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The NHS operating framework is a vital policy statement in guiding local NHS services in determining their priorities, yet the current guidance does not even mention the needs of looked-after children. That framework will be crucial in delivering the PSAs, as well as the National Service Framework for Children, Young People and Maternity Services and the Every Child Matters agenda. It is therefore imperative that it should be shaped to ensure that children in care have better and priority access to the full range of NHS care and support services, so that those children and young people can overcome the many obstacles in their present and past lives and become well rounded members of our communities.
Baroness Butler-Sloss: I very much support the amendments, as well as the words of the noble Baroness, Lady Sharp. I have had unhappy experience of cases going through the care system where both the PCT and CAMHS have been totally inadequate. The practical problem, which in a sense the amendments highlight, is the inadequacy of the services in many areas of the country, particularly the services of CAMHS, much of which is because it seems to be inadequately resourced. There are children who do not get a first appointment for up to 18 months. That is not good enough. To have a series of amendments like this would be a wake-up call to another government department that it has to co-operate to do something for children who have been so badly treated that they have to go into care. As has been said already, many have been physically, sexually or emotionally abused, or all three. They need more help, not less, but CAMHS is not there to help them. Even the PCT finds difficulty in providing even the most minimal support for these children.
Lord Ramsbotham: I lent my name to the amendment tabled by the noble Baroness, Lady Massey, for the very reasons that my noble friend Lady Butler-Sloss has just given and because of the point highlighted by the noble Lord, Lord Judd. My experience in prison of the number of people who had not had any form of assessment or treatment while they were in care was appalling. By the time they arrived in prison, there had been far too many wasted years in their life along the way. As the brief that we have had from the NSPCC and others says, there is substantial evidence of inequality of health outcomes for looked-after children, as we have all experienced, and the current guidance has not had a persuasive impact on PCTs. Everywhere you look—this includes the whole of the mental health area—the assessment of things like speech and language therapy, which are so important to the development of relationships, are missing because they are not included in PCT plans. We see the outcomes of that when they arrive in care.
I hope that in his reply the Minister will remember his own remarks in the last statements that he made at Second Reading, quoting a remark made by the noble Baroness, Lady Howarth:
- “we should regard this Bill as a wake-up call for everyone responsible for children in care and that ultimately ... depends on implementation”.
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I agree wholeheartedly. So do we all. There is no area where a wake-up call needs to be sent more clearly than those responsible for the healthcare, assessment and treatment of children in care.
Baroness Howarth of Breckland: I was surprised that there was nothing in the Bill about healthcare. That is a crucial part of the partnership, and the Government have done so well in making organisations work together. I thought this was a flaw that we might well want to look at, which is why I support the amendments.
There is a structural issue here. My attention was drawn to it particularly by the Local Government Association, which points out that councils do all they can to bring children into the services they need, with regard particularly to mental health services but also to services generally in terms of making assessments of their health. However, their partners, the primary care trusts, have to work to a set of objectives established by the NHS within which the needs of children generally, and children in care specifically, are usually not given high priority.
I quote two reinforcements for that. One is that when the Children’s Rights Director, Roger Morgan, was trying to look at the needs of children and wanted to be helpful to children in hospitals, that was a really difficult area for him to get into.
Secondly—I cannot quote the particular authority as it was a discussion under Chatham House rules—in a discussion with a chief executive of a hospital trust about how he would give priority to children’s needs and children’s issues, his answer was: “I wouldn’t do that if it actually interfered with my acute targets”. It is very clear that unless we take action children will not get the kind of service they need to promote their health, which will leave a huge gap in the Government’s policy of pulling together the partnership to make sure that the total holistic needs of the child are met. This barrier in improving the outcomes for children is not the ill will of the staff of the PCTs but because of the structure that exists, and the Government will need to intervene.
7.45 pm
Lord Williamson of Horton: I support very strongly these two amendments put down by my noble friend Lady Meacher and the amendments put down by the noble Baronesses, Lady Walmsley and Lady Massey. We have been very slow to recognise the importance of mental health in these difficult cases of prisoners, disturbed children, children in care and looked-after children. It is most important that we should now be specific in the Bill about the need for a proper assessment of mental health needs and have a method to ensure that those needs can be met, and make clear that there should be priority access to child and adolescent mental health services.
I am absolutely convinced that the problems that have been drawn to our attention are sufficiently serious to make it necessary to respond specifically. It is not good enough to talk about it; it is necessary to put provision in the Bill. I very much hope that the Government will agree to that. If they cannot agree it now, I hope that it will be agreed on Report.
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Baroness Murphy: I add my voice to those who have spoken about the need for improved mental health services. I want to talk about my perception of the practical problems. We have heard a lot about the need for CAMHS to respond positively. Certainly, I would not doubt that. I recognise that the Government since 2001 have funded a large number of very helpful initiatives to set up specialist teams for the assessment and prioritisation of looked-after children and specialist services in CAMHS. At present they work well.
There are still difficulties in other areas. The real difficulty is getting the initial health assessment appropriately carried out when a child first comes into care. The children arrive very late. Often they have already had several different placements. One of the reasons services can be reluctant is that they know the children may not stay with them very long. But the real problem is that they are not getting the primary assessment of healthcare when they first come into care. The health assessment has been a sort of “take it or leave it” one. Some children object to the assessment. They say, “Other children do not have to have an obligatory medical, why should I?”. The truth of the matter is that these children are so disadvantaged and the rate of mental disorder is so high—particularly psychosis, as the noble Baroness, Lady Meacher, has already outlined—that it is crucial that we get these children and young people into treatment very early on. That means having quite a simple but well trained assessment by a nurse who is familiar with the process and the questions that need to be asked, and who understands that conduct disorder is often a symptom of very serious mental illness and should not mean the child is dismissed as a “difficult kid”. The real problem here is that we must get these children assessed.
While I accept entirely that PCTs must set up the appropriate services and have those obligations in mind, I think that really it is too late and too little. We need a proper assessment in the early days. I strongly support the amendments of the noble Baroness, Lady Meacher, in this respect.
Lord Rix: I passed a note to my noble friend Lord Williamson because I knew he was going to speak about mental health problems. I was seeking his approval that what I was going to say was appropriate. The note states:
“I think I should stress that children with mental health problems are not learning-disabled children unless such a child has a mental health problem too, but healthcare for all disabled looked-after children must be included in these amendments as an absolute priority.”
The Earl of Listowel: I support these amendments. The level of conduct disorder in this group of children is extraordinarily high. I think we were all shocked when the Office for National Statistics first produced its study of these children, especially those in residential child care. I cannot remember the exact figures now but perhaps the Minister will be able to help when he replies.
What are we doing to these residential child care workers and foster carers by placing with them these
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I have one final point. One could always tell care leavers in the past because of their dental condition and the way their teeth had been looked after. I know there have been improvements but this issue needs continued attention.
Lord Elystan-Morgan: I shall detain the Committee for literally half a minute. The point has been made many times over, both today and on the previous occasion last week, that there must be cohesion and comprehensiveness in the services provided by a local authority for all children. Indeed, that is true also of agencies outside the local authority. It is the very failure of that cohesion in this field that amply justifies the amendment.
The Minister may say that this is catered for in A, B, C, D and other different ways, but if no such amendment is passed there is a very real danger that the present highly unsatisfactory situation will meander on in the same way. The psychological impact of the amendment would be very considerable. In the vast majority of cases one would be dealing with a care order situation, and before you can make a care order under Section 31 it is necessary to show that the child is suffering harm or is likely to suffer harm. Harm includes health, and health under Section 31 includes mental as well as physical health. So it is utterly specific, utterly central and very near to the heart, core and kernel of a high percentage of the cases with which we are dealing.
Lord Adonis: Perhaps I may start in my role as fact-provider-in-chief. The picture before us here is one of much done, but more to do. Between 2003 and 2006, there was a 78 per cent increase in the number of new cases being seen by CAMHS. The size of the CAMHS workforce has risen to its highest level: an increase of 26 per cent between 2003 and 2006. The number of children waiting to access CAMHS is reducing. Approximately 24,000 cases were waiting to be seen by specialist CAMHS at the end of 2006, which was a reduction from 29,000 cases in 2003. The number of looked-after children in social services-targeted CAMHS teams, the initiative to which the
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I hope that the Committee will agree that improvements have been made, but there is still more to do. It is precisely for that reason that, in last month’s children’s plan, we announced an independent review of CAMHS, which will look at how we ensure that children’s services support the well-being of children and young people, and provide integrated support across the spectrum of universal and specialist services, including for looked-after children. We are in the process of setting up that independent review, which will report in the summer.
I fear that the noble Lord, Lord Elystan-Morgan, anticipated entirely my response on the law. The law currently provides in most but not all respects for what is necessary. There is one important respect in which we propose to make changes and to which I shall refer in a moment. Regulation 7 of the Arrangements for Placement of Children (General) and the Review of Children’s Cases (Amendment) (Wales) Regulations already requires that,
- “before making a placement, or if that is not reasonably practicable, as soon as reasonably practicable after a placement is made”,
- “make arrangements for a registered medical practitioner to conduct an assessment, which may include a physical examination, of the child's state of health”.
The regulations provide also that the health assessment should have regard to the child’s,
This means that, unless it is not reasonably practicable—for example, it may not be possible to carry out a mental health assessment of a young baby—the assessment must cover each of these elements of a looked-after child’s health. The involvement of health services in these assessments is further underpinned by the duty in Section 10 of the Children Act 2004 for PCTs and strategic health authorities to co-operate to improve the well-being of children.
The noble Baroness, Lady Meacher, mentioned the professional status of those who conduct the health assessments. The guidance on promoting the health of looked-after children states that the medical practitioner who carries out a health assessment should,
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- “need a link into CAMHS for advice and consultation and a clear access route to refer children and young people who need more specialist help”.
In Amendment No. 47, the noble Baronesses, Lady Walmsley and Lady Sharp, and my noble friend Lord Judd seek to ensure that PCTs have regard to guidance issued by the relevant national authority about the health and well-being of the children and young people who are looked after. The guidance, Promoting the Health of Looked After Children,issued in 2002, is statutory for local authorities, but has no legal status for PCTs and other healthcare bodies. As stated in Care Matters, we intend to make revised guidance statutory for healthcare bodies as well as for local authorities for the first time. That provision is not in this Bill because the statutory authority to do it is given in Sections 10 and 11 of the Children Act 2004. It is on the basis of those sections that we will make the revised statutory guidance applicable to healthcare bodies. That will be a significant change in the direction sought by Members of the Committee.
Finally, I shall deal with the issue of Healthy Care partnerships that was raised by my noble friend Lady Massey. My department and the Department of Health have funded the development of the Healthy Care programme for four years using regional and local partnerships to promote the health and well-being of looked-after children. Activities have included improving the understanding of health issues in respect of looked-after children, training for foster carers and the engagement of looked-after children in arts, music and drama programmes. I will
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Baroness Meacher: As a Grand Committee, we owe our apologies to the staff here as we have overrun very considerably. I am sure everyone will wish to join me in that.
I thank the Minister for his response. Maybe there was a hint of something that will improve what all of us who are involved with the system know is a disastrous situation with regard to mental health. Whatever appears to be there does not seem to be happening on the ground. I thank all Members for their powerful contributions on these important issues, and I thank my noble friend Lord Judd for his generous comments. On the basis that we may well want to come back on this issue on Report in view of the strength of feeling, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
The Deputy Chairman of Committees (Lord Brougham and Vaux): I can confirm what the noble Baroness, Lady Meacher, said. Four and half hours is the maximum that Grand Committee can sit, and you are one minute over.
[Amendments Nos. 25 and 26 not moved.]
The Deputy Chairman of Committees: The Committee stands adjourned until Wednesday 16 January at 3.45 pm.
- The Committee adjourned at 8.01 pm.
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