Health and Social Care Bill

My Lords, this is a very important debate and the first opportunity we have had to look at the proposals affecting children. The Government’s plan that public health services for children under the age of five, including health visiting and the family-nurse partnership, will initially be commissioned by the NHS Commissioning Board. To facilitate its plans to increase the health visiting workforce by 4,200 over a four-year period from 2011, the intention is that eventually this responsibility will pass to local authorities, which from the outset commissioned services for children between the ages of five and 19, including the Healthy Child Programme for school-age children. Maternity care meanwhile will now be undertaken by CCGs, although it was originally intended that this would be undertaken by the NHS Commissioning Board. The board will still be responsible for specialist neonatal services. In the very helpful public health report recently published by the House of Commons Health Committee, Councillor Rogers of the LGG told the committee that the initial split of commissioning children’s public health services, "““doesn’t make sense. There is obviously a serious risk of a gap developing around the age of five, and it doesn’t make sense for school nursing to be in one place and health visiting to be in another””." The Government’s response to the Health Select Committee was: "““we believe that the commitment to raise the number of health visitors by 2015 is best achieved through NHS commissioning and thus will retain our existing proposal that the NHS Commission Board should lead commissioning in this area in the short-term””." My first question to the Minister is linked to Amendment 97 and other amendments in this group. In the drive to increase the number of health visitors, are the Government putting at risk the co-ordination of children’s services? Are proposals to increase the number of health visitors in the short term on the risk register and, if so, how are they graded? I make the obvious point, which those of us who are parents know, that childhood is very short. It passes quickly. Frankly, ““in the short term”” for the Government might mean that millions of children are lost in the gaps created by the Government’s short-term drive to recruit, although I agree that the drive to recruit health visitors is necessary. The conclusion the Health Select Committee reached was that there is a danger that the involvement of local authorities, Public Health England and the NHS Commissioning Board in various facets of public health commissioning will produce a lack of co-ordination and cohesion in public health services. This danger is compounded by the definition of mandated services that will be the responsibility of local government which in sexual health services and child health services creates a dysfunctional division between services that need to be co-ordinated. The committee recommends that these distinctions be reviewed. I agree with that recommendation and I would like to know whether the Minister does, too. That concern was amplified in evidence received by the committee from many organisations, including the NHS Confederation which said in its evidence on children’s public health: "““Commissioning children’s health services is often a complex, interdisciplinary and interagency process and in the new system it is not clear which commissioners will do what. In general, child health professionals do not consider the current system to work effectively enough and they are concerned that the new system will be even less effective in meeting children’s needs””." This group of amendments deals with some very serious issues. I agree with the noble Lord, Lord Ramsbotham, and those who have spoken to support the amendments dealing with child communication difficulties. The noble Lord, Lord Clement-Jones, and I share an affection and connection with I CAN, the organisation that deals with these issues. Indeed, I worked for it before I joined the then Government a few years ago. It does an excellent job. I would like to compliment the noble Lord, Lord Ramsbotham, as I did from a position as a Minister, for his persistence in this important issue and I do not think we should lose sight of it. My interest in these amendments is to explore and inquire what the Bill will do to help develop services for children and how the NHS component and the public health component fit into the bigger picture of public services, if indeed they do. We can all agree that the integration of services for children including services for children within families is a very good idea. Indeed, we are not short of attempts to bring it about. Children and young people’s strategic partnerships gave way to the children’s board approach after yet another horror story of how various services failed to join up and a child suffered terribly. Sadly, the latest in a string of similar inquiries is finding the same thing and now the children’s trust approach has been stopped with little or nothing else in its place. The local strategic partnerships which had components for children have also gone. So the intentions may be there but the delivery is not yet. I know of a case where a purpose-built facility to house the full range of children’s services is now very expensive PCT office accommodation and, with the rise of clinical commissioning groups, may even be empty office accommodation. We still have to get it right. Those working with children tell me of fragmentation not integration, of police who no longer turn up as there have been cuts, of schools being less joined together, education authorities winding down to zero, PCTs cutting back on services around the margins, and their own organisations being broken up, particularly in the voluntary sector. Good initiatives like those working with complex families with a cross-organisational approach are foundering as participant organisations struggle to find resources to add to the funding that is available. Duties around organisations responsible for safeguarding are far less clear, and the good practice of working together across boundaries to promote safeguarding its becoming weak or nonexistent. This is not a promising landscape and it is wholly unclear that the Bill will make it any better. I hope that the Minister will offer us practical reassurances. Where will the new architecture place the safeguarding of responsibilities? Who will lead on early intervention? Who will flag up children at risk? Who will bang collective heads together? Surely it cannot be only the local authority. Will it be the health and well-being board—is that the only connection? That conclusion does not appear to emerge from the role descriptions of clinical commissioning groups. How will that work? What role will schools play in public health? How will they flag up issues about wider health structures such as bad teeth, which are easily spotted at an early age and are almost certainly a strong predictor of impending health issues? How will GPs fit into schools if only a few pitch up on governing bodies? I fear that for the reasons outlined the fragmentation we are already seeing will be worse under a Bill whose architecture is so complex and convoluted; and that the outcome for children could be terrible if not fatal in some cases. Obviously we hope that it will not be. However, as we go through the Bill, at every stage we are stopping to think about things from the patient's perspective. Perhaps we need also to think about things more clearly from the child's perspective. The main concern is how we will get better integration of services for children that are led by local authorities, and how we will ensure that we do not fail those children. Finally, I ask the Minister about government Amendments 88 and 89. I had some experience in this area when I was a Minister, and it was not resolved. I would like an explanation from the Minister. It may be that I have not read the amendments correctly, but I am concerned that their effect will be to widen the powers with regard to children. What is the Government’s intention here? Which parts of children do they intend to measure and weigh, when and where do they intend to do it and which children do they intend to do it to? Do we mean 100 per cent of children in the UK, or only children who attend state-funded schools? Will that include children who go to free schools or the new government academies? Which children are we talking about here?