent in 1931. It is now only 7 per cent. And although the tendency to divorce has risen enormously—and a quick statistical calculation has shown me that, if we exclude the Bishops, something like 20 per cent of your Lordships have been through the divorce courts—most divorced people in fact remarry and reinforce the view that marriage may be unstable but it is extremely popular. Nevertheless, the consequence of much of this divorce, and also of the death of middle-aged adults through coronary heart disease caused by smoking and stress diseases, is to leave a substantial proportion of children in one-parent families; and, as our debate on the Finer Report showed recently, we still organise our society on the basis that all children are in a home with two parents.
I have given the noble and learned Lord, Lord Simon of Glaisdale, notice that I intended to refer to his eloquent speech on the Northern Ireland divorce Bill, which was introduced by the noble Lord, Lord Dunleath. Lord Simon drew attention to the horrid consequences for children of marriage breakdown. They are indeed often appalling, as we all know. But I think we should beware of attributing too much social ill to this particular social cause. What I would wish to say is this. First, the Finer Report and this magnificent report, the Court Report, show that 1624 most one-parent families do not result from divorce.
Next, the noble and learned Lord referred to the division of labour between husband and wife, the man being in employment and the woman looking after the children at home. This is no longer a true picture of family life. Thirdly, he referred to the problem of two-family husbands but, with great respect, that is an over simplification. What is clear is that the great majority of divorced women with children remarry; and although I regret the marriage breakdown, the evidence suggests that consequences are different from those which the noble and learned Lord suggested the other day. That is extremely relevant to the point that I should like to make now about the Court Report. It is very likely that in the modern home the mother will be working, and there is some evidence to suggest that in those homes where the mother is working the quality of care for the children is higher, as well as the physical conditions better, than in those homes where the mother does not work; so that we can no longer assume that there is the mother to take the child to the clinic, because the mother is at work and the family benefits from that work.
Nevertheless, in all homes there are certain major problems. One in 15 of our children are in one-parent families, and that is a major problem to which your Lordships' House has turned its attention in the past; but something like two-fifths of working-class mothers suffer at some stage from severe clinical depression. If medical science and the social services could alleviate this aspect of psychiatric illness, it is extremely probable that the conditions of stress and strain under which something like one-third of our children grow up could be alleviated very materially.
The family now, then—and this is the lesson that I take from this remarkable first chapter—is a much more complex family than it used to be, and our social services have not, I think, taken into account these fundamental changes in the family. As the report says, as a result of the housing programme most families now have their own house or flat, which is a good thing, but the consequence is this:mothers and their young children probably spend far more time alone together today than ever they did in the past, and very large numbers of young women live lonely and unhappy lives.1625 This seems to me to be extremely important. The girls concerned have given up a job, their careers are frustrated and they are bored and lonely. That is the other side of the apparently "happy" marriage to which the noble and learned Lord referred the other day as being the ideal which the divorce court should seek to avoid. Life is not as simple as it is sometimes thought to be.
What the report emphasises is that in this changed and complex pattern of family life, with marriage being very popular, but serial marriage far more common, with a substantial number of children growing up in one-parent families, with a significant number of children left alone for long periods of time with depressed and anxious young women, the need is vital for supporting services of great subtlety and care. This, it seems to me, points just as strongly to the schools as it does to the medical services and to the social services. It also suggests that we need very carefully to rethink things like advertising and television programmes which add to guilt and stress by suggesting that the norm is a two-parent family with the mother at home, not working, and with everybody enjoying radiant psychiatric health. This is no longer a true picture of our society, and it is no use trying to pretend that it is something that we are going to achieve by saying that we should like such a society. I do not want to give a picture of a society rent with psychiatric tensions and problems; but what I am suggesting is that there is some need to take account of this growing knowledge of the complexity of our social life.
What the report also emphasises is the growing significance of children in the lives of many people. In my view, this leads to recognition of the rights of children as individuals. Perhaps this right should be formalised by law, by the creation of officers who can argue directly on behalf of children even when those children are not subject to the care of a local authority. This I think is an important concept, not in the report, which needs thinking about; and something on which I should very much welcome discussion in this House.
In short, my Lords—and I have followed the noble Lord, Lord Winterbottom's earnest plea to the letter —I would commend this report to your 1626 Lordships as one of very great significance and, in particular, I should like to see a digest of Chapter 1 very widely distributed and discussed by all who are concerned with future trends in housing, employment, social work, health and education.
§ 6.35 p.m.
§ The Lord Bishop of CHELMSFORD
My Lords, I too rise to welcome this report. I welcome it first because it is community-based and has in mind an integrated community service in which the hospital, school and parents are not separated from one another but seen as a whole. I welcome it, too, because it is family-centred. It does not intend to usurp the responsibility of the family but to encourage it so that parents are better able to care for their own children. I welcome it also because it is child-centred. It recognises, as the noble Lord, Lord Vaizey, reminded us, that children have rights and sometimes those rights may militate against the rights of the parents. I imagine that in the debate to come erosion of parental rights will have to be watched. The rights of the children are of superior importance. They are individuals, as we have heard, and not chattels or playthings. Though we look back with horror to the days before the Factory Acts, it could be argued that children are perhaps at greater risk now than ever.
I am grateful to the noble Lord, Lord Vaizey—as I am sure your Lordships will be—because he has lifted almost entirely my next paragraph which was to underline the effects of divorce and the other factors that he mentioned which do mean that many children are going to experience stress complaints and psychological disorders in childhood and adolescence which are going to require first-rate, sensitive help; and hence I welcome the projected Child and Adolescent Psychiatry Service to replace the existing fragmented service. It also underlined the need for trained counsellors—and the word "trained" should be emphasised. I find there is a positive rash of organisations springing up offering counselling—sometimes, it seems to me, with very little training given to those who undertake this responsible service. Indeed, inexpert counselling for children and young people with psychological disorders can be dangerous in 1627 the extreme and we should therefore see that proper training for counsellors is provided.
I am depressed by parts of the report, those parts which the noble Lord, Lord Lovell-Davis, set up for us at the beginning of his speech. I too thank him for bringing this matter to our attention. It is unutterably depressing to know that one child in seven has a condition causing moderate or severe handicap sufficient to be a cause of concern to the child's education. It is appalling to learn of the great contrast in the variation of life expectation of children between regions in this country and between classes in this country. As the report itself says, the disadvantages of early life casts long shadows forward. I suppose in many ways it is easier to improve health services than the complex social factors which hamper a child's development. Certainly, this is a massive operation now to be mounted over the years. Dr. Tom Mayer in Medical News last month put it rather more harshly when he said:The recommendations would not effect a cure of what is in essence a social disease.But, my Lords, that is another debate.
§ 6.39 p.m.
§ Baroness FAITHFULL
My Lords, in initiating this debate the noble Lord, Lord Lovell-Davis, has provided an opportunity to pay tribute to the outstanding work of Professor Court and the distinguished members of his Committee. The objectives behind the recommendations in the report, as the noble Lord, Lord Lovell-Davis, outlined, are to provide a readily available and integrated medical service for children. The report emphasises that the service should be child-and family-centred, and that the role of the professional staff should not usurp the parental role.
The parents are the primary guardians of the child's health; and at a later date I must discuss this with the noble Lord, Lord Vaizey. I recognise that, equally, the child has rights, as has been said by the right reverend Prelate. We would agree with these precepts. It is interesting that such precepts are very much those stated in the Seebohm Report on the Reorganisation of the Social Services; namely, to provide a community based family-orientated social service. The 1628 Court Report with its wealth of information, much of it based on evidence given by nearly every relevant sphere and by individuals, has stimulated wide discussions.
Perhaps the greatest compliment one can pay to a committee is to probe the recommendations, call for clarification and, in some cases, be critical. In a group of general practitioners, as I understand it, one of them would specialise in medical work with children, carry out school medicals and act as medical adviser to the other doctors in the group on matters relating to children. This general practitioner paediatrician, as I understand it, would carry a case load of 70 per cent children. Does this mean that the general practitioner paediatrician would be unable to follow through the children on his list into adult life?
Furthermore, does this mean that the general practitioner paediatrician does not have as his or her patients the adult members of the child's family? To understand a child, surely a doctor must know the family. Does this recommendation not go against the family orientated service? I am not sure of the administrative arrangements concerning the designated child health visitors whose responsibility is for a geographical, territorial area which will inevitably be coterminous with a number of doctors; and will not her case load be more than she can carry? She is a key person in the situation but I am not sure that the duties allocated to her are going to be practicable.
The country, even under the reorganised Health Service, varies from area to area in its administration. In the area I know, and under a notable medical officer of health, a city of 110,000 population was organised into group practices each with a health centre, some purpose-built. The relationship as between the general practitioners at the health centres, the schools and the hospitals and the social services is on a very sound footing. On the other hand, in another large county the doctors, I am told, have resisted organisation in health centres fearing an encroachment of bureaucracy into their field. Again, the situation in the large industrial cities, the mining areas, is different and with different problems. Where there is good practice should it be disturbed, and should not the needs of each regional health board be looked at before overall changes are made?
1629 I support the concept of the legal rights of children. On page 276 of the report is recommended an enforceable medical without the removal of the child from home under the Children and Young Persons Act 1933. On page 152 is recommended allowing a child in school to be medically examined without the parents' permission. On page 138 it is stated that parents should notify change of address when claiming family allowances so that the area health board can be notified. While supporting these recommendations, it is hoped that they would be used sensitively and with circumspection. Seventy five per cent of parents co-operate with the medical services. Of the remaining 25 per cent., a large proportion are open to persuasion. It is only the small hard core to whom these recommendations of enforced medicals would apply; and while having this sanction, one would hope that it would not be used on a widespread basis.
Reference has been made to a council for children which should comprise the present children and family life group, a subcommittee of the personal social services council joined with the central health services council. I agree with the noble Lord, Lord Redesdale, in wondering whether this Committee has enough teeth. If it is to be a discussion unit, if it is to be another research unit, then I believe that it will not have enough teeth and that in some way it should be responsible to the Cabinet, to Parliament, so that recommended policies are carried out at the grass roots, so that the service reaches children in their own areas and that there is not just discussion at the national level.
The very first and outstanding chapter of the report has been referred to and I will not therefore refer to it again. But on page 4 it is stated that over the past 40 years there has been marked improvement due to the reduction of overcrowding, better nutrition, smaller and more "spaced" families as well as improved medical treatment. The improved health of children is achieved in part by constructive social policies, and improved medical services for children must go hand in hand with these improved social policies. I believe that if one is to have a council for children that council must not only look at the medical services for children but the social policies carried out or not carried out, as the case may be, in this country.
1630 May I touch on the question of training. The whole scheme recommended in the Court Report is going to depend on two things: one, a very deep awareness of the needs of children, and a very deep awareness of the needs of parents and training. I suggest that at the moment we are falling behind with the training of our nurses, with the training of the number of our doctors, and we are certainly falling behind with the training of social workers. I have been speaking for eight minutes and I have two more pages of notes which I shall not read. I commend very much the Court Report, as have so many noble Lords. I have asked these various questions and I hope that some day I may have an answer from the members of the Court Committee.
§ 6.48 p.m.
§ Lord ALEXANDER of POTTER-HILL
My Lords, you will not be surprised if I confine the few remarks that I want to make to the school health service, of which I have some experience. I gathered from the Court Report two messages. The first was that the Health Service had been overconcerned with the service and not sufficiently concerned with the clients, the customers. With that I find myself in complete agreement. Secondly—and I keep to the school health service—the weaknesses were that there was not sufficiently effective co-ordination between the various professional elements which were necessarily involved.
Thirty-five years ago we had a school health service which was effectively co-ordinated as part of the Education Service. My experience of the past 35 years has been to watch that Service become, in my judgment, increasingly unco-ordinated and less effective because of an over-concern with the integration of the health service—and the noble Baroness, Lady Faithfull, reminded me of a similar desire in the integration of the social services—and there has been a disintegration of the Education Service. Thirty-five years ago the school medical service in the city which I served was a part of the education department. The chief schools medical officer was on my staff. His nine doctors and 36 nurses were; the 39 welfare officers were also on my staff.
A good test of a service is when it is under pressure. I recall in December 1940 one 1631 Sunday morning being instructed to take care of 36,000 homeless people, with no previous preparation, to provide for emergency feeding services, rest centres, billeting and all that had to go with it. It was a task which, I say with modesty, I think we achieved very successfully, because we had nine doctors and 36 nurses who had been working in the closest co-operation with the teaching staff, not for a few months but for years. They were part of an integrated service. We had 39 welfare officers, and the billeting of 36,000 homeless people was completed in 48 hours, because they knew the homes in the area and could match those who required billeting with the homes which they knew.
What has happened since then? Here I am afraid I lay charges against the National Health Service. The maximum pressure was brought to bear from central Government that the school medical officers must not be in the education department; they must be under the care of the medical officer of health, who, let us face it, has different functions— we are talking about preventive medicine. Sheffield was indeed the second last authority which retained a school health service under the care of the Education Department; and the chief medical officer went to Birmingham, which was the last in the line. Pressures prevented that continuing.
What was the next stage? That occurred in 1974, when the National Health Service decided that they could not leave local authorities having anything to do with health. I wrote a minority report on the dangers to the school health service at that time in the Working Party of which I was a member, which feared the very things we are now discussing, the lack of effective co-operation and co-ordination, the inevitable problem of the conflict between curative and preventive services. I fear the Area Health Authority not giving the same priority to preventive service as to curative service; and this report follows completely that trend. I fear the proposals in it, hospital based. Why not, if you are dealing with handicapped children, base them in special schools which deal with those children? Why in hospitals? I sometimes wonder whether, in order to go forward, we may have to go back. I am myself not sure 1632 that we have not failed to recognise that the important thing is not the wholeness of the Health Service but that the important thing is the wholeness of the child.
§ 6.53 p.m.
§ Lord DAVIES of LEEK
My Lords, I sincerely hope that this magnificent report will receive the attention it deserves. I do not think that a short debate—that does not mean it is short on the quality of the speeches—is sufficient to do justice to the report. It deserves a full day, and perhaps two days, for a debate on the same scale as that we had recently on the Image of Industry, which was one of the best debates I have listened to in this Chamber. Having had more than 30 years' experience in Parliament and having sat on many Select Committees, how often have I, and others, seen the work of perhaps two or three years' duration debated, briefly, and then pushed into a pigeonhole and forgotten? I sincerely hope that, whatever may happen in politics over the next two years, this report will be debated and some of it, at least, implemented.
I wish to speak—and I will do it briefly because of the time factor—on the dental service. I would, to my noble friend Lord Vaizey, qualify a little, and I would even qualify to the noble Lord, Lord Alexander, the destiny of children since the 18th and 19th centuries. Look at the boys of today; look at the vagabonds at football matches; see the pictures in the Daily Mirror—they are about two stone heavier than their fathers were. Some of them have as many muscles as all-in wrestlers. They may be "Yobbos", but by God they are healthy ones! There is a problem because of the physical fitness, because of the feeding and the higher standards of life—and I agree with the noble Lord, Lord Vaizey, about cases where the parents go to work. See the food tables. I should like to quote from the report, at page 198:The School and Priority Service devotes five per cent of all sessions to the treatment of pre-school children and in 1973 78,000 were treated. In the General Dental Service in the same year over one million estimates for young children were approved"—that is a lot of work. The report continues:and nearly 500,000 of these related to treatment. Dentists are certainly giving time to this group but the need for treatment shows that present preventive methods are not yet effective.1633 That is the point just made. It continues:However, the 5-yearly surveys carried out since 1948, the last in 1973, show a considerable improvement in the dental health of five-year olds.I have made my point. They say the reason is not clear. I think I can add something. The reason is that the five-year old today gets pre-natal attention which is better than it was 15 or 20 years ago.
I think a tribute should be paid to the ugly ducklings of the school health service; namely, the cooks, who cook meals in the nursery schools and in the five-year-old schools. The qualified ones are now taking courses in diet and in the correct amount of carbonhydrates and calcium to give to the five-year-old. I hope to see a better training for many of those cooks. I hope that the parent teacher associations—I trust I am right about this, because I am speaking "off the cuff" without having enough time to study this marvellous report in full—also will make a contribution to the problem of the health of the school child.
I should like to spend my last few minutes speaking about the dental service. Unfortunately, we have not discovered a way to offer sufficient career opportunities to the dental student at university, who goes through the whole gamut and eventually becomes a consultant in the school dental service. The relatively poor state of dental health in Britain among our children after a quarter of a century of the National Health Service suggests that the approach to preventing and treating dental disease requires a major reorientation. That is a point which was made exactly, briefly but succinctly, by the noble Lord before he sat down. That can be done only if we get a dental system worthy of the country in which we are living. It is done in Switzerland, Sweden and even in Scotland, and we ought to be able to do it here. It is even done in Wales a little bit.
I suggest that if we can have nurses pumping things into us when we are in hospital—and we trust qualified SRNs—the dental profession should allow more women auxiliaries to come into their profession. In fact, in 1544 Henry VIII established a medical service and allowed women to play a part in it; so if he could do it, obviously the modern, well qualified, brushed-up dental service should not be 1634 jealous of a few nurses with a qualification equivalent to SRN coming in as auxiliaries to give attention needed for children's oral and dental treatment.
I should now like to draw attention to another job of work done by very responsible people. I refer to the working report prepared by Laurie Pavitt, who is a Member of another place, called A Challenge for Change in the Dental Services. He and the people with him, who are highly qualified, made the plea that ancillary dental workers should come into this auxiliary service for school dentistry. Much as I should like to develop this subject, and talk about the information I have gathered, that would trespass on the very important debate that is to follow and on the time available to my noble friend on the Front Bench who is to reply. Therefore, having made these brief points, I shall reluctantly sit down and await his reply.
§ 7.1 p.m.
§ Lord COLWYN
My Lords, I, too, should like to thank the noble Lord, Lord Lovell-Davis, for initiating our debate today. The report covers a very wide subject and I shall confine my remarks to my own speciality, and that of the noble Lord, Lord Davies, of dental surgery. As a practising dentist, I am clearly committed to the view that dental health is an essential ingredient of general health. I also believe firmly that the foundations of good health must be laid in childhood. This is true in most fields of health care, but especially important in dentistry. A national survey of child dental health, carried out in 1973, showed that by the age of 14 one child in 10 had lost four or more permanent teeth. From the age of six onwards, nine out of 10 children needed some kind of dental attention, because of decay, gum disease or growth irregularities.
The size of the problem is very daunting, and I welcome the way Professor Court and his Committee have recognised it. But I welcome even more one of their main conclusions, that immediate steps should be taken to introduce water fluoridation on a national scale, if decay is preventable, why is it not being prevented? If 8 per cent. of the people of Britain enjoy the 1635 benefits of water fluoridation, why are 92 per cent being deprived? Quite rightly, the Committee blame public apathy, minority prejudice and Governmental reluctance to impose a political solution.
Water fluoridation is one of the Court Committee's top priorities for improving child health, and without it Britain's dentists have no hope of coping with the problem of dental decay. The Government's recent decision to earmark funds to assist health authorities to pay the capital cost of fluoridation schemes was a helpful move. But I urge the Government now to do more, in the light of the Court Committee's findings. The opponents of water fluoridation have recently been questioning its legality and, although the Department of Health has assured us that water authorities are fully empowered to fluoridate, there is still much uncertainty. I suggest that the best end to this uncertainty would be a Government Bill to make fluoridation mandatory, immediately and nationally.
But preventive measures, although an essential first step, are not the whole answer to our dental problems. We must also strengthen the treatment services for children, in both general practice and the community health services. Most children receiving dental treatment are seen by a general practitioner—a family dentist who probably also treats the child's parents, and who can continue to treat the child later on in adult life. This is as it should be, with child care integrated into other general dental care. The child grows up with the idea of visiting a dentist regularly, and the dentist knows the parents and can discuss and explain the child's needs with them.
General dental practitioners currently provide about 10 million courses of treatment a year for children of 15 or under, and children make more frequent and regular use of the general dental service than any other age group. There is therefore no evidence that the general dental service fee system of payment has failed children by deterring dentists from treating them. But, equally, there can be no objection to the Court Committee's proposal that we should experiment with an alternative system, using capitation fees for child patients. As the Committee 1636 say, there could be readily apparent advantages if one practitioner in a group practice could provide total therapeutic and preventive dental care for all the children in an area. Many dental practices today are big enough for this idea to be a practical possibility, but we need to experiment to find out whether the financial details of such a system can be worked out satisfactorily.
I feel bound to observe, however, that the Department of Health's record is not good when it comes to investigating possible improvements in the dental services. As long ago as 1973, DHSS officials agreed to set up some experimental dental emergency centres, to assess the need for treatment at bank holidays and weekends. These experiments are still not off the ground, because of the Department's refusal to acknowledge the unsocial hours of dentists working in the centres. If the Department moves as swiftly on the capitation fee experiment as on the emergency service study, we shall be lucky if anything comes of it before the mid-'eighties.
If I may speak about the lack of an NHS dental emergency service for a moment longer, it is frequently children who are the victims of dental emergencies. It is often forgotton that over the last 25 years the dental profession has repeatedly declared its willingness to man such a service. But the service must be organised and financed by the Government since a dentist, paid only for work done, cannot carry the considerable costs of keeping his surgery open on the off-chance that a patient might appear. All the initiatives about setting up an emergency dental service have been made by the dental profession, and all the delays and obstructions have come from the Department. It is difficult to avoid the conclusion that, perhaps, the Department does not want an emergency service. If this is the case, then I ask the Minister to say so and stop the blame for its absence falling on my colleagues in the dental profession.
But to return to the principal question, most children are, and should continue to be, treated in a general practice environment with the rest of their families. But there are, unfortunately, children whose parents do not recognise or assert 1637 their dental needs, and for whom access to general dental service treatment is not enough. Their needs would go unmet without a service which sought them out and initiated care, as the school and priority dental service does. There are approximately 1,800 dentists now working in this service, inspecting about 5 million schoolchildren each year and treating about 1½ million. It is encouraging to find that their inspections show a declining proportion of children needing treatment—about 50 per cent today, compared with 70 per cent 20 years ago. But we still have a long way to go and it is right, as the Court Committee have recommended, that there should be a further expansion of this service. The Committee are also right to draw attention to the regional disparities in the provision of dental care.
Fortunately, however, there is now prospect of building up the school and priority service, and improving the dental services in deprived regions, without damaging the services for non-priority groups or the services in other regions. By international standards, and in terms of the ambitious aims of the National Health Service, Britain is very short of dental manpower. But during the last decade our dental schools have expanded by 50 per cent., and over the next 30 years or so we can expect a steady improvement in the situation, which will make possible a balanced development of the dental services. However, it is important to avoid over-reaction to the problems of children, creating levels of health and expectations which cannot be maintained into adulthood. This is the mistake which New Zealand has made, running an effective children's dental service, but without any public dental programme for adults to follow it up. The result is that New Zealand has an even worse level of odontolousness, or toothlessness, than Britain.
It sometimes seems that we are about to make the same mistake. At the beginning of April, adults will be required to pay substantially more for their National Health Service treatment—the second major increase in charges made by the present Government. As the British Dental Association say, in their evidence to the Royal Commission on the National Health Service, 1638It is hard to escape the conclusion that the Government is moving towards a dental service confined to the priority classes and recipients of social security grants.I strongly urge the Government not to cut back any further on spending in the adult dental services.
Finally, I should like to draw attention to the special, and now largely unmet, dental needs of handicapped children. The Court Committee recommended—and there can be no argument with this—that their dental care should be brought up to the level provided for other children and that in certain types of physical handicap (children suffering from heart or blood disease, for instance) the highest levels of dental health should be maintained continuously. For severely handicapped children, even simple dental treatment can entail great difficulty, and in certain cases, as the Court Report recognises, there can be serious risk. We should therefore be doing everything possible to prevent dental disease in such children.
There may perhaps be arguments against the general use in the Health Service of topical fluorides to prevent dental decay when a so much more cost effective alternative is available in water fluoridation. But in the case of the handicapped child an exception must be made. I ask the Minister to agree that topical fluorides and also fissure sealants should be available to handicapped children, through all branches of the National Health Service dental services, including general practice.
§ 7.11 p.m.
§ Baroness MASHAM of ILTON
My Lords, having just spoken in the last debate on integrating the disabled, I find that there are many aspects of this report on child health services which merge into each other. If you have a disabled parent or a disabled child, you have a family which must cope with the disability. I should like to thank the noble Lord, Lord Lovell-Davis, for initiating this most interesting debate. It is still too soon to have fully studied and digested the contents, but I hope that this debate will bring to the notice of many that the long awaited and most important report is now available. I should like to ask the Minister—and here I am seconding the noble Lord, Lord Lovell-Davis—whether there is to be made available a 1639 consolidated version which would fit the pocket of all who wish to read it and which would encourage some people, who may be frightened off by its size. This is already being asked for. Looking at the report as a whole makes me wonder whether or not the Government should make up their mind before any further reorganisation within the Health Service—if it is going to do away with one tier of administration—takes place. "Too much administration" seems to be the cry up and down the country. The present Government are not to blame for this problem.
The report brings to our notice that Britain is lagging behind several countries in infant mortality. This point has been stressed by nearly all noble Lords. I think that we should do far more about educating our society in health education and child care as a whole. We used to have a child care class at the borstal I visit, and this was a most popular and well attended class. I think in the school curriculum this subject ought to be included and that children ought to have the opportunity to take GCE in health care. After all, it is possible to do so in cooking and home economics. I should like to ask the Minister whether he does not agree that health care is more important for the good of our children and society. Having asked a Question on school medical records on 15th October last year in your Lordships' House, I am very pleased to see the recommendations on this subject in the report.
I am a member of a community health council and I agree with the suggestion that membership should include mothers of young children. I am the youngest female member of our community health council. I am well on in middle age and our youngest child is nine. To get young members to sit on any committee seems difficult, but it should be encouraged. I should like to take this opportunity of telling the Minister that our community health council and the district community physician have good communication and consultation. He nearly always attends our monthly meetings. I agree with the report that a consultant in community paediatrics seems an excellent idea and that he or she could be a much needed link with hospital and community. This post would, I feel, be of great benefit for handicapped children.
1640 The report states that the standard of diagnosis, assessment and care for children suffering from physical, mental or multiple handicaps does not reach that achieved by the National Health Service for the treatment of acute illness. I feel the reason for this partly is that interest in this subject has not been stimulated and taught in the medical schools and that the problems have not been brought out into the open but rather pushed into the background. Parents of spina bifida children are grateful for the services they receive in Sheffield where they see specialist consultants who are totally interested and help in all the problems. But in many other cities the services seem to be fragmented, with no special leader, and the parents feel neglected.
I was disappointed that the report did not include in the district handicap team physiotherapists, occupational therapists and speech therapists especially trained in work with children. I have personally witnessed the assessment of children by physiotherapists at the Great Ormond Street Hospital for Sick Children. They are the people who generally know far more about wheelchairs and other aids rather than the doctors or nurses. I would feel far happier if they were included in the team, because the correct assessment and reassessment of children who are growing and have a handicap is vital if they are not to become more deformed.
I applaud the suggestion, when discussing doctor and patient relationships, that there should be some open surgeries. How can parents arrange when their children are to be ill? Many parents who are desperately worried are rebuffed and it is no wonder that when this happens they prefer to use the casualty department of a hospital. But now so many of these have closed. I could not see a mention in the report of anything about the wonderful voluntary work which goes on in our hospitals. To give your Lordships an example, the League of Friends of Harrogate Hospital raised £4,950 last year to buy equipment for the maternity wards. Voluntary helpers, who play and help feed children, are a valuable part of our child health services, and I think that they deserve a mention.
I should like to bring to your Lordships' notice the different circumstances of the remote rural districts. Here there are still 1641 some single handed practices which cause great problems, tied up with practice area numbers. The district nurse has triple duties. She is a State registered nurse, a State certified midwife and a health visitor. How can she do more? In my health district we do not have one psychiatric bed and there is no community psychiatric cover. In our district general hospital many people are admitted for attempted suicide over the year. In six months there were 75 cases, and this is a hospital with only just over 300 beds. These poor, unfortunate patients are sent home, with no follow up, and many of them are young people with children.
These tragedies put terrible pressures on children. If only we had some trained psychiatric nurses working in the community and an extension of the crossroad care scheme, there would be an improvement. Also I think that we need some trained psychiatric social workers. I asked my area health committee about this and they said that they did not exist, but at King's College Hospital last night I sat next to one at dinner. I should be grateful if the noble Lord would give an assurance that the Government will not forget the special circumstances of the rural areas.
In ending, I should like to congratulate the report when it stresses the need for professional staff to work together. What could be more important than the DHSS and the DES working together over the problems of dyslexic children? At national level this seems to happen, but at district level there is a need for improvement. I should like to thank all noble Lords for their controlled speeches, as it is always a little nerve wracking, in a short debate, to be the 11th person in the batting order.
§ 7.19 p.m.
§ Lord WELLS-PESTELL
My Lords, my noble friend Lord Lovell-Davis has provided a valuable opportunity for discussion of the report of the Committee on child health services. It is just this wides-spread and informed discussion of the Committee's proposals that the Government are anxious should take place before they come to a decision on the Committee's major recommendations. There can be no doubt—and I say this most sincerely—that the Committee have provided a most challenging review of the child health 1642 services in this country. A debate provides me with an opportunity which I should like to take to thank Professor Court and his Committee on behalf of the Government, and I hope on behalf of all those who are engaged in child health services, for what is, as everyone has said tonight, a most comprehensive review undertaken in depth of the situation today and of the needs for the future.
The report indicates in no uncertain manner the strength and weaknesses of the existing child health services, and I believe that it serves as a signpost to the road ahead and for this the Government and my Department are very grateful. We acknowledge the immense value that the report will have on Government thinking and Government planning in the course of time. Therefore, I say to Professor Court and to those who have served him, it has been a volume of service to the community that cannot be adequately acknowledged by mere words, however carefully they are chosen.
I know that my noble friend Lord Lovell-Davis will anticipate some of the things I am going to say. He has had experience of being a Minister in a Department where so much needed to be done and sometimes it took so long to do it. He knows, of course, of some of the restraints with which we are faced at the present moment, and although I did not want to start by reminding your Lordships of the current severe constraints on public expenditure, I am encouraged to do so because the Court Committee themselves recognised that the full implementation of their proposals would have significant resource implications, particularly in respect of manpower and training, and would have to be seen as long-term objectives which could be achieved only over a long period as the economic recovery of the nation proceeds and the current restraints on expenditure can be lifted.
It is against that background that consideration of the report has to be given and it is with this knowledge in mind that one has to analyse and get certain priorities. I am fully aware of the fact that the report lists four high priority recommendations which the report says are "Without major resource implications". The first is the district handicapped teams, the second is the Joint 1643 Committee for Children, the third is the Children's Departments, and the fourth, the training and career opportunities for married women doctors. I want to say a few words about the second, because I gained the impression that my noble friend Lord Lovell-Davis, quite rightly, laid a good deal of stress upon the Joint Committee for Children, and I happen to know that his wife, who was a member of this Committee, herself feels strongly about it. The Government share the conviction which underlies this recommendation that only a combined approach from all the services concerned with children can bring about the improvements that we all wish to see.
At a meeting with Professor Court last June Lord James, who was then chairman of the Personal Social Services Council, expressed a general welcome for this proposal and I understand that the Council's Children and Family Life Group has already given some preliminary thought to how a joint committee might work. Your Lordships will appreciate that there are many other groups, not least the Central Health Services Council, which have not yet expressed a view, including the principal professional interests whose views we shall have to take into account when they are available. This is always one of the problems with a report of this kind which ranges over a wide area which has to take into account not only a number of facets but also the number of organisations, professional and otherwise, which are working in a field. I suggest it would be quite wrong for the Government to anticipate and precipitate certain courses of action until we have been able to draw on the wealth of experience and the fund of knowledge which is possessed in this country at the present moment.
I think the report will be talked about for years to come. I can foresee—and I say this with great respect—that it might even become the "Bible" of the children's health services in this country. It contains 670 pages of informed investigations and one might almost say (if I may use the word in an extravagant way) research. One is not going to be able to implement this report overnight. I am sure my noble friend Lord Lovell-Davis will understand that it is not possible for my right honourable friends, the Secretaries of 1644 State for Social Services, for Wales and for the Department of Education and Science, to reach any conclusions until the outcome of these consultations is known. However, there is one thing I can say to him. I can assure him that there will be no avoidable delay. At the same time it has to be acknowledged that many of the recommendations, particularly those which call for far-reaching changes in the organisation of primary health care for children, will have major implications for the staff concerned and that in any circumstances they could be embarked upon only after the widest possible consultation. I want to emphasise this because the question of consultation must be a real thing, it must have meaning, and it will take time. Unfortunately in a country like this where there are so many activities, all indirectly bearing on each other, one has to get a consensus, and that takes time.
In order not to lose the impetus given by the publication of the Court Report the three Government Departments involved, namely, the Department of Education and Science, the Welsh Office and the Department of Health and Social Security, wrote on the day of publication, which was 16th December last, to health and local authorities, to community health councils and some 140 organisations concerned in the care and education of children seeking their views on the report and asking them specifically for their reactions to the key structural changes proposed. We have asked those commenting to let us have their views by the end of June, and I can assure your Lordships that we shall take careful account of all the points that have been raised today in our consideration of the general reaction to the report. But bearing in mind that the report was available on 16th December, I think your Lordships will agree that we have not wasted any time. I do not believe we could have moved any more quickly.
In parallel with these external consultations, the Department of Health and Social Security will be attempting a more rigorous analysis of the human and financial resource implications than was possible for the Court Committee. It will clearly take some time after June to digest the results of these two exercises, but the Government hope to be able to make an announcement on their position as soon after June as possible. We are very much aware of the interest with which 1645 the report was awaited. We know of the interest that people in all walks of life have shown in the report, and we recognise that this long-awaited report emphasises the importance to child health services and those working in them of an early decision on the major recommendations. We shall do everything that is within available resources to ensure that the quality of services is sustained during any transitional period.
We believe, too, that prima facie there are recommendations which could be implemented with little or no additional resources, and I said a moment or two ago that we are looking at these. In seeking the view of the interested organisations and the field authorities, we have specifically asked them to tell us where they think there is scope for action in the short-term despite the existing restraints on availability and money. Noble Lords will also be aware that the Secretary of State for Social Services and the Secretary of State for Wales issued Consultative Documents on priorities for the health and social services last year, both of which identify services for children as among those needing priority over the subsequent three or four years.
It is our intention that the outcome of consultations on the Court Report should be taken into account along with other factors in the preparation of subsequent plans for the development of the health and personal social services. Where the Court Committee have lent support to the proposals put forward in the Consultative Document we shall be taking their views into account wherever possible in the revision of the planning guidelines for health authorities in 1977/1978.
With regard to prevention, in his Statement on the report my right honourable friend the Secretary of State drew attention to one of the Court Committee's central conclusions, that much child ill- health is preventable. Your Lordships will know that the Government last year published a Consultative Document on prevention called Prevention and Health; Everybody's Business. Work is already proceeding on a follow-up paper which will deal specifically with services relating to pregnancy and childbirth, and which will emphasise among other things the importance of preventing handicap, whether of physical or emotional origin.
1646 We are also looking generally at ways of carrying further the initiatives already taken on preparing young people for parenthood, to which the Committee referred in their report. We must recognise, as they did, the difficulties in determining how far it is justifiable to promulgate a particular set of values and attitudes about what constitutes good parenting. This is an extremely difficult matter for a Government Department, and, as some of your Lordships will know, in debates last year we were faced with this difficulty of Governments, and Departments in particular, laying down what certain standards and attitudes should be. We will continue to encourage and support initiatives on preparation for parenthood from the funds available for research purposes, and relevant work is already being undertaken by other organisations, including the Health Education Council and the National Children's Bureau.
My Lords, since the publication of the Court Report the Department of Health has agreed with the National Association for Maternal and Child Welfare to assist in their work in providing education in parenthood for schoolchildren and expectant mothers and those with young children. In this they will be liaising with the Health Education Council. We also share the Committee's concern with the need to prevent handicap through pre-natal diagnosis. Research is already being undertaken in this field, and in particular we hope that in the near future a more widely applicable screening procedure will be available for screening for neural tube defects, including spina bifida. The Department of Health and the Welsh Office are at present jointly funding a feasibility study to ascertain whether it will be possible to introduce this test into routine ante-natal care.
In their report the Court Committee particularly emphasised the importance of the health visiting service, and we fully share the Committee's view of the vital role played by health visitors in establishing and maintaining contact between the primary health care services and families with young children, particularly the most vulnerable. In the Consultative Document on priorities in England, to which I have already referred, we propose an expansion of the health visiting services at the rate of 6 per cent per annum, to allow for improvements in monitoring child health 1647 and welfare and support to mothers, and in recognition particularly of the need for more home visiting to all children, and especially those of the lower socio-economic group. In case my noble friend Lord Davies of Leek asks me, when I say that the Welsh document does not give a specific figure for the rate of expansion, may I hasten to say that while it does not give a specific figure I know that a similar improvement is intended.
My Lords, I want to say just a word or two on infant mortality, because this is a matter, I know, of very real concern to the Court Committee, of very real concern because we have been over this ground once or twice in your Lordships' House. The Court Committee expressed particular concern about the level of infant mortality in this country, and my noble friend Lord Lovell-Davis also drew attention to it. We share their concern that although the level is being reduced we are not achieving the same rate of success as other European countries. The Department of Health is sponsoring a number of studies and research projects into the field of infant mortality and morbidity, aimed at trying to identify factors that will result in a reduction of the rate, and the Children's Research Liaison Group has a working group studying priorities for further research into this field.
It is so easy for some of your Lordships, and, if I may say so, for the vast army of people outside your Lordships' House, to think perhaps that nothing is really being done in this field. My noble friend Lord Lovell-Davis was quite right in drawing attention to the fact that infant mortality and perinatal mortality rate fell quite dramatically in recent years. However, we acknowledge that it is not good enough, that it does not compare with the fall in some other countries. But we must not labour under the misapprehension that it is because we are not doing enough. We have at the present moment working and researching at a number of hospitals and universities throughout the country multi-disciplinary teams concerned with infant mortality and morbidity. Each of these teams is led by an outstanding academic with medical qualifications. There are about 25 such persons scattered throughout the country in our hospitals and universities—18 of them professors—working day after day, 1648 week after week and month after month on this problem.
This problem is not something that we have taken lying down. It is something that the Government—and, to be quite frank, previous Governments—have been working on. A considerable amount of money has been made available. In August 1976 a circular was issued to the health authorities asking them to review their facilities for neo-natal care and drawing attention to the relatively high infant mortality rate in England and Wales. There is a limit as to what the Government or a Department can do. They can provide facilities, but in the last analysis one is dependent upon the good will and co-operation, which I think we get, of those who have to carry out the work.
We fully share the views of the Court Committee on the importance of the emotional and social needs of both the mother and her family during child birth and the post-natal period. We have supported a number of innovations in this field. We also recognise that sensitive support is required by a mother in handling her new baby and establishing breast feeding. Your Lordships will be interested to learn in this context that work is already in hand on the total revision and updating of a former Ministry of Health booklet called, Human Relations in Obstetrics, which discusses how a sympathetic and understanding approach to parents can best be achieved. The new version will be issued this year.
I turn to hospital services for children generally. Your Lordships will be interested to know that the Court Committee fully endorse the overall policy guidance issued to health authorities in 1971. Perhaps because there is such complete unanimity between the Court Committee and ourselves on this matter, I can remind noble Lords that that Committee fully endorse that policy guidance which recommends that, wherever possible, children should be treated in their own homes, and that where children are admitted to hospital they should be gathered together in a children's department.
§ Lord LOVELL-DAVIS
My Lords, if the Minister will give way, I think that it is stated in Standing Orders that the Minister should take 20 minutes. I consider that noble Lords who have taken part in this debate have been unduly hurried. I do not wish to press the Minister, but I hope he will give me time to reply.
§ Lord WELLS-PESTELL
Standing Orders say that the Minister shall have 20 minutes; they do not say that he should finish in 20 minutes, but I shall.
§ 7.44 p.m.
§ Lord LOVELL-DAVIS
My Lords, his debate has been of considerable value to the cause of improved child health services. Although I consider what I have just said to be the case, I think that as noble Lords were asked in the middle of the debate to speak for only ten minutes, several noble Lords tended to spoil their contributions. It is not quite fair that they should have been asked to do so.
The debate has been of considerable value and I am sure that there will be wide appreciation of the contributions made by noble Lords. As the noble Countess, Lady Loudoun, said, it is clear that a short debate does not do justice to this subject, which is really the subject for a full debate. All we have been able to examine during the last two hours and ten minutes is the tip of the iceberg. We must be allowed to take a much closer look at this very large subject.
I should like, if I may, to refer briefly to some of the matters raised by noble Lords. The noble Lord, Lord Redesdale, considered that possibly the joint committee for children, which the report recommends, will not have enough strength. But it will be in a very good position to draw together the three principal Departments concerned. It will have a direct line of contact to the Secretary of State. That is a considerable strength and something which does not exist at present. I am grateful for the contribution made by the noble Lord, 1650 Lord Amulree, who has had to leave his place. Despite his reservations about the general practitioner-paediatrician, I am pleased to know that he generally supports the concept of total care for the child. I agree with the point he made, that although the rate of infant mortality is very high—and it is a sad fact that we have slipped behind countries we once led in having a much lower rate of infant mortality—the fact is that the figure is much lower than it has been hitherto.
I am sure that we are all grateful for the remarks made by the noble Countess, Lady Loudoun, about handicapped children, and for the very forceful plea she made for a better organisation of services for them and for greater liaison between the health and social services. I entirely agree with the remarks made by my noble friend Lord Vaizey. I agree that the first chapter is an extremely important social document—one of the most important social documents produced in a long time—giving a remarkably full picture of family life at this time with, indeed, as the noble Lord pointed out, some surprises. It shows up aspects of social life that perhaps we are not taking fully into account. I also agree with what he said about the need for supporting services of considerable subtlety, and care from the school service as well as the medical service, and the extensions that there are into all areas of our social life which need closer inspection. I am glad of his support, and of the support from the noble Baroness, Lady Masham of Ilton, for the need to publish certainly Chapter 1, and possibly a digest which includes Chapter 1 and the principal recommendations.
I am sorry that the right reverend Prelate the Bishop of Chelmsford had some of his speech pre-empted by my noble friend Lord Vaizey, though no doubt the Front Bench in their hurry were quite pleased about it. I agree with the view of the right reverend Prelate that the report will not suddenly resolve all our basic social problems which go far wider than that. The report is an important step in that direction.
The noble Baroness, Lady Faithfull, referred to the difficulties facing the general practitioner-paediatrician in this case load, and wondered whether this would not go against the concept of the ability to 1651 maintain family care in the practice. An important aspect of this is teamwork and co-operation. This must surely be the aim and strength of the group practice. The noble Baroness also raised the point of whether the joint committee for children would have enough teeth. I hope that she will accept that what I have said makes a good case for this.
I am grateful for the intervention of the noble Lord, Lord Alexander of Potter-hill. Much of what he said must give us cause to think, and it is important. I think the report stresses, and he emphasised, that the wholeness of the child in totality is much more important than the wholeness of the National Health Service. I am also grateful for what my noble friend Lord Davies of Leek said. He pointed out that the five-yearly surveys show that there is an improvement in dental health. I agree that we have to get a better dental health service. It is clear that the service is not fully meeting our needs at the moment. I think in the report there is produced a statistic extrapolated from some figures, which indicates that out of a school population of about 9 million children 6 million need dental treatment in some form or another. The noble Lord, Lord Colwyn, carried this further. I agree with him entirely and with the Committee's report about the need for introducing fluoridation. I am perpetually surprised that this subject raises such controversy.
It is also true that there is a need for experimentation with alternate systems of providing dental care. Clearly, the financial aspects need to be carefully looked at, for these are an absolutely essential element in the mix. I agree with the noble Lord about the need for speed. Our dental services seem to me to be in complete disarray. I do not know how much longer we can put up with this situation, particularly as it affects children.
The noble Baroness, Lady Masham of Ilton, called for a cheaper report. She raised a question underlining the important matter of regional variations in the services. She also raised the matter of occupational therapists, speech therapists, and physiotherapists. There would be nothing to stop them being called into the district handicapped team, as I understand it. The team would be able to 1652 call in a number of different specialities. The noble Baroness said—and I am afraid I cannot recall the report word for word—that nothing was said about voluntary workers in the report. If it is omitted I am sure that that was not intended at all, and that no member of the Committee fails to appreciate the value of the voluntary worker. I accept absolutely what she said, emphasising what the report has pointed out, that there are wide and appalling variations in services in the rural areas, and a need for improvement.
My noble friend Lord Wells-Pestell said some encouraging and some less encouraging things about the report. I hope that the space of time in which it will have its effect on Government thinking will not be too long. As he says, it is not unexpected to me, as a one-time Member of the Front Bench at a difficult economic time, that reference should be made to resources. That is why the report, in its main recommendations, stresses the lower cost ones.
I am glad to know that thought is being given to the concept of the joint committee for children. Of course much has to be taken into account. I fully understand that. But we are talking about our children, and they pass through childhood very rapidly. How many generations are going to grow into adulthood before we stop talking and consulting, and take some action? Despite that, I am glad that the Department of Health and Social Services have called for views on the report. I hope that they will be able to collect them quickly.
I have no doubt that the DHSS are attempting an analysis of the implications of the report. I do not suppose that it was in fact the remit of the Committee themselves to consider the economic implication. My noble friend Lord Wells-Pestell says that people are taking the report seriously. I should hope that they are. The question still remains: what recommendations are going to be accepted and implemented by the Government? Without wishing to be in any way offensive to my noble friend, as might have been expected, his reply to the debate has been something of a curate's egg. In spite of this, I hope that the Government will act upon the report of the Court Committee, 1653 at least in implementing without undue delay proposals such as that for setting up the joint committee for children, and that outside the Government general practitioners and others in the medical profession will take up its challenge. I should like to express my thanks to those noble Lords who have participated in the debate, and to those who have attended it. Having said that, my Lords, I beg leave to withdraw the Motion.
§ Motion for Papers, by leave, withdrawn.