Lords pass Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) (Amendment) Regulations

... I refer the Minister to table 29 on page 58 of the report by Public Health England. It is a summary of written feedback from professional representative and membership organisations. Comments were made by the Society of Local Authority Chief Executives on the issue of the mandation of services, about which clearly local authorities have some reservations. It suggests that the Government collect and review all mandated public health services next year, including health visiting, when the overall position on local government funding and business rate reforms is clearer. In a sense, the Local Government Association has made the same request. Will the Minister inform the House whether the Government are going to respond to that?

...As the Local Government Association said, given that the Government issued a firm commitment to the NHS five-year forward view, with prevention put very much at its heart, to then make significant cuts to the public health service budget over the next five years sends entirely the wrong message and could undermine the objectives that we all share to improve the public’s health and keep pressure off the NHS and adult social care.

...In a sense, the Local Government Association has made the same request. Will the Minister inform the House whether the Government are going to respond to that?

Debate in full:

Lord O'Shaughnessy

That the draft Regulations laid before the House on 1 March be approved.

The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)

My Lords, I am delighted to speak about these important regulations, which will continue to ensure the provision of five mandatory health and development assessments and reviews as set out in the Healthy Child Programme. It was a policy I first worked on over 10 years ago. Having had three children in that time, whose births and early months were not always straightforward, my wife and I know from personal experience the benefits of the programme.

The Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) and Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) (Amendment) Regulations 2015 transferred responsibility for commissioning public health services for children aged zero to five from NHS England to local authorities, allowing local public health services to be shaped to meet local needs. This includes responsibility for delivering the healthy child programme. This programme is the main universal health service for improving the health and well-being of children, providing families with health and development assessments and reviews, health promotion, screening and immunisation. This is supplemented by advice around health, well-being and parenting. The five reviews are offered by health visitors to pregnant women, new mothers and children from birth to age five and include the antenatal visit, the newborn review, the six to eight week check, the one year review and the two to two and a half year review. They are required to be provided by all local authorities in England.

I know that your Lordships will agree that health visitors play a crucial role in ensuring that children have the best possible start in life and lead the delivery of the elements of the healthy child programme which relate to these children. Health visitors provide valuable advice and support to families and are trained to identify health and well-being concerns. Through the health visitor programme, the Government have supported the profession more than ever before to transform the service and I pay warm tribute to its excellent work. In April 2015, at the end of the health visitor programme, there was an increase of around 4,000 in the number of full-time equivalent health visitors in the workplace since May 2010. Health Education England is now ensuring sustainable development of the health visitor workforce and there are presently more than 800 health visitor student training places commissioned. This, along with service transformation, means that more families now have access to the support they need in those precious early years.

The Government are also committed to supporting school-aged children and young people by promoting their health and well-being through school nursing services. There are currently around 1,100 school nurses in England, supported by other professionals, such as community staff nurses, health care support workers and nursery nurses. In January 2016, Public Health England published commissioning guidance for school nursing which makes it clear that school nurses should be accessible and responsive to children’s needs. The current 2015 regulations, which place a duty on local authorities to provide the five universal health visitor reviews, contain a sunset clause and so will lapse on 31 March 2017—tomorrow. The legal obligation on local authorities to provide health visitor services is also set to lapse tomorrow. The draft regulations before the House will prevent this. The current regulations also include provision for a review to be undertaken of the operation of the regulations.

The Department of Health commissioned Public Health England to carry out a review of the operation of the five mandated universal health visitor reviews following the transfer of responsibility to local authorities, as set out in the 2015 regulations. A review was carried out in summer 2016 and Public Health England’s report of the review was published on 1 March 2017. The review found widespread support from local authorities and commissioners for the universal health visitor programme remaining in place, in order to secure the delivery of long-term benefits from the healthy child programme, including improved health and well-being outcomes for children and their families. There was also a strong view held by professional representatives of local government and the nursing profession that the services are essential for prevention and early intervention and a general agreement that they deliver a positive return on investment and contribute to other government priorities such as reducing childhood obesity, controlling tobacco and improving maternal mental health. I thank Public Health England for its important work on the review and for helping to inform these regulations.

Local authorities will continue to be funded to deliver the mandated health visitor reviews. They will receive more than £16 billion between 2015-16 and 2020-21 to spend on public health, which includes children’s services including health visitors. This is in addition to what the NHS will continue to spend on vaccinations, screening and other preventive interventions. The Government announced earlier this month that the ring-fence on the public health grant will be retained for a further year, until 2019, as we move towards implementing 100% local business rate retention. This is a step on the way to a more locally-owned system and will help smooth the transition by providing some certainty for the next two financial years.

It is right that local authorities should have appropriate flexibility to deliver against their local priorities, but it is also appropriate that there are some key requirements set nationally, such as the five universal health visitor reviews. By continuing these mandated elements of the healthy child programme, this Government intend to maintain consistency across all local authorities when ensuring the delivery of these services. The draft regulations before your Lordships today will remove the sunset clause from the current regulations, ensuring that local authorities continue to provide these important visits to families. Removing the sunset clause will ensure that the current duty on local authorities to provide these services does not lapse on 1 April. I am confident that this sends a clear signal to health visitors, family nurses, local authorities and the public of the Government’s ongoing commitment to universal public health support for pregnant women, children, and their families.

This Government are committed to improving the health outcomes of our children and young people, so that they become among the best in the world. What happens in pregnancy and during the early years of life has a huge impact throughout the life course. Therefore, a healthy start for all children is vital for individuals, families, communities and ultimately the nation. I commend these regulations to the House.

1.00 pm

Lord Hunt of Kings Heath (Lab)

My Lords, I am very grateful to the Minister for explaining the intent of this statutory instrument. The Opposition supported the transfer of public health functions from the NHS to local government, including those for children from birth until the age of five in public health services. Indeed, that was the only bit of a lamentable Act of 2012 that we did support. We also support the provision of a universal health visiting service and the prescribed reviews, which are elements of the healthy child programme. The noble Lord has said that this decision was supported by the outcome of the PHE review, and I would like to come back to that.

I want first to refer him to the question of resources. He mentioned the changes in local government funding but he will be aware that, overall, the Government’s record in funding public health services has been lamentable. In February 2017, the Department of Health told local authorities that an average 3.9% real terms cut to health service budgets per annum would take place until 2020. This is a large reduction, as it accumulates. According to the King’s Fund, which has done an analysis of the impact that has had, as a result of these reductions stop-smoking services and interventions have lost 25% between 2015-16 and 2016-17, while other areas such as the health check programmes and sexual health services lost 7% to 14% of their funding. As the Local Government Association said, given that the Government issued a firm commitment to the NHS five-year forward view, with prevention put very much at its heart, to then make significant cuts to the public health service budget over the next five years sends entirely the wrong message and could undermine the objectives that we all share to improve the public’s health and keep pressure off the NHS and adult social care.

Recent work by the King’s Fund on sustainability and transformation plans—an Orwellian phrase, if ever there was one—points out that what is actually happening on the ground is going in the opposite direction to that which was set out in this plan. It is the same in public health. I would therefore like the Minister to explain a little more about how the Government justify the reductions in funding for public health services.

I refer the Minister to table 29 on page 58 of the report by Public Health England. It is a summary of written feedback from professional representative and membership organisations. Comments were made by the Society of Local Authority Chief Executives on the issue of the mandation of services, about which clearly local authorities have some reservations. It suggests that the Government collect and review all mandated public health services next year, including health visiting, when the overall position on local government funding and business rate reforms is clearer. In a sense, the Local Government Association has made the same request. Will the Minister inform the House whether the Government are going to respond to that?

On the outcome of services so far and the PHE review, it says that there was a statistically significant increase in the eligible population reach by a universal service during 2015-16. It states also that, largely, there is a positive national picture of progress with statistically significant improvement observed in many relevant outcomes over the lifetime of the national health visiting programme. However, it points to some large local variation and trends in the rates of breastfeeding, which it says are disappointing. It points also to the fall in the number of health visitors in employment in 2015-16. Will the Minister comment on the issue of disappointing rates of breastfeeding on the one hand and the fall in the number of health visitors on the other? What action do the Government intend to take on that?

Baroness Walmsley (LD)

My Lords, I am delighted to support these regulations because I am an enormous fan of a universal health visitor service, and in particular the healthy child programme. Our economy is never going to keep up with the demand for health services unless we pay more attention to the issue of prevention. That really is the public health agenda. Any doctor will tell you that you really must lay the foundations for a healthy body, lifestyle and habits in the early years or you will get illnesses later on. The review of the programme so far has been very positive. As the noble Lord, Lord Hunt, said, there have been significant improvements in the populations reached. However, we will not see the true benefit of this programme until we are years down the track and find that those young children who have been given a healthy foundation grow up to have fewer of the terrible but preventable chronic diseases that are costing the country so much.

I am very proud of the coalition Government’s vision of improving the health outcomes of children, young people and their families. Transferring the responsibility to local authorities was part of that: it gives them the chance to combine services, right up to the age of 19. However, as the noble Lord, Lord Hunt, said, there are serious questions to be asked. The first, of course, is about resources. Although these services are mandated, and although the Minister may say that the money has been ring-fenced, budgets have been cut and are going to be further cut. Local authority councillor friends of mine tell me that it is getting more and more difficult for local authorities to provide even those services which they are mandated to provide because things are getting so tight financially. I hope the Minister can give us some encouragement on that, although I somehow doubt it.

The other question on resources is about people. We have heard from the Minister about the number of health visitors in training. Are they going to be enough to serve rising demand? We have a rising population and a lot of additional young people and families who require services. A universal service is terribly important because you do not just get health problems among the most deprived. However, there is a great deal of poverty in this country and the need for these services is growing. How confident is the Minister that we will have enough sufficiently trained nurses, given the stresses on all health service staff and given that so many people are leaving and retention is getting more difficult? Are we going to have enough people?

Are there any plans to extend these services a little further up the age range? I am particularly concerned about the large number of children who are starting school between the ages of four and five already overweight, obese or with poor eating habits. So, although the healthy child programme and the reviews that are mandated here in these regulations go up to the final check at two to two and a half years, it is really important that we do it again just before the child goes to school, because at that point they are already at a disadvantage. Many of these children are from a disadvantaged background and sadly these problems occur more frequently in those backgrounds. They get to school and they are already developmentally a good deal behind children from more advantaged backgrounds. I think the proof that we have had over the few years that this programme has been in place is sufficiently convincing to tell us that perhaps we ought to extend it a little bit further.

Lord O'Shaughnessy

My Lords, I am grateful to both the noble Lord, Lord Hunt, and the noble Baroness, Lady Walmsley, for their endorsement of the universal health visiting service. The noble Baroness is quite right to emphasise the long-term benefits that derive from a universal health visiting service of high quality and it is true that it is a great coalition achievement that we should be proud of. I am also grateful to the noble Lord, Lord Hunt, for his endorsement of not only the programme but also the mandated reviews and indeed of local authorities taking ownership of the programme.

To deal with the funding issue first, as I set out there is both the £16 billion that is going into local authorities for public health and the extension of the ring fence for another year. I will not gloss over the fact that it is a challenging fiscal environment. We know why that is; it is because the country continues to borrow more than it is bringing in in tax. I do not want to go into the reasons for that for fear of being accused of being too political, but we do operate in a challenging environment. That is why the business rate retention and reform is so important, to give local authorities more sustainability for their own funding base. I should also point out that, whether the issue is smoking or other risky behaviours, we are still making good progress, so it is possible to continue to reduce these kinds of risky behaviours, notwithstanding the pressures that are inevitably placed on budgets. In the round, total health budgets are increasing, not just in the NHS but across all health budgets. So while I do not gloss over the fact that it is a challenging fiscal environment, we are still making very strong progress, not just on health visitors but on a number of important public health issues.

In terms of the point that the noble Lord, Lord Hunt, made about the review by Public Health England of mandated services, obviously there are no plans to review the health visiting service, as I think we are all agreed that this is something we want to happen. Health visitors are popular and desired. I am not in a position to say at this point whether any other services are under review but I shall certainly write to him about that.

Both the noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt, asked about the numbers of health visitors. They increased by 50% in the last Parliament, which I think is a huge achievement. It has become slightly more difficult to track their numbers because they have a number of employers now that the budget has been devolved, but there are still very high numbers of them as a result of the changes made in the last Parliament. There are over 800 training places for health visitors and there are more nurses in the system as well. So there is investment going into the workforce, and I absolutely recognise that there has got to be a high-quality workforce. It is also the case that other healthcare professionals are able to deliver some of these services. If a family, which of course will more likely be a poorer or more disadvantaged family, is receiving support from a family nurse partnership, then the nurses that are delivering that can also deliver the health visit and some of the early reviews, so it is a mixed picture. The number of family nurse partnership places has increased over the past few years as well.

There are a couple of final issues. Breastfeeding is part of health visitor training and indeed their mandate is to encourage greater breastfeeding. I am not aware of the specifics of the variability. I shall certainly look into that. It is a critical part of maternal and child health and to be encouraged. I know that there are variations from one part of the country to another. Whether they are due to training and workforce or to other cultural or longer-term issues is a different question and it is bound to be more challenging in some areas than others.

The noble Baroness, Lady Walmsley, asked about the age range. It is important for the health visiting service to stick to what it does best. I certainly recognise the picture she is describing, having worked in primary schools. There is an increase in children coming unprepared to school, or increasingly to nurseries, whether in their eating habits or toilet habits or whatever it is. The increase in formal childcare places that has been made available to both three year-olds and disadvantaged two year-olds will go some way to addressing that but I shall certainly keep an eye on that issue.

Baroness Walmsley

Sorry to spring this on the noble Lord but there was something that I forgot to ask him. He mentioned the accessibility of school nurses. The fact is that if a school nurse is looking after five schools they are not terribly accessible. I wonder if he might write to me as to whether there are any plans to increase the number of school nurses, because that is part of increasing the child’s health right the way through the age range.

Lord O'Shaughnessy

Yes, I shall certainly be happy to do that, probably looking at it in the round in terms of all the local health support that is available for school-age children. I hope, in responding, that I have been able to talk to all the points that have been made by noble Lords in this debate. I am glad that we all agree that health visitor support to families is vital and is about giving children the best possible start in life. It is why the Government have taken this action to continue to ensure the provision of the five mandatory health and development assessments and reviews so that this service continues to be provided for all families with children aged nought to five. I beg to move.

Motion agreed.