§ 2 pm
§ Mr. Andrew Lansley (South Cambridgeshire)
I am very grateful for the opportunity to debate this important subject this afternoon. Some Members present have participated in previous debates on the subject and it will not have escaped their notice that I have already raised the issue several times, most notably in last year's debate on the Kennedy report on the Bristol royal infirmary inquiry, in a subsequent debate in the Chamber on maternity and child health services, and in questions in response to Lord Laming's report on the Victoria Climbié inquiry. This debate provides me with slightly longer than those debates afforded to set out some of my views on how we are developing children's services, and to ask the Government questions about how the various initiatives will fit together nationally and work, with particular reference to my constituency by way of illustration.
It may be helpful to begin by setting out the context. We should not forget the good news on children's health: infant mortality rates have been reduced and the incidence of sudden infant death syndrome is about a quarter of that 20 years ago. Children are healthier than ever and deaths arising from some common viral infections have been much reduced through immunisation programmes, but—there is always a but—we still have far to go.
United Kingdom infant mortality rates are still the second worst in the European Union. We have continuing childhood morbidity due to cancer and to injuries, especially in the home and on roads. There is a rising prevalence of diseases such as asthma, which is now the most common chronic disease. There are also major inequalities in children's health care: some 750,000 children live in poor housing, and poorer children are 10 times more likely than others to die from severe head injuries and 15 times more likely to die in a house fire.
Despite health promotion strategies, we are seeing a worrying incidence of some factors that will lead to substantial illness and disease in later life. An example that is the subject of attention is obesity among children, which is an increasing problem. In a speech in January, Professor Aynsley-Green described it as a pandemic that could lead to a dramatic increase in disease in future years if unconstrained.
The British Medical Association is reportedly proposing today that fatty foods be taxed by doubling the VAT on them. I confess that that strikes me as an ill-judged response to the problem, as it would be likely to have severely regressive effects on the income of poorer families. However, I will not dwell on that proposal.
As a consequence not least of obesity, there is a rising incidence of type 2 diabetes. Despite anti-smoking strategies, many young people continue to smoke, especially in their teenage years. Binge drinking is getting worse, and there are attendant diseases. There are also diseases attendant on drug taking and a rising prevalence of mental illness among adolescents and the young.
There are still problems in the system, such as shortages in paediatric specialities, a shortage of specialised nursing staff, gaps in the public health and 200WH preventative strategies due to lack of resources, and—the substance of most of my argument—the lack of a coherent, child-focused and accountable service for children, which has been much sought after for many years.
The historical context of my remarks will be familiar to those who participated in the report on the Bristol royal infirmary inquiry. Indeed, over the years, there have been many reports on the provision of children's health services. At page 416, the Kenney report states thatit is a remarkable feature of children's healthcare services that, over a period of 40 years, successive independent reports have made the same or similar recommendations.At page 417, it says:Remarkably, some would say scandalously, despite the consistency of these recommendations over such a long period of time, there has been an equally consistent failure fully to implement these fundamental principles, a failure which continues to this day.Professor Kennedy referred to the 1959 Platt report, the 1976 Court report, the 1991 Department of Health guidance, the 1993 Audit Commission report and Health Committee reports on children's health services before the 1997 election. Since the election, we have had a range of further reports, which are giving rise to a renewed focus on how we deliver children's services. That is what I shall focus on.
Those reports are consistent in stating that we need a child-centred approach. They say that we have to understand the family context for supporting children in their health needs and that we have to take a holistic view of children's needs, which is not to allow the hospital or other agencies to see children's needs only in the institutional context, but to consider the whole child in the child's context. They say also that we need greater community-led services, because hospitalisation has to be the exception for children, not the rule.
Requirements for specialisation and expertise were reflected in the six principles listed in the Audit Commission's 1993 report. They are child and family-centred care, specialist skilled staff, separate facilities, effective treatments, appropriate hospitalisation and strategic commissioning.
§ Miss Julie Kirkbride (Bromsgrove)
I congratulate my hon. Friend on securing this debate. Sadly, I cannot be here for all of it, because of Select Committee commitments. I wonder whether the list might include a particular focus on foster children and children who are adopted. I know from my constituency work that their needs are much greater. It not just that social service provision is inadequate. For example, I know of foster carers looking after two children whose parents had died and who were traumatised by being split up. The foster carers cannot get a bigger house to accommodate both children, but they are clearly doing good for society and for the children. Should such issues form a separate plank in that list?
§ Mr. Lansley
I am grateful to my hon. Friend. I recently secured a debate here on the film industry—a subject in which I am interested and one that, if I understand her correctly, she will be pursuing this afternoon.
201WH My hon. Friend makes a good point. I had the privilege of joining a number of foster carers who visited Parliament a few weeks ago, during foster care week, to discuss the provision of services and what support is needed. It is not that children need additional care in the wake of the Adoption and Children Act 2002; their needs should be seen in the wider context. For instance, my recollection is that about 30 per cent. of children in foster care do not get the appropriate immunisations. [Interruption.]If I am wrong, the Minister of State, Department of Health, the hon. Member for Redditch (Jacqui Smith) will correct me.
We need to be sure that children in foster care and those looked after by local authorities are looked after in the wider context. It is not enough simply to get a good placement with foster parents. The foster parents need support and vulnerable children—those at risk even more so—need the connections with other agencies that would help to achieve the holistic view of children's needs. That reminds me of my first opportunity to discuss the issue in the House. I think that the Minister and I were members of the same Select Committee, where we considered children who were looked after by local authorities.
§ The Minister of State, Department of Health (Jacqui Smith)
§ Mr. Lansley
Perhaps not. I am trying to remember the dim and distant days of 1997 and 1998. However, that experience provided the base for my intentions in children's policy.
As I was saying, the Kennedy report picked up on the Audit Commission principles, saying at page 419 thathad the principles set out in the DoH's 1991 guidelines and the Audit Commission's report been implemented in Bristol, a good number of the shortcomings in care would have been addressed much earlier.The problem is that there has been a persistent failure to implement those reports in the national health service. We must all admit that, in practice under successive Governments and over many years, children's services have been seen as a Cinderella service in the NHS and that the specialism or institution has tended to focus on care rather than the children. Children's services have been the add-on, rather than the focus of specialist services, and children have been regarded as small versions of adults, with smaller beds, smaller portions of food and smaller doses of medicines that were licensed and intended for adults. That needs to change.
§ Sitting suspended for a Division in the House.2.19 pm
§ On resuming—
§ Mr. Lansley
I was suggesting that the Kennedy report is illustrative of previous reports on children's health care services. It is certainly not alone in commenting on the fact that the intentions behind children's services were not reflected in the quality of provision. For example, Lord Laming's report on the tragic murder of Victoria Climbié is also characterised 202WH by the understanding that institutions and agencies chronically failed to provide the standard of care expected of them. Similarly, individuals in those services failed to adhere to the good practice expected of them.
Neither the Bristol royal infirmary case nor that of Victoria Climbié can be described as resulting from a failure to provide the necessary resources. In both, the available resources were broadly equivalent to those elsewhere. Good practice was being achieved in other parts of the country, but practice in those two cases was poor. I shall return to that issue, but we must recognise the fact that, to a large extent, we are discussing organisation, good practice and co-ordination, not resources.
Let me summarise the issues that I hope to address. The first is why we have failed to implement the recommendations in the range of reports on children's health and how we ensure that that does not happen with the latest reports by Kennedy, Laming and others. Issue No. 1 is therefore about a commitment and sustained follow-up to the Kennedy report.
Issue No. 2 relates to implementing reports in practice. How do we create a reformed structure for children's services—one that is child centred and focused on children's needs? How do we ensure that high standards of care are integral to its functions? How can we make such a structure managerially focused and accountable for its priorities and the quality of its practice?
The context for all that—the material from which I am working and the developments that I have in mind—includes the Kennedy report and the Government's response to it; the First module of the national service framework, which was published in April; the reconfiguration of acute hospital services for children; Lord Laming's report on the Victoria Climbié inquiry; the establishment of children's trusts and, as a tangent to that, the Health and Social Care (Community Health and Standards) Bill; and the prospective content of the Government's Green Paper on children at risk.
The Government accepted the bulk of the Kennedy report's recommendations, but the Minister will recall that several were not accepted. The decision on them was deferred and 17 months have passed. I am talking particularly about recommendation 167 and recommendations 172 to 176, which deal with setting standards for children's health care services. I also have in mind recommendations 177 to 183, which deal with planning the future of children's health services.
Some of those recommendations have been acted on, and we now have the national clinical directive for children. In that respect, I had the privilege of meeting Professor Aynsley-Green last year to discuss the work of the children's taskforce and the preparation of the national service framework. We have the first module of that framework, which indicates the character and standard of the work that is expected. As things stand, however, the framework's 10-year timetable—standards have to be met in 10 years—does not make clear what should be happening at intermediate points. What is the timetable during those 10 years? How are individual institutions to interpret what standards are expected of them at intermediate points? I am not clear, for example, what specifically is asked of health service bodies in the next three years under the improvement, 203WH expansion and reform programme, and what precisely is to be included in the performance indicators that will form part of the performance assessment.
The national service framework, as published so far, does not appear to set out a programme to establish those standards, starting from where we are now, but it gives an aspirational picture. Other national service frameworks—the Minister is perhaps more familiar with those than I am—such as that relating to older people and strokes set specific deadlines by which key elements of the standards should be achieved and indicative timetables for achieving those standards. At the moment, that does not appear to be the case with this national service framework, and I believe that such indicators should be included.
Recommendation 174 of the Kennedy report distinguishes between obligatory and aspirational standards—between the minimum standards that must be achieved to ensure quality of care and those that might be achieved over time with the changes that will take place in health service bodies, leading to a high quality of care. I understand that that distinction is connected to recommendation 183, which concerns the validation and revalidation of acute hospital services, and which the Government did not accept.
As I understood the explanation given to me by Ministers last year, that recommendation was not accepted because it was thought preferable to continue with such services and improve them, rather than lose them to the NHS because they had failed to be revalidated. However, that does not mean that there should not be a clear indication in the national service framework of the minimum standards that are expected. Through such minimum standards, performance indicators can be set which, if not met, will give rise to special measures and the intervention of the Commission for Health Improvement.
Recommendations 178, 179 and 181 concern the configuration of acute hospital services, which is not included in the national service framework. As I understood it last year, the intention was that the acute hospital services module would be published and that the configuration issues arising from it would follow. However, that seems not to be the case. Issues arising from the national service framework need that configuration guidance to be produced very quickly. The throughput of cases, the competence of staff and the assurance that staff dealing with children have the expertise as well as the specialist skills necessary to ensure a quality outcome are at the heart of the Bristol royal infirmary report.
If quality is to be assured in children's services through the national service framework, we need to know what will be recommended in terms of throughput of cases for particular specialisms and, as a consequence, the extent to which there should be a concentration of services in particular acute hospital environments. That example shows how children's services have not developed according to a focused, discrete understanding of children's medical needs.
A greater understanding of the need to integrate hospital and community care is also needed. For example, in what is proposed, I have not yet seen any 204WH guidance on the relationship between community paediatrics and acute hospital care. There are examples throughout the UK of community paediatrics services operating out of the acute sector, but in the national service framework it is not clear to what extent that is considered desirable. If children are hospitalised, there is a particular need for high-dependency care beds and paediatric intensive care units. Of course, the Government have been supporting that need with additional resources. There is a framework for that. However, we must identify the framework for the transfer of cases and referrals to hospitals that provide high-dependency care or paediatric intensive care. We do not yet know how far that will go.
Across the country, we see that the number of referrals due to constraints on local district general hospitals that undertake paediatric work is increasing all the time. There are examples across the country of hospitals not undertaking surgery that requires general anaesthetics for children under the age of two. That can lead to the referral of a significant additional number of cases to centres that offer high-dependency care or paediatric intensive care.
Those consequences flow from decisions that are continually being made in the NHS, which result in substantial increases in demand for work at certain centres. For example, Addenbrooke's hospital in my constituency has experienced a 13 per cent. per annum increase in its paediatric activity and a 10 per cent. per annum increase in its paediatric intensive care work load. Staff at that hospital do not know to what extent the national specialist services definition sets, which are a reference to the throughput of cases for particular specialisms, will increase the number of referrals to them for a range of other treatments.
The requirement for adolescent specialisation and capacity is going to add yet further increases in demand, particularly for specialist care. All that points to a need, in response to the Kennedy report, to know what the configuration of acute hospital services is going to look like. Recommendation 178 of the report states:Children's acute hospital services should ideally be located in a children's hospital which should be physically as close as possible to an acute general hospital. This should be the preferred model for the future.Will the Government accept that recommendation? Will the reconfiguration of acute services follow swiftly on the first module of the national service framework? Will the resources necessary to create a new configuration of services be provided through a specific capital allocation from the Government, such as that which has accompanied information technology or the NHS Modernisation Agency programme?
Alternatively, should the funds be ring-fenced for a managed clinical network for children's services, as has been the case with the cancer network? How will the plans for foundation hospitals and a new independent regulator provide for the substantial change in services that will be consequent on reconfiguring services for children, particularly in respect of the integration of services between children's hospitals and community services? As the relevant Bill is in Committee upstairs, I cannot expand on that relationship, but it would be an obvious one in the context of how foundation hospital trusts connect with other NHS bodies effectively. That 205WH will become a distinct organisational feature in the NHS. Those questions relate specifically to the Kennedy report.
I would like to widen the debate. The Kennedy report, the Laming report and Professor Aynsley-Green, head of the children's national service framework, are all asking the same question: who is in charge? Structures of standards are increasingly being put in place. There will be a structure of local networks through children's trusts, although we will find out only over time how those children's trusts are designed in particular localities. I hope that, as a consequence of that, we will have a structure of accountability—managerial accountability on one hand and democratic accountability on the other. That matter requires further discussion. We will also have a structure of audit and inspection.
Where is the leadership in all this? Each of us, in our daily lives, thinks about our children. I certainly think about mine, and they are my top priority. In a curious sense, each of us knows that individually, but when the Government and institutions deal with such issues collectively, they cease to be top priorities. We must ensure that they are. How do we make that happen?
§ Mr. Mark Francois (Rayleigh)
On precisely the point about who is in charge, I have in my constituency a number of parents whose children appear to be suffering from autism spectrum disorders—Asperger syndrome springs to mind. Such parents and children have terrible problems in that they are often batted from pillar to post between health service trusts, social services departments and the county council's education department. Nobody ever seems to be willing to grasp the nettle and accept full responsibility. I mention that as a classic example of the "who is in charge?" problem coming sharply into focus. Has my hon. Friend any comment on that?
§ Mr. Lansley
I am grateful to my hon. Friend for illustrating the problem. We are trying to address it so that we know who is in charge and, more to the point, so that the person responsible can take action that flows. Lord Laming's report on the Victoria Climbié inquiry pointed towards the necessity for such integration—agencies and professional groups should be able to work together, and we must escape from service silos. Once we have done so, we must find a mechanism through which we do not merely state that as an aspiration but deliver in each locality through an organisational structure. Professor Aynsley-Green and the children's taskforce might consider a managed children's network. That could be reflected in the structure of children's trusts.
§ Mr. Hilton Dawson (Lancaster and Wyre)
The hon. Member for Rayleigh (Mr. Francois) has provided an excellent example. Surely the response to the acute problem that he identified cannot be merely structural. He suggested an absence of values and a failure of individual professionals to take responsibility for the child.
§ Mr. Lansley
The hon. Gentleman is right, and Lord Laming's report reflects that dichotomy. I have been talking to the assistant director responsible for children's services in Cambridgeshire about the 206WH implementation of the recommendations and the review of good practice. Justifiably, his attitude is that he is being asked to look carefully to see whether he does the things that he has always done. There is some chagrin—I put it no more strongly than that—over the costs and implications of trying to deal with the report's recommendations in places where there is already good practice. However, we accept the necessity of responding to the report.
The issue is as the hon. Gentleman has said: should we seek an institutional structural response to what is essentially a failure of professions and organisations to do their jobs effectively within the current structure? The answer is that we must ensure that professions understand what best practice is and are sufficiently held accountable to deliver it. At the same time, we must recognise that the structural problems that have persisted for years give rise to problems, such as those illustrated by my hen. Friend the Member for Rayleigh (Mr Francois), far more often than would be the case if there were simply a failure of individuals in an otherwise well-functioning organisation. Private business, in considering the process of building quality into an organisation, generally recognises that it involves combining structures and processes with individuals who have training, expertise and commitment. Those things have to travel together, and that is what we seek here.
That brings me back to children's trusts and their objectives. Lord Laming's report says:The single most important change must be the drawing of a clear line of accountability from top to bottom, without doubt or ambiguity about who is responsible at every level for the well being of vulnerable children.That is the proposition he was pursuing. Children's trusts need to be understood in this context as ways in which localities can devise a structure that meets that objective. Localities are variable, however. I think that we are approaching the point at which Ministers have an opportunity to tell us a bit more about what the pilot areas look like, because they have, if I understand the timetable correctly, received a range of submissions on pilot areas. I assume that they are about to tell us where those pilot areas are and what they look like. Perhaps this Minister will say more about that today.
It is important that children's trusts should, among other things, reflect certain principles. I declare a non-pecuniary interest as a vice-president of the Local Government Association. The LGA, in promoting the model entitled "Serving Children Well", has, with its partners, reflected principles that should apply to children's trusts. Local authorities, as they are democratically accountable, are the best local means of creating partnerships to deliver the services. They can combine democratic and managerial accountability. Education is a universal service that forms part of the responsibility of local government, and it might therefore be the best lead service with which others might be connected. I subscribe to that quite heartily, because it is undesirable for children's trusts to be led from a service that is designed solely around the needs of vulnerable children or children at risk. Children's trusts, if they are to grow in a locality, should be understood to be a universal service and should be initially located in, or driven from, a universal service.
207WH The attributes of children's trusts should be multi-agency working; rationalised processes for information and assessment; unified work force development plans; and community involvement in setting priorities and assessing services from the family and the children's perspective.
Other issues relating to the establishment of children's trusts have not yet been thoroughly dealt with, following on from the Laming report. For example, there is the risk that service silos may be turned into professional silos inside an institution that provides an umbrella to several professions. We need to ensure that we do not just provide institutional cover that allows the same failings between organisations and professions to continue. We must not create an institution that lacks transparency between commissioning on one hand and provision on the other, because we have made gains over years past and understood that those two must be distinguished. We must not create an institution that closes ranks to defend some collective line to take on local issues when they arise. It must be much more open to external scrutiny, inspection and intervention than agencies have been up to now.
In that context, although I will not go on about it, I have been persuaded for some time that the role of the children's rights director is too limited and not sufficiently independent. A children's rights commissioner would still have a valuable role to play in relation to the external scrutiny of such an organisation.
This debate is not about Cambridgeshire or my constituency interests, although many issues that I am discussing arise in my constituency. It is primarily about the national policy framework. I shall finish with a range of questions, which are as yet unanswered. I say that because of my experience of discussing the matter with hospitals, social services, local authorities, primary care trusts and others in my constituency, and of talking to them about how we should move forward on the development of those services locally, taking account of all the national policy initiatives. Those questions must be answered pretty quickly if we are to put good-quality structures in place rapidly in my constituency and in Cambridgeshire as a whole.
First, what is the timetable for implementing the children's national service framework and its standards? What will be the mechanism for delivering targeted funding to secure the delivery of the children's NSF? When, and with what objective, will guidance on the reconfiguration of acute hospital services for children be published? How will the Government move from early pilots in 2004 to a wider roll-out of children's trusts in 2005, and with what additional guidance? Will the timing not be incredibly tight in terms of trying to offer any guidance based on an evaluation of the pilots before a trust starts in 2005? Will children's trusts be required to focus on children at risk, or will they be understood from the outset, as I confess I would prefer, as a framework for the co-ordination of universal and targeted services for children?
How will the provision for children's trusts mesh with the establishment of NHS foundation trusts? Addenbrooke's hospital in my constituency is one of the 29 initially approved potential NHS foundation trusts. 208WH Will the framework of children's trusts and the Government's forthcoming Green Paper be flexible enough to permit the development of models based on the "Serving Children Well" approach that has already been developed between agencies? Will the framework be flexible enough to enable the partners in Cambridgeshire to come together to define our vision and timetable for the creation of focused services for children? That should include the establishment of a children's hospital at Addenbrooke's that will then serve Cambridgeshire and the wider region.
Will we be able to articulate the plans in a way that will engage the public's interest and commitment? I freely confess that I could not now explain to the public at large what the new shape of children's services in Cambridgeshire will be five or 10 years from now. I would like to be able to do that and to know the answers to the questions.
We need to work together on the answers so that perhaps within a year or two, or possibly in 2005, a children's trust can be established in Cambridgeshire, which I can talk to people about in the wider context of a children's hospital at Addenbrooke's. I would also like to be able to talk about how that is going to relate to children's services in the county as a whole and how things will develop during the next five or 10 years. I cannot do that yet, and being unable to do so makes it difficult to engage the public's support and commitment.
Will the Government help us to escape from the paralysis of analysis, all the reports that are produced but not acted on, not knowing who is in charge and the failure to do the job that is required? We must escape from all that so that we can deliver, not only by way of a structure but in reality, high-quality services for children that are genuinely co-ordinated across the range of organisations, and genuinely focused primarily on the interests of children and how they need the services to be provided.
§ Mr. Deputy Speaker (Mr. Frank Cook)
Order. We are carrying eight minutes of injury time. As we normally begin the first of the three winding-up speeches 30 minutes before termination, as it stands and if there are no Divisions, we must commence the first winding-up speech at 8 minutes past 3 o'clock. That means that we have 21 minutes left for those others who wish to contribute, so I hope that Members will bear that fact in mind when making their contributions and when accepting or making interventions.
§ Mr. Hilton Dawson (Lancaster and Wyre)
I congratulate the hon. Member for South Cambridgeshire (Mr. Lansley) on securing this timely debate and, most of all, on coming up with such an important and relevant subject. I also congratulate him on the way in which he introduced the debate and linked health and social care. I strongly believe that, in any context, we should resist talking about health on its own; we should always ally and integrate health with social care. I agree with everything that the hon. Gentleman said about his concerns over the fragmentation of services.
209WH I am pleased that Professor A1 Aynsley-Green has agreed to come to Lancaster in September to help a group of children, young people, parents, professionals and others, including me, to answer the question of what life is like for children in Lancaster. We are trying to approach the issue holistically and from a child's point of view. We are trying to integrate services such as health, social care, education and youth justice—all those who have any involvement with children—in that discussion.
It is profoundly important that we concentrate our attention on children's services. We parents have a tremendous commitment to our own children; we recognise that children are the most powerless and vulnerable people in society. They have no vote and often no voice but they are the future of our society, so we must emphasise services and support to help them to grow and develop.
I was delighted with the hon. Gentleman's emphasis on the Kennedy report, which was a seminal contribution to the development of children's services. Kennedy said that some of his sections on children were written in anger, which is an appropriate emotion to have about services for children. As the hon. Gentleman said, those services have too often been subjugated to the needs of adults, and they show a lack of concern for the most vulnerable, who need quality care. Fragmented services, which are not properly led and in which individuals fail to take responsibility, have little to do with effective partnerships. For the reasons that we have already heard, we should approach the development and improvement of children's services with passion and a determination to get them right at national and local level.
The debate is timely because the Laming report was published during the development of the national service framework for children. We await the Green Paper on children at risk, which I hope will lead to a service based on children's rights and their participation, a children's commissioner and an effective system of independent representation and complaint for children, not just in Wales, Northern Ireland and Scotland but in England.
The Government have made enormous strides in developments for children, the most important of which is the attack on poverty that is at the heart of so much health inequality. They have introduced profoundly important legislation, much of it related to children in care, such as the Children (Leaving Care) Act 2000 and the Adoption and Children Act 2002. Those are built on the principles of the Children Act 1989, a remarkably good Act—probably the only one—introduced by the Conservative Government.
We should listen to the responses to the draft review of children and family proceedings carried out by the National Society for the Prevention of Cruelty to Children. The review stressed that 12 years after the implementation of the Children Act, its principles—
§ Mr. Dawson
No, it was implemented in 1991.
The Act has proved its worth, but we should learn about some of its limitations. It was never resourced properly, and local authorities were allowed to develop 210WH their own concepts of children in need, which equated much more with their available resources than with any broader definition or assessment of the needs of children in their community. The Act did not cover the whole range of children's services, so many children were left out. I refer in particular to children in the youth justice system, although a recent important judgment said that children in prison are subject to the Children Act.
We have an important opportunity. Huge resources are being invested in public services, and some good legislation has been passed. We have a Government who are prepared, as they say in their 10-year NHS plan, to shift the balance of power and take a fundamental approach to the reorganisation of services. I want several children's centres and trusts in my constituency, and considering all that I said earlier about individual responsibility and values, restructuring will be necessary to bring together the key services for children. I hope that the Government will build on developments that have been piloted, and extend the work throughout the country.
We have a huge problem with children's services. They have already been referred to as a Cinderella service, and it is essential that we attract more people into work with children. We have seen good progress with the new three-year social work training course and the efforts of many local authorities to attract staff who in the past would not have felt able to take on such work. There is more investment in day care, foster care and the all-round integration and development of global services for children.
There is a great deal more to do, however, and we can do no better than to return to the words of the previous Secretary of State for Health, my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), and ask everyone who works in children's services or their policy development whether the services would be good enough for their own child. Each individual who works with children should apply that measure every day of their working lives.
I appreciate that there is not much time and that other hon. Members want to speak, so I shall end by saying that we have a profoundly important opportunity to take a radical step forward in the modernisation and development of children's services. We could easily fail at this point because there are great challenges and institutional barriers to overcome, but with a passionate commitment from central Government and by energising and supporting a work force who, if given their head, could do an excellent job, we can make the radical changes that are needed.
§ Mr. Deputy Speaker
I remind hon. Members that we have no more than nine casual debating minutes left.
§ Dr. Ashok Kumar (Middlesbrough, South and Cleveland, East)
I have quite a lot to get through in nine minutes. First, I congratulate the hon. Member for South Cambridgeshire (Mr. Lansley) on securing the debate. I know that he has a long-standing interest in child care and children's welfare, and it is a great credit to him that he could secure this debate. I agree with the spirit of everything that he said about the grave issues arising from the Victoria Climbié case and the other issues that he highlighted.
211WH I want to draw the Minister's attention to issues relating to young children and care assistants in my area, and to highlight emerging issues in mental health. Most people generally accept that an unfortunate side effect of the pressure of modern society is the amount of mental stress suffered by young people. I understand from a pamphlet produced by YoungMinds that it believes that 10 per cent. of young children can beoverwhelmed by misery, anger or fear.It says that 10.4 per cent. of all children between five and 15 have some sort of mental disorder, including eating disorders, emotional disorders and hyperactivity. Significantly, higher rates of mental illness were observed in areas of economic disadvantage. I say with some confidence that my area of Teesside, which covers parts of the boroughs of Middlesbrough, Redcar and Cleveland will have a particular problem with mental health, given the social demography of my constituency. I am pleased that the Government have recognised that. In Teesside, following Government guidelines, a proper multi-agency child and adolescent mental health service has been set up by all the agencies working in the field.
The Government have said that such a service must function fully and provide a comprehensive service dedicated to early intervention by 2006. I am glad that the programme is now under way in my constituency. In the borough of Redcar and Cleveland and, to an extent, in the borough of Middlesbrough, the service has identified services for looked-after children—children in the care system—as the top priority in a mental health strategy for youngsters.
Maurice Bates, the director of social services in Redcar and Cleveland, tells me that funding is steadily coming on stream for the service. For 2003–04, the grant will be some £136,000—an increase of £86,000 from the previous year. An additional £45,000 has been granted from the local primary care trust to match that. The cash must meet the number of young people identified as needing intervention from the service. Last year, the Redcar and Cleveland locality team dealt with 151 new referrals on top of its existing case load.
We can see where the pressures are when we examine the case load of youngsters in the care system. In Redcar and Cleveland, which is a relatively small social services authority, some 160 young people are in the care system at any one time. As I said, many of them have complex mental health needs, and a specialist model of care has been devised, with a correspondingly high work load. During 2002–03, some 156 clinical contacts were made involving new case referrals, consultations with social workers and medical professionals, and, most importantly, sessions with individual children and young people.
The team undertaking the work is doing a sterling job under very trying and emotional circumstances. However, it identifies several issues that must be highlighted. My constituency lies in Redcar and Cleveland, which is a very dispersed and rural area with a large number of small towns and villages. Access issues are therefore very important. However, the existing specialist children's service team is based—by necessity—in Middlesbrough, the nearest big town. There is a good argument—in cultural, geographical 212WH and community terms—that the team is too distant really to benefit and help those young people at an extremely critical period in their lives.
There are always problems involved with running services that are both cross-boundary and cross-organisational. A business case is being made to the Langbaurgh primary care trust board to secure resources to set up a specialist base in the east Cleveland area, which is the rural part of the constituency. While that is a matter in the first instance for the professional and non-executive members of the board, I hope that the Minister will take note of the proposal.
There is also a growing issue concerning the emergence of a cohort of young people within the local care system who are displaying very challenging behaviour patterns. Those young people need specialist help that simply is not available across Teesside. I am told that the local social services departments have to make arrangements with specialist national facilities for the young people's care and treatment. The issue is simply one of cost. A small social services department has to operate on a tight cost rein, and the same applies to local facilities provided by a PCT or a local hospital trust. Those bodies must take decisions—made in the best interests of the young person—to locate them with a national facility, but at great cost. That cost impacts directly on resources that could be used for other young people for whom those organisations have a care responsibility.
I am not making any direct plea to the Government. I merely ask that such circumstances, which are becoming ever more common, are taken into account when determining the resource support made available to professionals working on the ground. I have great admiration for the professionals working for both our local social services and our health services in a challenging and complex field. They tell me that they are grateful to the Government for the increased support that they are getting and for the fact that the Government are encouraging cross-cutting collaborative work of a high standard, and have slashed bureaucracy in achieving that. However, I feel that it is at times like this—and in debates like this—that the voice of the people working at the grass roots deserves to be heard, and the issues that are of concern to them voiced. Time is running out. I am referring to a group of people who, if they are allowed to do their job properly with adequate resources and backing, can help young people to make a success of their lives.
§ 3.8 pm
§ Mr. Paul Marsden (Shrewsbury and Atcham)
I, too, congratulate the hon. Member for South Cambridgeshire (Mr. Lansley) on securing the debate. I pay tribute to his dedication over several years to children's health and welfare. I also pay tribute to other hon. Members for the part that they have played. As a parent, I know all too well what it is like to experience that heart-stopping moment when one thinks that there may he a problem with one's own child. As a father of two, I appreciate that we can count ourselves lucky in this country. We must not forget that today, like every other day, 30,000 children around the world will die because of the want of basic inoculations and lack of food.
213WH Having said that, there are all sorts of issues to be raised about the direction of Government policy. The first place to start is the United Nations convention on the rights of the child. It sets out the basic rights of any child anywhere, with the aim of ensuring that no child be deprived of access to health care services. It sets out measures that should be taken to diminish infant and child mortality, to ensure the provision of necessary medical assistance to combat disease and malnutrition and to secure good child nutrition. Importantly, article 24 refers to developing preventative health care. That is what it should be about, prevention is always better than cure.
The Government deserve credit. They have moved along the agenda for children's health in leaps and bounds with the success of the sure start programme, and the national service framework for children is promising. I had hoped that it would embrace the Kennedy report and the report on little Victoria. Clearly, an enormous breakdown in services occurred in that tragic case. However, the national service framework's principle of putting children at the centre of their care and building services around them is paramount.
The Government have published the children and young people's unit document "Aim High: Stay Real". It is worthy in its aims. Typically, it is rather heavy, but nevertheless it should be looked at. I support what it is trying to put across: the importance of listening to young people and children. That is made clear on page 47. The children's focus group said that children wanted to have more sport in school, and that they wantedNice and healthy school dinners".It seems that, in the 25 years since I last tasted one of those, they have not improved much. I would have some sympathy with a Government who tried to enhance them.
The report also makes clear what parents want. They have stated that they want "ongoing medical check-ups" and the analysis of children's dental records, as well as more advice on nutrition. Health is one of the six outcomes in the document, and one of its key aspects is the problem of obesity and nutrition. One child in four, depending on how one counts, is obese—a fourfold increase since 1984—and one child in five eats no fruit. I do not think that we should force people to sign bits of paper in the form of a GP contract. However, we are on the verge of an epidemic. By 2020, if the estimates are correct, some 10 million people in this country will face diabetes because of obesity. I do not only knock corporations that do wrong—such as Cadbury's, which was offering to give away sports equipment by encouraging children to eat more chocolate, flying in the face of the good, healthy eating messages that the Government are trying to put out—I praise those that help, such as Tesco, which is promoting five-a-day portions of fruit and vegetables.
I look forward to seeing the Food Standards Agency's review of food promotion in July. Ultimately, we should be getting children more involved in exercise. While I welcome what the Government have done with an extra £1 billion of funding for physical education and school sport over the next three years, it is rather tame to set a target for 2006 of 75 per cent. of schoolchildren undertaking a minimum of two hours' PE a week. Faced 214WH with a possible epidemic of obesity, surely we should be aiming slightly higher than that? Over the past nine years, £2 billion has gone into Government-funded school sports promotion, but that has resulted in a mere 0.3 per cent. rise in participation.
Another issue is mental health. One child in 10 suffers from mental health problems, resulting in very high suicide rates among young males compared with those in the wider community. Those young males usually come from the social underclass. They are disadvantaged and living in poverty, although many of the root causes are to be found in childhood.
There has been an explosion of sexually transmitted infection over the past six years by 34 per cent. There has also been an increase in drug and alcohol abuse. About 11 per cent. of schoolchildren are experimenting with drugs and half of all 15-year-old boys admit that they drink alcohol regularly, and that is without mentioning the effects of smoking.
With regard to child protection, I welcome the Laming report and congratulate the Government on taking quick and decisive action on it. Nevertheless, the report was a damning indictment of what had gone before. The findings show that it is important to find ways of getting all the organisations—health, housing, education, social services, the voluntary sector and the police—that come across children every day to improve their co-operation. The jury may be out on children's trusts—I believe that the principle is right, and I appreciate that the Government have now introduced a great deal more flexibility into the concept, but there is still some confusion about how that can be applied.
Vulnerable children need the most help. I welcome the fact that we have a children's commissioner of sorts, but I hope that that role becomes truly independent and not subsumed into another position. I also want the increased investment to reach the front-line services. For example, the Government's own figures show that, since 1997, there has been a 20 per cent. decrease in the number of neonatal cots, which means that the money is not reaching the areas that it should.
The hon. Member for South Thanet (Dr. Ladyman), who chairs the all-party group on autism, said that more research into autism was needed. The Government commissioned a report from the Medical Research Council into the state of current knowledge, and awarded it £2.5 million to do the extra work. It is therefore a disappointment to see that the MRC has as yet been unable to identify studies to meet those criteria, and that so far not a penny has been spent. Sometimes we are overwhelmed with a deluge of targets and paperwork, which prevent the services from being carried out on the ground.
I welcome much of what the Government have done and give them credit for it, but much more must be done, and there are some worrying trends in children's health that must be tackled now, as otherwise we will reap their effects in the years to come.
§ Tim Loughton (East Worthing and Shoreham)
I, too, congratulate my hon. Friend the Member for South Cambridgeshire (Mr. Lansley). He has a great track record in standing up for children's issues, and speaks with great knowledge of the Kennedy report and children's trusts.
215WH Although those contributing to the debate have been limited in number, there have been some good contributions. As usual, the hon. Member for Lancaster and Wyre (Mr. Dawson) spoke with the benefit of experience. He praised the last Conservative Government for their introduction of the Children Act 1989, but in characteristic form then blew it by blaming the same Government for everything that went wrong with regard to children after that. He then became characteristically greedy in saying that he wanted a range of facilities for children in his constituency, including children's centres and children's trusts. The hon. Member for Middlesbrough, South and Cleveland, East (Dr. Kumar) also made some excellent points.
Children's health is an enormous subject, to which 90 minutes of debate, with or without interruptions, cannot do justice. We could have had a debate entirely on adolescent mental health, as the hon. Member for Shrewsbury and Atcham (Mr. Marsden) mentioned. We could also have discussed the high incidence of perinatal deaths and the shortage of midwives—I will not go into the subject of birthing positions, which is of particular interest to me and the Minister—and attachment theory, and the importance of early -years development in shaping the character of children in difficult years later on. We are admitting three times more zero to four-year-olds to hospital than we were 30 years ago, and we have a chronic shortage of specialists in adolescent mental health. Even though children are supposed to be healthier than ever, as my hon. Friend the Member for South Cambridgeshire pointed out, some 30 per cent. of looked-after children have not been immunised against basic diseases, and a two-year-old in London may wait for up to two and a half years to get speech and language therapy—a wait that can lead to other health and social complications.
We could have debated the problems with drugs or the growing number of disabled children who are not being properly catered for. The figures for obesity among young children do not quite show what the hon. Member for Shrewsbury and Atcham said—that one in four children are obese—but that one in four obese children are already showing signs of diabetes. There are still enormous implications, and there will be a ticking time-bomb effect on the health of those young adults as they grow up. We need far more preventative steps and interventions by school nurses, and GPs must be given the time to spend on proper nutritional conversations with and education of young children.
The fact that some 20,000 children in Britain have life-limiting conditions could have been debated. That number is growing because children are living longer with those conditions, including cystic fibrosis, Rett's syndrome and Batten's disease, but we have only 250 beds to provide specialist hospice care for such children, and hospices get less than 7 per cent. of their funding from the state. The number of children infected with sexually transmitted diseases is growing alarmingly. There is a shortage of foster carers, and I hope that the Minister will support my Bill on the registration of private foster carers when she has the chance to do so in a few weeks.
216WH All those issues could have taken individual debates, and they all appeared at the Conservative summit on children's health that we held in January as part of our exercise to consult on and raise the profile of children's health issues. For too long, children's health has had a raw deal in this country, particularly if the child cannot be shoehorned into the infant or young adult categories. Lucy Thorpe, the policy director of the National Society for the Prevention of Cruelty to Children, said:Children are one quarter of the population and for too long their health needs, from a child-centred perspective, have come a poor second to those of adults.As my hon. Friend the Member for South Cambridgeshire rightly said, children have been too often the add-on rather than the focus of health care. Will the Minister comment on the progress of the children's national service framework? It has been delayed, and the last indication from the children's tsar was that we would have the full Monty in December. Are we still on course for that, and what updates will there be in the coming months?
A common feature of all the problems is the need for a joined-up approach. All hon. Members have recognised that and mentioned linking up the agencies and bodies that touch on children and their welfare. That is why, like my hon. Friend the Member for South Cambridgeshire, I welcome the "A New Vision for Children's Services" partnership between the Local Government Association, the Association of Directors of Social Services and the NHS Confederation. Its work to establish closer partnerships and produce models of the interaction among schools, early-years development, sure start, child protection services, youth offending teams, looked-after children and children and adolescent mental health services is especially important.
As that partnership has pointed out, it is essential to ensure that the new arrangements focus on a vision to improve children's lives rather than just starting from the development of yet more new structures and organisations. What consideration has the Minister given to its proposals for common assessment processes to prevent children from undergoing numerous assessments with their families, a universal child indicator to ensure that vulnerable children are not lost to the system and a new statutory duty for agencies to safeguard and promote the well-being of children, and a supporting duty to form partnerships to this end?
What does the Minister think about the proposal that local authorities should be identified as the statutorily accountable bodies for the partnerships established under the new duty, that each local authority and partner agency should name a lead member and senior officer for children who will be ultimately accountable for child protection—a children's champion, as the partnership puts it—and that there should be new powers for co-operation and scrutiny to ensure a joined-up approach that is transparent and accountable to local communities? We concur with those sentiments and look forward to practical proposals from the consultation exercise. We will be interested to know how sympathetic the Minister will be to them.
Much health and special needs care is relatively good for well children who can negotiate the system, and reasonably good at dealing with children in severe need, 217WH but there are big gaps in the system for the many vulnerable children in between, who often have complex problems that are not easily pigeonholed.
Joined-up thinking is essential in respect of child protection, as was sharply demonstrated by Lord Laming's report on Victoria Climbié. We therefore set great store by the forthcoming Green Paper on children at risk. The Secretary of State promised that it would be available in the spring when he responded to the Climbié report on 28 January. There is some confusion about which Department is leading on the matter; it seems to be under the aegis of the Chief Secretary to the Treasury, but we do not know whether it is predominantly a Health, Home Office or Education and Skills matter. Perhaps the Minister will clarify the position.
Will the Minister give us an update on the ramifications of the Climbié report? It is 133 days since it was published and the Secretary of State responded to it, and three years and three months after Victoria Climbié's death in the most tragic circumstances. Child abuse and child harm still occur all too often: every week at least one child dies as a result of an adult's cruelty; a quarter of all rape victims are children; and most abuse is committed by someone the child knows and trusts. I could go on—it is a catalogue of despair that hon. Members know only too well.
In response to the Climbié report, the Secretary of State said:Sound legislative policy and guidance is, frankly, useless unless we can be sure that it is implemented effectively and consistently."—[Official Report, 28 January 2003; Vol. 398. c. 738.]What resources are being allocated to implement the report's recommendations? How many new social workers are coming through the system? There is a drastic shortage of skilled professionals to provide the new services that need to be put in place. The Home Secretary and the Health Secretary pledged to ask the inspectorates responsible for health, police and social services to undertake further joint monitoring of local services in north London to provide independent assurance that standards are improving. What is happening in that respect?
The Secretary of State was supposed to write to the chief executives of local health services and local authorities emphasising their duties towards vulnerable children, which should be reflected in their budget decisions. He also offered to oversee a review of training needs. What is the current position? The plethora of out-of-date, confused guidance was supposed to have been swept aside by now. Has that been done? When will there be a report on the pilot study of the first generation of children's trusts? Will child protection remain at the heart of those trusts?
People are becoming increasingly impatient for answers to their questions. On 28 January, we were promised a response in three months' time. The Green Paper was supposed to be a panacea for all the problems, and we urgently need an update on the position before the summer recess. Under the Children Act 1989, children must be at the centre of policy considerations on health and social care, and we must ensure that they are. I hope that the Minister will answer my questions and assure the House that action is being taken, which will help to allay some of my fears.
§ The Minister of State, Department of Health (Jacqui Smith)
I echo what hon. Members said about the high quality of the debate, and I congratulate the hon. Member for South Cambridgeshire (Mr. Lansley) on securing it. A wide range of issues have been raised and, without exception, contributions have been intelligent. [Interruption.] Yes, without exception. I shall try to cover as many issues as possible in the short time available.
Healthy children have a better chance of becoming healthy adults; much adult disease and many emotional and psychological difficulties have their roots in childhood. Much is good about the services provided by the NHS and local authorities to support children, young people and their families, and the work force are dedicated to them. Lives are being saved, diseases previously believed to be incurable are now being treated effectively and children are being protected. There are new opportunities for disabled children, those in public care and those with mental health problems. However, we need to do far more. The effect of inequalities and poverty on the lives and health of children must be tackled.
As hon. Members said, we need services that are more child and family focused. Despite the high quality of many children's services and the dedication of staff, we need that focus, and high standards, throughout health and social care services. That is why we appointed Professor Aynsley- Green as the national clinical director for children, and it is a tribute to his work in raising the profile of children's health services that he has been mentioned so frequently today. It is also why we published the hospital standard on 10 April as part of developing the national service framework. As the hon. Member for South Cambridgeshire suggested, that is a major part of our response to the Kennedy inquiry, which highlighted the need for services to be more child centred. It also reflects some of the concerns expressed in the Climbié report about the need for children to be safeguarded in and by hospitals.
The new standard covers the design and delivery of hospital services for children and the safety and quality of care. It will help to ensure that children are cared for in hospital settings that adequately reflect the needs of their age group. In response to a point made by the hon. Member for Shrewsbury and Atcham (Mr. Marsden), I can tell the Chamber that we also announced in April £17 million of investment in intensive care. Following recommendations made in the Kennedy inquiry, hospitals will now expected to appoint a children's champion at board level to ensure that standards are being met. That is one of the ways in which we can achieve the necessary change. In line with recommendations made in the Laming inquiry, no child should be discharged from hospital without a care plan.
The new standards also mean that NHS hospitals should consider introducing facilities for young children that are separate from those provided for adults, as well as designated play areas for young children, privacy for adolescents, education support so that children do not fall behind, special menus that encourage children to enjoy their meals, regular security reviews, specialist training for staff dealing with children, and play specialists who help children to cope with the distress of being in hospital.
219WH Understandably, the hon. Member for South Cambridgeshire pressed us about the delivery of the NSF and about the new standard in particular. We are now, rightly, operating in a different context that is about shifting the balance of power to a local level at which some of the national targets and milestones, although appropriate for delivering previous national service frameworks, may not be appropriate for this one.
What are the levers for ensuring that such change will happen? I am pleased with what ray hon. Friend the Member for Lancaster and Wyre (Mr. Dawson) said about the approach being taken in Lancaster to examining children's services and children's experience of them. That will be important locally, as will clear definitions of local outcomes, local information on children and their services to identify gaps, and local strategic planning. However, we will also provide support for commissioning services and integrating them appropriately.
We have made it clear that the targets applicable to the next three years in the planning and priorities framework include targets on child and adolescent mental health services, which my hon. Friend the Member for Middlesbrough, South and Cleveland, East (Dr. Kumar) mentioned, services for vulnerable children, screening, work on inequalities, substance abuse, early booking for maternity services, as well as general improvements in their overall capacity and in access to them, and resourcing the delivery over the next three years of those plans.
The National Institute for Clinical Excellence will have an important role in developing guidelines that have been commissioned for particular interventions. We also, of course, need to develop better child-centred inspection. We need to work with the new inspectorates, the Commission for Healthcare Audit and Inspection and the Commission for Social Care Inspection, to ensure that the standards are reflected in the inspection regimes and that tools are developed to monitor progress. In the end, however, it is for each locality, according to its own baseline position and priorities, to decide the speed at which work towards meeting the standards will be done and which standards and improvements will be made at which time. The needs in Cambridgeshire are not the same as those in Lancaster, and it is right that those different needs are reflected, given the national standards made clear in the hospital standard and the increased investment to help to deliver them.
I turn now to the points that the hon. Member for South Cambridgeshire made about configuration. Although there is more work to be done, I disagree that 220WH there is not a clear idea of the direction in which hospital services should go. In publishing "Keeping the NHS Local—A New Direction of Travel", we made clear the principles on which local configuration issues should be addressed. We will carry out further work, for example, on modelling some of the difficult issues involved in configuring children's services, particularly those relating to paediatrics, and maternity and obstetrics, which the hon. Gentleman mentioned. That work will show some of the models that enable us to make the best use of increasing numbers of staff in the system, and ensure that, whereas previously we may have thought that specialisation and large hospitals were the only way to deliver services safely, we can provide those services near the people who need them.
As the hon. Gentleman said, we will encourage the development of clinical networks. The hospital standard sets out what is expected of tertiary services. Alongside, for example, the £70 million investment in neonatal intensive care, we are asking local areas to develop those networks. That is the hospital standard; the NSF also covers a range of other areas. This has been an extremely complex task, and a large number of stakeholders have been involved.
To respond to the question asked by the hon. Member for East Worthing and Shoreham (Tim Loughton) about timing, we are looking at publishing the NSF in 2004, but to ensure that the direction of travel was clear, we published the "Emerging Findings" consultation document at the same time as the hospital standard. That allows local discussions to be informed by the principles of the work that has already been done, which will help to ensure that progress continues.
Several hon. Members mentioned children's trusts. One of Laming's starkest conclusions related to the inability of organisations to work together. Children's trusts are intended to tackle the lack of co-ordination of the services delivered to children. Local authorities have responded to that opportunity extremely well. Nearly a third have applied to create a new trust with their health partners. The majority are commissioning services for 0 to 19-year-olds, although they are often focused on vulnerable children.
I agree with my hon. Friend the Member for Lancaster and Wyre that structural change alone cannot deliver what we want. That is why the fundamental building blocks of children's trusts and of our services must be shared objectives, common assessments, the sharing of information between professionals and direct accountability. Working with those building blocks, we can change practice. I expect the first tranche to be announced in the next month or so—
§ Mr. Deputy Speaker
Order. We must now turn our attention to the next topic for consideration this afternoon.