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Child Health Services

Volume 489: debated on Wednesday 28 October 1987

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3.24 p.m.

rose to call attention to the state of child health services in the United Kingdom, with reference to the recent report Investing in the Future: Child Health 10 years after the Court Report (Policy and Practice Review Group; the National Children's Bureau); and to move for Papers.

The noble Lord said: My Lords, the Court Report was published over 10 years ago in December, 1976. Entitled Fit for the Future, it was the first review ever undertaken of child health services in this country. The group of knowledgeable and dedicated people who, under the chairmanship of Professor Donald Court, one of this country's leading paediatricians, devoted three years of hard work to its production, unlike some committees, looked forward optimistically to its major recommendations being taken up by government and the professions. That was its only error of judgment.

Ten years later, in the foreword to the report that we are now considering, Investing in the Future, the chairman of the Policy and Practice Review Group of the National Children's Bureau, Professor Philip Graham, states:

"There is good evidence that children's needs have been given lower priority over the last 10 years than previously".

So much for all the experience, expertise, time, trouble and devotion freely expended by the members of the Court Committee, and so much for our children. The fact is that within the National Health Service children and young people (13 00BD; million or 27 per cent. of our population) are not a priority group even though in their 1981 document Care in Action the Government identified services for children as a priority and repeated their concern that health authorities should develop plans for an integrated child health service.

One of the principal recommendations of the Court Committee was for an integrated service to help parents care for their children so that they could perceive the services as being relevant, all of a piece, with prevention as the main thrust and close ties between the preventive and curative elements. However, since the Griffiths reorganisation of the National Health Service in 1984 the management of children's services has become increasingly fragmented. There is no such thing as an integrated health service.

I welcome the report of the review group. It may be disheartening but it is timely. When I first saw its sub-title, Child Health 10 Years after the Court Report, I was pleased because I had been intending to ask for a debate on that very subject, because in February, 1977, I had the privilege of initiating the first debate on the Court Report in your Lordships' House. I am also delighted that one of the participants in that debate, the noble Baroness, Lady Faithful, is with us this afternoon, not least because of her role as president of the National Children's Bureau.

Investing in the Future looks at the pattern of child health services in the mid-1980s and compares it with the situation when the Court Committee reported 10 years ago. Ten years after the Court recommendations this latest review points out that since then we have lived through two major reorganisations in the National Health Service, tighter financial constraints have been imposed on the health, education and social services, and there have been changes in family formation and in the social structure, with greater levels of unemployment and individual financial hardship. All those factors have influenced the health and development of our children.

The report continues:

"Meanwhile disenchantment with the way that the child health services are working has grown among many of the professional groups concerned".

In pointing out that there has been no lack of committees, reports and studies on the subject, the review group states bluntly:

"We have been most unimpressed by the action that has arisen as a result of these studies and deliberations".

And, my Lords, well they might be.

The Court Committee recognised the crucial need for effective working relationships between the health, education and social services. The Policy and Practice Review Group set its report, just as Court did in 1976, firmly within a social and economic context. In doing so, it gathered a wide range of views from health, education, social work and voluntary services. It decided that, instead of attempting to cover all the many areas considered by the Court Committee, it would concentrate on preventive services, the school health services and services for adolescents. Those cover the three broad divisions of early life; the very young child with its parents, the school child and the adolescent. They are also the areas which the review group considered to have been most neglected.

Before taking off into the rather grey skies of the review group's findings and reaching the clearer air of their recommendations, it is fair to point out that the

report acknowledges some local improvement in the direction that Court indicated, principally, that there is:

"greater awareness amongst parents and professionals that parents can and should take greater responsibility for their children's health."

The report then moves on to identify key points of special concern and it is hardly surprising that it first refers to one of the most grim scenes in that distressing panorama; namely poverty and disadvantage. We are constantly being told that we are living in a booming, economically stronger society. If that is so, it is all the more reason why we should be ashamed of the fact that the proportion of our children living in poverty has increased, that many more children live in families deemed homeless, with all the accompanying ill-health and misery that that implies, that more children today have unemployed parents and more face unemployment themselves as young adults. Our inner cities are violent, racist, unsafe and frightening places for all children. Children from ethnic minority groups, who are among the most disadvantaged, present new and formidable challenges to the health and social services.

Then there is family breakdown which, irrespective of material conditions, means that more children than ever before will face the trauma of having to cope with the divorce or separation of their parents and the prospect of living in a single-parent family or adjusting to the new partners of their divorced parents.

Finally, the review group turned to the changes in health problems and changes in the health services themselves. The health service problems have changed little in the 10 years since Court. In fact, many of them have grown worse. Immunisation rates remain unsatisfactory, physical abuse is still a major problem, and it is clear that sexual abuse is a far greater and infinitely more complicated problem than most of us have ever realised.

More children and young people today are dying from solvent abuse and drug addiction—indeed more are committing suicide. The young are drinking more and it is a sad reflection on the effectiveness of our efforts at prevention that they are even smoking more. Teenage pregnancy is still a serious problem and the only major change is that today there is actually an increased risk of morbidity in the young mother and her baby.

In the face of those terrible facts, what progress has been made in the integration of health services for children, as the Court Committee recommended over 10 years ago? The depressing answer is "very little". In fact, the present report even states that:

"In some respects there has been a decline in those very areas in which the Court Committee hoped to see improvement".

It is at this point that the Policy and Practice Review Group addressed itself to the areas which it considered of particular concern. That is the heart of the report and I shall devote the remainder of my speech today to those priorities and the recommendations made by the group.

As I indicated earlier, services for young children and their families were chosen as one of the three major areas of concern. A family has two main requirements from the health services, the first of which is to get help in a crisis. That is the area of acute medicine, involving general practitioners or hospitals or both. The second need is based on a long-term relationship between parents and the child health services. Parents must get the support and help that they need to raise healthy children or to bring up a chronically sick or handicapped child. At certain times they will want access to immunisation, developmental check-ups on hearing and sight tests. Those are the areas of preventive medicine. Where are they to obtain these services? Court estimated that about 10 per cent. of children are never seen by a doctor except when an emergency takes them to hospital.

The Court Committee looked at the problem from the point of view of the family and recommended in favour of one first-line source of advice for preventive and acute medicine; namely, the general practitioner in combination with the health visitor and the social worker—that is, the primary health care team. They emphasised the need for special training for all those dealing with children. What progress has been made in 10 years in integrating preventive and acute medicine?

That brings us to the core of the problem—the so-called "turf problems" which bedevil not only child health services but the National Health Service as a whole. The Court Committee did not expect its recommendations on prevention instantly to be put into effect; Donald Court said that it might take 20 years to implement them fully, but I am sure that neither he nor the members of his committee expected that the professions would still be arguing about their territorial rights and practices 10 years later. The children cry out for attention and all that the grownups can do is squabble about who does what. The question is: who in the Government is supposed to be doing what? What is needed here is a strong lead from the Government and an end to the present arguments and confusion.

The second area of particular concern identified by the review group is the school health service. Way back in 1976 the Court Report stated:

"There has been growing concern about the school health service [and] its ability to meet the current needs of the children in school and their teachers and parents".

Ten years later the only discernible change is in the wording of the review group's comment:

"There is a widespread view that, in many areas of the country, the quality of the school health service fails to meet the needs of children, parents and teachers".

There is still no national or local policy aimed at achieving rational and efficient co-operation between GPs and school doctors or resolving the underlying dichotomy between promoting health and treating illness.

Among the recommendations made for the school health service in both Court and the report before us are that every school should have an appropriately trained and named doctor and nurse; that there should be a comprehensive examination of all primary school entrants at about the age of five with parents present; that there should be "open door" personal health counselling for all children in secondary education, with independent access to doctor and nurse; and that there should be a routine health interview between the age of 13 and a year before the pupil leaves school. The group also points to the need for a clear definition of the work of the school doctor and nurse and an agreed code of conduct to guide the professional activity of family doctors, school nurses and school doctors.

The last review of the school health service was carried out in 1974, even before the Court Report. Does the Minister not consider that it is time for another look at the service?

The third area of special concern to which the review group turned its attention was adolescents. The Court Report, which devoted a full chapter to adolescents, stated:

"In recent years it has become increasingly evident that adolescents have needs and problems sufficiently distinguishable from those on the one hand of children and on the other of adults to warrant consideration as a distinct group for health care provision".

So, how have the children's health services been adapted to meet the problems and needs of that special group? The short answer is that they have not. It appears from the review group's report that:

"There has been virtually no movement to improve services for adolescents who are ill, or healthy but experiencing life problems, and rather slow movement to improve services for the chronically handicapped".

One of the Court Committee's recommendations was that there should be provision for small adolescent units in hospitals or, failing that, for a partitioned "adolescent area" in a children's ward. The report before us repeats, 10 years on, that:

"An adolescent ward should he established in each health district".

The present situation is perhaps most graphically illustrated by a recent report from The Caring for Children in the Health Services Group, entitled Where are the Children?, which shows that 62 per cent. of adolescents are in mixed adult-children wards. Most adult patients in hospitals are older people so that adolescents are being nursed in wards where most of the patients are over 65.

Now, the main problems of adolescents are not those of ill-health but of emotional adjustment to the adult world. Those problems will be found in a high proportion of adolescents admitted to hospital. It is for this reason that they need, above all, their own environment, treatment from understanding and appropriately trained doctors and nurses, and readily available services from psychologists, social workers and child and adolescent psychiatrists.

The problems for the handicapped adolescent, unable to take part in normal teenage activities, as he or she tries to negotiate this period of intense emotional and intellectual ferment, are hard to imagine. That they need special care and support is undeniable, not least, as the report says,

"to counter the marked reduction in the quality of both health and welfare services available to disabled teenagers as they enter adulthood".

The report calls for the establishment by 1990 of district health teams to provide the services needed by the young/adult handicapped. Will the Government respond to this and address the overall health problems facing adolescents?

I referred earlier to the major areas of concern, but there is one more which is highlighted in the review group's report. This fourth area is headed "Responsibility for Children". They might well have put a question mark after it, for where is the integrated child health service which Court recommended over 10 years ago?—where the extra paediatric training, the general practitioner paediatricians, the specialised health visitors, the consultant community paediatricians?

The new body recommended by Court, the children's committee, set up by the Labour Government in 1978 was abolished by the Conservative Government in 1981. Ministers have no statutory duty to report to Parliament on health services for children. The effect of these 1974 and 1982 reorganisations of the health service, which among other things took out the area health authorities, was to remove even the obligation on health authorities to employ a senior nurse and doctor whose first responsibility is for child health matters. Consequently, at no level in the National Health Service can responsibility for child health he identified.

Why are we not looking after our children's health as we should be, or providing them with the services they so desperately need? In Investing in the Future the review group identify two main contributory factors. The first is all too frighteningly familiar in our health and social services: lack of resources. Apparently, this country cannot afford even to look after its children properly and this of course, as the report says, is,

"linked to a lack of commitment to the care of children at government. local authority and health authority level".

The second contributory factor must seem incomprehensible, if not reprehensible, to the layperson: the

"unwillingness both by government and by the professions to come to firm decisions about who should have responsibility for different aspects of the preventive services".

With the Government apparently washing their hands of the whole affair, the professionals are left to quarrel among themselves and nothing gets done.

Why, as a country, do we seem unable to recognise and accept the importance of investing in our children? They are our future. Quite apart from having to shoulder in adult life the heavy responsibilities imposed by a complex and difficult world, we should realise, simply as a matter of self-interest, that they are also going to have to look after us and discover how to deal with a large and growing number of very elderly people.

Professor John Tomlinson, a member of the Policy and Practice Review Group and also of the Court Committee, in a recent article in The Times Education Supplement writes:

"The Review Group throw out a challenge to those who manage health and other services. How are children's services planned, delivered and monitored? Who is responsible for coverage? Why do differences exist between districts? Why, for example, after correcting for differences in child population, do some districts run five times as many child health clinics as others?"

This afternoon I hope that other noble Lords on all sides of the House will join me in demanding that the Government, the DHSS and the professions take up this challenge—and provide our children with the services they desperately need.

The report contains a number of important recommendations, many directed to district level. I should like to ask the Minister whether he will tell the House what the Government intend to do to give the leadership called for in this report. Also, do the Government intend to monitor and report on progress? For years there has been talk about making children a priority group. I ask the noble Lord: when are children going to be made a priority group? Also, do the Government intend to use the machinery of the review system to ask for a report on progress towards the integration of child health services, and the setting up of child development and young/adult handicapped teams? Government have a responsibility, which they cannot devolve, to care for the next generation.

In this shockingly materialistic society we are constantly being exhorted to invest in British Gas, British Airways, British Telecom, British Petroleum. Why are we not investing in British Children; investing in the future? My Lords, I beg to move for Papers.

3.45 p.m.

My Lords, first, let me say that the noble Lord, Lord Lovell-Davis, has performed a public service in putting down this Motion. He has given your Lordships' House the opportunity to focus on a very important question—that of child health. I can certainly agree with the statements made in both of the reports named in the Motion, that there can be no more important investment for the future than healthy children.

The Court Report, as the noble Lord said, was the first of its kind. Before this there was little organisation, but much disjointed activity about child health matters. The report called for an integrated service:

"to facilitate the ability of parents to care for their children",
and that is a direct quote from the report. It emphasised many ways of doing this, but basically it tried to link up all those existing services through the family practitioner service, through primary and secondary care functions, and recommended a number of other developments, such as the development of so-called general practitioner paediatricians—I suppose you would call them semi-specialists—in this field to co-ordinate it. It also recommended special provisions for the disabled, the disturbed and the mentally deficient.

Over the last 10 years quite a lot has happened, if not enough, between these two reports, not least the very considerable development of medical technology in this field, such as the development of neonatal intensive care units, special care baby units, neonatal surgery, and so on. These developments, however, are also criticised in the later report on grounds of their rather impersonal approach to the child, the child's parents and the events surrounding the admission of a child to such units.

Time does not permit me to discuss in detail all these various recommendations and comments that are made in the report, and I should like to concentrate upon three—the health service changes, professional inter-rivalry, which has already been referred to, and the fundamental and underlying question of poverty and deprivation.

First, there are the changes in the health services concerned. Over these last few years, and indeed even more so before, child health has been something of a football, for whereas, for example, the area health authorities, as we have already been told, had a statutory responsibility to set up a chain of responsibility, it is true that the newer district health authorities are not obliged to do so and often do not have them. But Court set a target, and, between the time that Court reported and today, there has been a change from some 10 per cent. to some 66 per cent. of districts that have some form of child care team in operation. There are great variations in their actual activities. Court recommended the specially trained GPP to take primary responsibility for child health, and of course advocated various supporting functions of child health visitors and nurses, school nurses and the like.

A great many differences in these variations have taken place, and with considerable enthusiasm these have been promoted in certain areas; for example, Oxford, Dorset, Nottingham and Sheffield. I am sure that many of your Lordships know of many other places where this has happened. The child development teams, as they are now called, and the district handicap teams, as they used to be called, have functioned in a somewhat patchy way and, unfortunately, some one-third of districts are still without such teams.

Much is made in the National Children's Bureau report of the structure that could help to push forward the development of child health. It speaks of liaison teams, community paediatricians, links with the district nursing officers, the training of paediatricians, district teams and so forth. I certainly laud those aims, but I challenge the means.

Elsewhere the report states:

"There has been no lack of committees … We have been impressed by many of them. We have been unimpressed by the resulting action".
I regret to see, however, that much of the report's recommendation is to do with setting up further teams or committees. I have had a lot of experience of such teams. To borrow the report's own words, I have been unimpressed.

I think that the Warnock Committee in 1978 was much nearer the mark when it said:

"there should be a named person who will provide a single and continuing point of contact".
It might seem to your Lordships that the obvious one is the consultant community paediatrician, who should make it his or her business to be in touch with all the appropriate services and who could guide parents and their children and arrange for any help. By all means let us recommend this, but not, I hope, too many teams and committees. I have been a member of too many such teams, including child abuse teams, and I have felt very frustrated. Nowadays the mere name "multidiscipliniary team" conjures before me the image of wasted hours of waffle, often in the best technical jargon but with little to show for it at the end.

This leads me to the second point on which I wish to comment—the interprofessional disagreements. There is perhaps a lack of understanding here, which I am sure the Minister would rapidly point out. The basis upon which the health service was set up in regard to practitioner services was that every citizen should have a family doctor with responsibility for the care of that patient. This of course includes children in all respects.

It is indeed the basis of the so-called independent contractor status of the general practitioner. He often sees any other involvement as an invasion of his territory, yet, wearing the hat of a school doctor, he may do the same to one of his own colleagues without realising the paradox. Worse still, the general practitioner may in some way feel that there is interference from someone called a clinical medical officer or a district community physician, whom he would often regard as some form of administrative doctor. The whole charade goes on in reverse if it is the clinical medical officer who intervenes.

This, I am afraid, is a responsibility that must rest with the profession. I know who will be blamed and the Minister knows who will be blamed: it is the DHSS and therefore indirectly the Government. I have only one suggestion for my noble friend the Minister in this connection. It is to see that every district appoints a consultant community paediatrician of sufficient rank and standing with appropriate sessions at the district general hospital, or, if there is one, a children's hospital to create the necessary machinery and to forge the necessary links. I suggest that these people should be instructed to make an annual report on progress not only to their own district health authorities but also to the DHSS.

I believe that the DHSS could form out of its family division or whatever a special interdepartmental organisation with the Department of Education and Science and the Home Office and should present a report to Ministers on a three-yearly or five-yearly basis, to be laid before Parliament. I accept that this is not easy for there are interdepartmental rivalries in the Civil Service as indeed there are in the medical profession. If there are responsibilities for the hold-ups, these two suggestions might go some way to assist in the development of the child health service.

Finally, I turn to the question of poverty and deprivation. Nearly 40 years ago in a well-known election speech on the improved health of the nation, the Radio Doctor, Dr. Charles Hill, made a famous comment in which he said that it was not MPs but penicillin that was responsible. I would not wish to deny the valuable contribution of penicillin and other antibiotics to health, but actually Lord Hill had it the wrong way round. If by MPs he meant what Parliament does, or the social or economic state of the nation over which it presides then he was completely wrong, for there is now overwhelming evidence that socio-economic factors influence health. In stark terms, people in social class 5 lose on average six years of life to people in social class 1.

That is a very important fact. It overshadows all the medical activities, discoveries and successes over the past 40 years, however much we doctors might like to think that any change was due to our own skills. This applies particularly to children, and is manifest in all the parameters that one cares to mention—physical health, mental health, disturbance rates, educational achievement, and possibly the crime rate. Between social classes 1, 2 and 3A. there is little difference. From social class 3B through to 4 and 5, there is a sharp and progressive decline.

I do not wish to widen the discussion—rather, I do, but I shall not—but it is a fundamental factor in many of the problems that we discuss in other debates, whether on the inner cities, education or whatever. There are all sorts of unfortunate reactions to the publishing of these figures. That is why I listen with a degree of cynicism to some comments made on the health service, social services or employment.

I believe that the fundamental problem must be targeted correctly; it is of course people. I hear all about the ancillary measures, be it housing, change in benefits or the development of small businesses and so forth, which I believe to be important but secondary.

Many years ago I made a maiden speech in another place—nobody listened, I might add—but I am afraid that I have not yet seen the evidence to change my mind. Depending on how one counts them, there are 50 to 400 different possible grants, benefits, supplementary payments, pensions, rebates and the like. All these should be amalgamated into one benefit payable through the tax system and graduated to avoid the poverty trap.

An axial point of requirement can he calculated on the basis of age, marital status, number of children and the like. One knows that the level of change is between socio-economic classes 3A and 3B. By means of negative income tax, this can be adjusted. Thus, if your income was above your requirement, you would pay tax; if it was below your requirement. in or out of work, you would be paid. Incentives can he built in, but there is no time now to discuss that.

That to my mind would be a true social contract between government and people, and all the ancillary engines of public or private origin could still be used to accelerate the development. It should be the next great social reform of the coming years. It has always been talked about but has been deferred on the grounds of cost, difficulty of introduction or because it is too radical. I believe that it is a necessary step to achieve the social contract that I mentioned. While it is not a be-all and end-all answer, it will certainly provide a more just and fair foundation upon which to build.

3.59 p.m.

My Lords, as the noble Lord, Lord Trafford, has implied in a truly splendid speech, there is nothing more important to the nation than the health of our children. Indeed, it is upon our children's health—and incidentally, upon their education—that our social future depends. We should all be grateful to the noble Lord, Lord Lovell-Davis, for giving us an opportunity to discuss the matter, even though he exceeded his time by seven minutes, for which the rest of us will do our best to make amends.

The Court Report was a wise and perceptive document. Its recommendations were widely acclaimed; but, as this new report by the National Children's Bureau makes clear, too few of those recommendations have been implemented, in a short debate such as this I shall merely pick out three specific aspects of this subject in which I have some experience and about which I have some knowledge and some suggestions to make.

First I shall comment on the need for integration, for links as the noble Lord, Lord Trafford, said and to which the noble Lord, Lord Lovell-Davis, referred. In both reports it is stated that children very often receive their health care from a wide variety of sources such as the community consultant paediatrician, the general practitioner, the school medical service, the hospital service and others. It has been my experience from many years spent in medical practice that when many people are responsible for a patient's health there is a tendency for no one person to accept the responsibility. I found that with the elderly and it is now true with children.

I too should like to see a named individual in each area with specific responsibility to monitor the adequacy of the provisions for child health care in that area. In some areas there is such a person because people with initiative, enterprise and qualities of leadership have taken up that position; but we cannot wait for that to happen. We must make sure that it happens in every area.

I wish to highlight and underline what has been stated in both reports and in the two speeches that we have heard today about the socially and economically disadvantaged. Section 6 of the latest report dealing with patterns of mortality, morbidity and handicap seems to me to echo the words of the Black Report, Inequalities in Health, and the later report of the Health Education Council.

I listened with great interest to a debate that took place here last week on inner cities. I did not take part in that debate, but it is perhaps of some interest to noble Lords that the week before I spent a day in Moss Side in Manchester in the company of a social worker and a consultant venereologist trying to talk to a number of 12 year-old girls many of whom were regularly engaged in prostitution and most of whom were riddled with venereal disease. That is a child health problem. It is not a problem to which I have any immediate solution; but in the light of this debate, and the debate on inner cities, it is right that I should have mentioned that particular very sad and distressing experience that I had only a fortnight ago.

I now move on to the subject of nutrition. This is a subject about which a junior Minister in another place has said a great deal in many places. When I first entered the other place many years ago as a member of a small party, sometimes we voted with the Government (which was a Labour Government at that time) sometimes with the Conservative Opposition. I soon learnt to tell which party was which because on average the Conservatives were three inches taller than the Labour Members. I was able to confirm that fact scientifically as a doctor in the House during the years that followed. That difference arises on the one hand from centuries of good nutrition, and on the other hand from centuries of inadequate nutrition. Improved nutrition for our children in deprived areas is absolutely vital.

I now wish to say something about a substance which perhaps the noble Lord, Lord Trafford, and I daresay the noble Lord, Lord Rea, who will be speaking presently, will regard as dangerous. That substance is milk. There are doctors who think that every bottle should carry a government health warning. I am well aware of the potential dangers of excessive ingestion of cholesterol and animal fats, but I believe that milk as a source of nutrition for under-nourished children is very valuable indeed. I believe that the disappearance of free school milk was a very sad step.

Only a year ago on the 5th November 1986 I asked a Question of Her Majesty's Government. That Question was:
"What would be the cost of restoring free school milk to all children attending state primary schools?"
The Answer that I received from the noble Baroness, Lady Hooper, was:
"The annual cost of offering one-third of a pint of milk free to all children attending state primary schools in the United Kingdom on each school day is estimated at £10 million".—[Official Report, 5.11.87: col. 1175.]
That is chicken feed. I believe that the restoration of free school milk would help nutrition in some of the underprivileged areas. I have no doubt that it would receive enthusiastic support from the dairy farmers but that is another matter.

I refer briefly to the sections on immunisation which appeared in both reports. This is a vital subject and there is no doubt that adherence to the immunisation programme has effected radical changes in the health outlook of our children. Noble Lords will know that the immunisation programme has been damaged from time to time by rumours about the potential dangers of certain vaccines, in particular pertussis or the whooping cough vaccine. After the case of Johnny Kinnear, the case of Susan Loveday is coming before the courts. She claims that the whooping cough vaccine left her brain damaged. The judge in the case has wisely decided that first he must decide whether or not the vaccine does or does not cause brain damage.

Not long ago I introduced a short debate on an Unstarred Question on this subject asking the Government about steps that had been taken to introduce and develop a wholly safe and yet effective vaccine. The noble Baroness, Lady Trumpington, who was replying told the House that work was going on with a new acellular vaccine and not the whole cell vaccine. The noble Baroness also said that the vaccine had been pioneered and developed at Porton Down and that it was now ready for clinical trials. However one of the scientists at Porton Down told me that the vaccine had been ready for two years. That is water under the bridge and I make no complaint about that but it is a fact that that acellular vaccine has been in use in Japan, in Sweden and in the United States for some time. It is high time it was in use here.

I hope that when the noble Lord replies he can tell us about those clinical trials and when, if at all, we shall have the advantage of that new, safer and effective vaccine because that will do much to ensure that the immunisation programmes throughout the country is adhered to. This is an important debate and I hope that Ministers are listening to what is said.

4.7 P.m.

My Lords, I should like to thank the noble Lord, Lord Lovell-Davis, for giving us the opportunity of discussing this report today. I bring to your Lordships a few relevant matters concerning sick children which are of the greatest concern to many at this moment.

Chapter 4 of the report Developments in medical knowledge and technology states that:
"medical advances have occurred in the management of most chronic disorders".
I wish to tell noble Lords about the problems of children with two of the conditions mentioned in the report: cystic fibrosis and leukaemia.

In one of the biggest hospitals in Europe, if not the biggest, St. James University Hospital in Leeds, is a paediatric ward which is the most crowded and active ward that I have ever seen. I visited that ward some weeks ago. In it are children from all over the Yorkshire region and beyond who have cystic fibrosis and leukaemia as well as the general sick children from the local health district of Leeds East.

In the last few years there have been encouraging advances in the treatments of these specialised conditions. The ward was packed with the most appealing children, some of whom were walking round with their transfusions attached. At either end of the ward there are playrooms which are so small that much movement is difficult. The doctors and nurses had to write up their notes squeezed into the ward and had no privacy.

One of the greatest concerns is the low staffing levels and the changing nurses, which is due to the stress under which they are working and the difficulty of recruiting nurses at this time. It is well known that children prefer to have continuity of care, especially those who have a condition which means frequent return visits to hospital.

After my visit I wrote to our regional chairman telling him of these circumstances and stressing the need for further facilities so that all children who need treatment can be treated without the stress of waiting, which could mean life or death.

The specialised regional units such as the Leeds Oncology Unit need the security of specialised funding. Yorkshire has pockets of high leukaemia numbers. The parents are grateful for the treatment that their children receive. They have raised about £250,000 over the last few years for research and equipment but some of that has had to be spent on staff wages.

It seems to me vital that all children who need specialised treatment should have it in a centre of excellence where the expertise and equipment are concentrated. It also seems unfair that the districts where the units are situated should have to find most of the funds. I wonder, should these units either be funded with money coming from the patient's home district or be funded by the regions themselves? All specialised units perhaps have this problem across the country.

With the medical advances in treatment and the greater demands on the National Health Service, somehow more money must be forthcoming from whatever source it can be retrieved. There is nothing so important as good health and the correct treatment when a child is ill. Should districts have to pay the bills to the specialised units outside their own district there would have to be a safeguard that they would do this: otherwise, should they refuse to do it, the child might die. One must never let an argument between districts cause an unnecessary death.

Some weeks after I had visited the children's ward at St. James's, Yorkshire Television showed some programmes including this ward, and there has been much public support for it. However, for long-term funding we must find a satisfactory way of ensuring on-going support for all such units, which give such excellent and life-giving treatment.

Another problem which has recently arisen in the other Leeds Western district—I received communication about this—is that a paediatrician who was treating various handicapped children has been taken off to work on child abuse. Children's appointments have been cancelled and there are some very worried parents. The concern about child abuse must of course be tackled with the utmost care and good practice, but growing handicapped children who need expert over-seeing should not be left out in the cold or neglected because of this.

One of the greatest modern tragedies must be the infection of haemophiliac children with the HIV virus from infected Factor VIII serum and from their mothers who have been infected. On page 40 of the report it says that it is uncertain whether these challenges can be met effectively. I have visited the haemophiliac unit at Newcastle-upon-Tyne. I have read in the press that the Government are to give extra money to the London health districts most affected by AIDS, and I should like to ask whether the haemophiliac unit in Newcastle will be helped too.

The staff at that unit are excellent; but one can see the emotional stress and the cramped facilities which the staff have to suffer. I hope that the Government will not forget the North, which seems to have been badly hit by infected Factor VIII. Will there be any compensation for these families which are now having to cope with HIV?

I end by quoting from page 73 of the report:
"More and more children are known to drink alcohol and there is evidence that alcohol-related health and social problems in young people are rising".
Having chaired a committee on young people and alcohol for the past few months, I can wholeheartedly agree with that. Realistic health education should be given to all young children and their parents on the dangers of alcohol, drugs and cigarettes.

Also, concerted efforts to crack down on the problem of under-age drinking should take place in every local community, such as has been done in Driffield. A youth worker who runs a popular club is quoted in the Yorkshire Post of 22nd October as having said:
"We had very young children arriving at the club drunk. One girl was in such a bad state that she had to be taken to hospital. I felt something had to be done urgently".
Children are now searched for drink when entering the premises and warned that anyone found either drunk or in possession of alcohol can expect to have their parents informed. There is also co-operation from the town council and the police. The results sound encouraging. There is a great deal to be done to stop children ruining their own lives and to make them realise how important a healthy lifestyle is for a successful future.

4.15 p.m.

My Lords, I am limited by time and therefore I shall concentrate on the particular aspect which I see from the point of view of a general practitioner with an interest in child health, working at clinical level in a National Health Service group practice in a health centre, with very much a team approach to the problem. I am not talking about the administrative teams who talk about things; I am talking about the teams who actually do things on the ground.

I am fully aware that many general practitioners in this country do not have any training in paediatrics and do not have a particular interest in providing preventive services and surveillance for the child population on their list. But it is also true that the number of general practitioners who have had some experience in curative paediatrics and who are holding a child health clinic in their practice setting is increasing.

However, it is perfectly clear that another group of medical practitioners—the clinical medical officers—will need to exist for some time to fill in the gaps which are not provided for by the general practitioners, however much one might favour an eventual solution in which general practitioners will be the sole providers of the primary care branch of an integrated child health service.

Court recognised that the clinical medical officers would be needed for some time and suggested that they should become child health practitioners. It was suggested that their more senior colleagues, the senior clinical medical officers, should in many cases be upgraded to become consultant paediatricians with a special interest in community child health care, alongside a new generation of specially trained consultants in that field. I was delighted to hear the noble Lord, Lord Trafford, come out so strongly in favour of the further strengthening of this group of professionals.

This consultant community paediatrician should take overall charge of the community aspects of child health care in the district, particularly the preventive aspects, and would supervise the arrangements for the care of children with special needs. There are now some 80 of these specialists appointed around the country, but it must be remembered that there are some 190 districts and it is thought that in some cases two or even more specialist community paediatricians will be needed for each district; so there is still a long way to go.

Since the first reorganisation of the National Health Service in 1974 the clinical medical officers, who were formerly led by the often much-lamented medical officers of health, have not been a happy group. I think it is reasonable to say that one of the main obstacles to implementation of the Court recommendations has come from that body, sometimes known as the third force. But general practitioners themselves could not accept the concept of the general practitioner paediatrician which was put forward by Court and which created a general practitioner who was a different kind of animal from other general practitioners who were providing a comprehensive service, so they said.

It has been said that the Court recommendations, admirable though they were, represented an ideal solution and were ahead of their time. It has also been said that they were possibly out of touch with the reality on the ground and the feeling of "the troops". But in fact the basic soundness of the proposals has been borne out by a number of joint committees and fora—numerous, as the noble Lord said—which have subsequently considered where to go from here.

The general practitioner paediatrician was not acceptable as such, but there is general awareness that all general practitioners should be better trained in paediatrics, and this is now being steadily accomplished by the vocational training programme for new principals in general practice which has become mandatory since 1981. Ideally, all vocationally trained general practitioners should have spent six months in a hospital paediatric post, since children's health forms a very large and absolutely vital part of the work of all general practitioners. Sadly, there are not enough senior house officer posts to go round, so that of the 1,200 or so GP trainees in any one year, rather less than 80 per cent. manage to find junior paediatric hospital jobs.

I believe that the Government should address that problem and I suggest that additional senior house officer posts in paediatrics should be created. Those need not necessarily be in hospital paediatrics, although I think that sound training in clinical paediatrics is an essential part of the training of all doctors who are going to provide family care in the community. I suggest that the problem might be accommodated by the creation of an additional 100 or so posts in community aspects of child care throughout the country. I should like to see all paediatric senior house officers spend part of their time in such jobs so that they have the equivalent of perhaps four to five months in hospital paediatrics and one or two months in community paediatrics.

In the long term, that course need not result in any extra expenditure because the rundown of numbers of clinical medical officers, coupled with the increase in GPs competent to undertake child health care in the full sense in their own practice, will result in savings which will more than offset the additional cost. But as with any new development, to start with additional moneys may have to be found. However, in the long term a financial saving might well result.

Perhaps I may remark in passing that in their anxiety to cut expenditure in all fields, this Government do not necessarily take sufficiently into account the fact that sometimes a little extra expenditure now may result in not only a better service in the future but also in less expenditure and possibly considerable profit, particularly in other fields. That is certainly true with regard to the Government's attitude towards scientific and medical research. Too often one hears remarks, not only about selling the family silver (even though that looks a bit more like pewter just now), but also about eating the seed corn. With the forthcoming White Paper concerning primary care, the Government have a good opportunity to put forward proposals which will encourage GPs to provide the sort of comprehensive primary care for children which is suggested in the excellent paper which we are discussing.

There is little doubt that where curative and preventive services are integrated, better coverage of the child population is achieved both in screening and in immunisation. Many group practices have achieved a far better immunisation rate than that achieved by child health clinics held apart from the familiar GP who provides curative services for the child and its family. In actual practice the major part of screening, health education and preventive services, including immunisation and the collection of statistics, is carried out by health visitors. It is valuable for health visitors to work with the doctor with whom the family is familiar.

I agree with other speakers that the intraprofessional and interprofessional disagreements are beginning to be cleared up. I suggest that it is up to the Department of Health and Social Security to take a lead both centrally and by encouraging districts to come up with working plans for the implentation of a comprehensive health service within a set period.

I strongly support all the main recommendations made in Investing in the Future. I particularly like the suggestion that parents should hold their children's health record. Fewer such records are lost with that system than if they are filed and brought out at each attendance. For instance, practically no records were lost, even in a primitive and illiterate Nigerian community, when such a system was first begun on an experimental basis by Professor David Morley in the early 1960s. On the other hand, in hospital outpatient clinics it is true that regularly 5 per cent. to 10 per cent. of hospital records cannot be found when they are needed.

Another point which I strongly support is the need for continuing research on methods of surveillance of young children. Many of the procedures now in use have never been fully evaluated. I endorse the suggestion which has been made about school health services. There should be one doctor and one nurse per school.

Like the noble Lord, Lord Trafford, I am convinced that the future lies in a service which is consultant-led in each district and in which the actual care of children is carried out by suitably trained general practitioners in conjuction with health visitors. I hope that the Government will take action along the lines which are suggested in this excellent report.

4.25 p.m.

My Lords, I should like to take the opportunity of congratulating the Policy and Practice Review Group for the production of this report under its distinguished chairman. Professor Graham, the Dean of the Institute of Child Health at Great Ormond Street Hospital, and the 17 members of that committee, drawn from the statutory and voluntary sectors of health, education and social services. The noble Lord, Lord Lovell-Davis, introduced a debate in this House on 17th February 1977 following the production of the Court Report in December 1976. I am not going to list what has been done—and well done—since then, and much that needs to be done. Other noble Lords have referred to those matters.

However, I should like to cite four points on which there is overlapping between different ministries and different local authority departments and health services. I shall also touch upon what I think should be done about those matters.

First, I cite the position of families who are living in bed-and-breakfast accommodation. That means that the family lives, sleeps and eats in one room. The effect upon children, who have no place to play, is absolutely appalling. In 1972, as director of social services in Oxford, I called a meeting in the town hall to bring to the notice of Members at Westminster, civil servants and local government officers the position with regard to homeless families and the effect that it had on children. I regret to say that the position now is worse than it was, rather than better.

Secondly, school dinners are no longer served except to those on supplementary benefit and family income support. I am told that in some areas—particularly the inner city areas—children do not have a nourishing midday meal. That is very understandable. Furthermore the positive social help which a school dinner provides is not given to children. No allowance is made for supervision of such meals. That is an example of the difficulties we find between education and the Department of Health and Social Security.

Thirdly, I am concerned with the matter of disturbed children. I am the governor of two schools for maladjusted children and I visit a third school. The staff of all three schools say that children show signs of deeper emotional disturbance than ever before. In addition, the policy of the education department is to deal with those children so late in their lives that in adolescence they have real problems. Had they been given specialised help at an earlier stage, perhaps such difficulties would not occur.

My fourth point concerns the uneasy relationship between education, social services and health services. That uneasy relationship exists not only at a local level but also at government level. In Chapter 16, paragraph 9 of the Court Report, it is recommended that:
"The Secretary of State for Social Services in England and Wales should have a statutory duty to lay before Parliament from 1979 a triennial report on all aspects of their responsibilities for children together with relevant reports from the Department of Education and the Home Office".
My noble friend Lord Trafford has already referred to that matter.

What is most worrying is the fragmented, uncoordinated and overlapping services given by the Department of Health and Social Security, the Department of Education and the Home Office. May I suggest, first, that the Policy and Practice Review Group of the National Children's Bureau, who produced this excellent report, should remain in being and it should be resourced at any rate in part by the Government.

Secondly, at local government level there should be produced every three years—I think my noble friend Lord Trafford said one year, and perhaps he is right—a joint report from Health—that is, the general manager, the district medical officer, the consultant community physician, the social services, the education department—and this report should be produced and referred to the local authority, the government departments and the regional health authority.

Thirdly, at central government level there should be produced, possibly based on local reports, by the Department of Education and Science, the Department of Health and Social Security, the Home Office and the Department of the Environment, which covers housing, a joint report covering the services for children. This joint report should be presented to Parliament. Thus the services for children could be monitored and recommendations made, and perhaps the present fragmented services could take a unified look. Perhaps such an exercise would bring together those working for children in the different areas.

Until people at local and central government level come together we shall be unable to get satisfactory service for children. The social services departments in local authorities, the health departments and the education departments are coming closer together but I contend that if they had to report together and produce a report together this might bring them together.

The noble Lord, Lord Lovell-Davis, said that investment in children is a positive investment, and it is one which the nation cannot afford not to make.

4.33 p.m.

My Lords, I should also like to thank my noble friend for introducing this debate, the more so because I do not think that children's issues are debated often enough in the House. For that reason we are doubly grateful to him.

The Policy and Practice Review Group, which in my view is a body nearest to having an Ombudsman for children and a Minister for children, and about which I have spoken in this House, is of enormous importance in integrating all the interests of children from one central position. The report shows the importance of greater integration of all services concerned with children's health. The noble Baroness, Lady Faithfull, made this point very strongly, saying that there should he an effective working relationship between the health service, the education and social services and all voluntary organisations concerned with children's health.

The report makes some very important recommendations which have already been commented upon. I should like to mention briefly three of them. First, I should like to comment upon the recommendation about the psycho-social aspects of child health. The report says that family doctors, community-based nurses working with children, paediatricians and clinical medical officers need more in their training about the psychological and social problems they meet and the impact that these have on the health of children. Surely, this must be of enormous importance. We really do not know the effect on the health of a child of having an unemployed father although we have quite a good idea now what homelessness means to a child's health. As the noble Baroness, Lady Faithfull, said, we shall soon know what effect the loss of nutritional value in school meals is going to have on the health of a child. All these aspects really must be considered by family doctors and by all other groups mentioned in the recommendation.

Secondly, I comment briefly on immunisation. I am interested in this subject through my work with UNICEF, especially the idea that parents should provide evidence that a child entering school has been immunised. The report says this should enable us to reach the immunisation level of 90 per cent. by 1990. I hope very much that this will be so because China, which is a poor country where a quarter of the world's children live, has the objective of 85 per cent. nationwide immunisation for the same year. This objective has the support of both UNICEF and the TUC.

The recommendation regarding greater care for adolescents is, I feel, very important. From my knowledge of adolescents and my own children in particular, it is a very difficult time for parents to involve themselves in the health care of their child. Adolescents are becoming more and more independent. Parents are not allowed to involve themselves although adolescents are not really adult enough to care for their own health.

Many health risks confront adolescents. These have been mentioned today—abuses of drink and drugs, the abuse of glue and the danger of anorexia which seems to be a growing illness among girls. There are other health risks which seem to affect young people. I do not believe that we are taking enough precautions to help adolescents through that very difficult time.

I give a personal example. It concerns my daughter who is a serious asthmatic. She has just gone to university leaving her parent in a great state of anxiety. On arriving at university she found that there was a clinic specially designed to look after young people with chronic illnesses such as asthma. The young people were made to feel that they were not making a fuss. A young person is very worried about seeming to make a fuss about an illness. The clinic made her feel that she was responsible for her health and her asthmatic state and that it wished to support her and to do everything possible to help her.

This is a real example of how adolescents need extra support. They are out of the reach of their parents for all sorts of different reasons even in families where everything goes very well.

A very important area of child health is what happens in hospital. I was going to refer to another important report. It is called Where are the Children? It is a joint report from Caring for Children in the Health Services of which the National Association for the Welfare of Children in Hospital is one representative. They base their report upon four standards. The first standard is that children should be admitted to hospital only if the care they require cannot equally well be provided at home or on a day basis. This seems a very important standard. The most common stay for a child in hospital is two days. This means that an enormous amount of extra responsibility will be put onto the parents. They will need greater support in looking after a child returned home earlier than would previously have been the case. There must also be greater support in the community, with a greater number of registered sick children's nurses to help parents whose child is returned to them still ill and who will be looked after at home instead of in hospital.

The next standard is that children should be cared for in hospital with other children of the same age group. This again seems very important. Yet this report comes out with a figure which is worrying—namely, that in 1984 as many as a quarter of the children discharged from hospital had been in adult or mixed wards. It is important from every point of view, including the psychological one, to keep children together in a ward. It is worrying for them to see grown-ups who are ill. I am again thinking of an asthma case. It is worrying for a child to see a grown-up asthmatic. If children are kept together in a ward, their play, education and special visiting can continue.

A further standard is:
"Children in hospital shall have the right to have their parents with them at all times provided this is in the best interest of the child."
Accommodation should therefore be offered to parents if they wish to stay the night. Visits by relations or parents to a child should not be seen just as a social visit but as a truly therapeutic and preventive occasion. Although some hospitals allow parents at any time, they do not welcome them and include them as part of the child's treatment, which would seem to be the best way in which to involve parents in the care of the child when the child is released from hospital after a short stay.

The fourth standard is:
"Children shall enjoy the care of appropriately trained staff, fully aware of the physical and emotional needs of each age group".
A child will go to an X-ray department, which for a child is again a frightening experience. The radiologist will not be trained in the care of children, and the child will therefore be upset at being X-rayed. All staff involved with the care of children in hospital should have special training in the care of children.

I was pleased to be able to point out this important report on the worrying time in a child's life, which is when they spend a little time in hospital. It suggests how they could leave without any trauma, and how at the same time their parents could he involved in their care. Parents could be initiated into how best to look after their children. I should like to congratulate the authors of this important report. I hope that the Government will view its recommendations favourably.

4.43 p.m.

My Lords, I also add my thanks to the noble Lord, Lord Lovell-Davis, for initiating this interesting debate. The 19th century public health movement in this country depended for its success in coping with infectious and deficiency diseases upon a range of local government activities beyond medical ones. Some were legislative and some were regulatory; for example, with regard to housing and the workplace. Many of their activities were involved with the care of children in school.

In these respects we led the world. An important central figure of great influence was the medical officer of health. He co-ordinated all efforts. In the 1974 reorganisation of the National Health Service, as has been mentioned, local authorities handed over to the health service a number of important functions. The medical officer of health disappeared, leaving a number of his staff in limbo between local government and the National Health Service.

Child welfare and school health services were brought within the NHS, so general practitioners were responsible for the children. However, the primary care service did not statutorily include developmental assessment, previously the responsibility of the local authorities. After 1974, the child services continued to be the responsibility of the community health doctors employed by local authorities.

Clearly, as has been said, the 1974 reorganisation gave rise to much overlap, confusion and inefficiency in the child health services, and the children suffered. Child patients had to attend too many clinics and there was a great deal of friction and confusion in the running of the service.

Conscious of the unsatisfactory fragmentation of child health services, the Government set up the Court Committee in England and the Brotherston Committee in Scotland. They both came to the same conclusion; namely, that the National Health Service should provide an integrated child health service. Both reports envisaged the phasing out of local authority based staff, and that the basis of an integrated service should be the traditional primary care services provided by general practitioners and secondary care by consultants and supporting staff.

Local authority staff were substantial at this time. They consisted of 650 senior clinical medical officers and 1,100 part-time clinical medical officers in England and Wales. General practitioners were not happy with the Court Report because the proposal for a general practitioner paediatrician—a principal recommendation—seemed to them to undermine the general nature of general practice. And many of the original functions of local government medical officers were to become the responsibility of the emerging specialty of community medicine.

The community medicine committee of the British Medical Association proposed an arrangement called a third force which was unacceptable to the royal colleges and to the Central Committee on Hospital Medical Services. The Government have consistently said that they cannot proceed with reorganisation until there is agreement within the profession. I understand that the point has now been reached that there is agreement within the profession.

A substantial debt is due to the British Medical Association, which set up a forum of all those involved to discuss these matters. The idea of a third force has been abandoned, and the general principles of the Court Report have been accepted.

Two of the important agreements are that clinical medical officers will work with general practitioners and provide the child surveillance service within general practice. Local government senior clinical medical officers have accepted that they will either be promoted to consultant rank, if they meet the required criteria, or while enjoying a good deal of autonomy will he under the general supervision of consultant paediatricians, with special interests and training in community child health.

Thus at last the prospect of an integrated child health service, so widely recognised as necessary, seems hopeful of achievement. It is now agreed that curative and preventive children's services should be part of the one service.

Because there are so many special problems involved with schooling—psychological, dyslexia, dysgraphia, specific learning difficulties, the education of the physically and mentally handicapped and others—the school health service requires to remain a separate service. The consultant staff should be provided by clinical paediatricians, but each school should have an indentifiable medical officer to whom the teachers at that school can relate. That point has been stressed by a number of speakers. The payment of general practitioners for undertaking assessment duties will have to be resolved. They will also require special training.

Unfortunately, the Cumberlege Report on nursing in 1986 runs contrary to the Court Report. It envisages general duty neighbourhood nurses working only in the community and divorced from the hospital. If children are to be allowed out of hospital as soon as possible, it is essential that specialised nursing should be available at home. This should be in two forms: children's nurses working in the community, and nurses from specialised paediatric departments going to the homes of children who have been discharged from hospital. Many speakers have stressed the importance of this aspect of the care of children.

It has taken 10 years to get agreement within the profession, but integration of all children's services, curative and preventive, is necessary and it is to be hoped that the Government will pursue with vigour this policy agreed by the profession.

However, as the noble Lord, Lord Trafford, has said, our central problem remains. Until it is resolved chaos will continue in spite of many of the committees that the noble Baroness, Lady Faithfull, has mentioned. Who is to be the person who conducts the orchestra in a district? Who is going to be the co-ordinator of the service? If the medical officer of health had continued, he would have done it beautifully. Should it be the community paediatrician? Is this the job for a good, experienced, senior clinical medical officer versed in the ways of local government and the National Health Service? Should the responsibility be discharged by the community medical officer or by an administrator? I suspect that the solution could vary according to the circumstances, but I make a plea for no more national inquiries.

4.52 p.m.

My Lords, perhaps I too may say how indebted we are to my noble friend Lord Lovell-Davis for introducing this excellent debate. I also say in particular to the noble Baroness, Lady Faithfull, how much I agree with everything she had to say.

One central theme of the debate goes back a great many years to the early 1960s when the pressure group, Mothercare for Children in Hospital, was founded. Several of our wives were involved in the foundation of that pressure group. In those days most medical staff were antipathetic to parents, telling them little, keeping visiting hours to a minimum, and assuming that parental presence was inimical to the child's recovery. Since those days great victories have been won, especially with regard to visiting and patient information, in both cases adding to the effectiveness of treatment and reducing the trauma of hospitalisation.

However, it is apparent from the NAWCH Report Where are the Children?, to which the noble Baroness, Lady Ewart-Biggs, has referred, and the National Children's Bureau Report that there is still a vast amount to be done. There are still far too many examples of young people, even the very young, not being in separate wards. It is a theme of the moment. With the number of beds being so drastically reduced, for example, in London hospitals, the position is likely to deteriorate. We cannot expect that children's beds will be exempt from the cuts being forced by government on the health authorities, who must keep within their budgets however inadequate those budgets are. We also say that there is a danger, I understand, that the specialist teams of nurses that have been built up to care for children will be split up, again as a result of these cuts.

The main point is that it is necessary continuously to involve the parent much more in all this. Let me say how much I agree with the noble Lord, Lord Rea, in underlining that particularly useful recommendation in the National Children's Bureau Report that there should be a standardised health record kept by the parent. In quoting that report, I support the suggestion that the record card should include space specifically to record the parent's own observations about the child. It is important that the parent should be correctly informed about the child's medical problem and the course of treatment to be employed.

Let me say in agreeing again with the noble Lord, Lord Rea, on training in paediatrics that I hope that some aspect of that training would be to advise doctors that they ought to treat parents as adults and that where there are risks in the treatment these should be made clear; and that should be especially true of the risks with the use of drugs. Regarding drugs, an important technical point is that there should always be paediatric doses of the relevant drugs available. I understand that the way in which small doses for children are dispensed is currently under review. I am not sure whether the Minister can add anything to that.

I am bound to say, because of my interest in pharmacy, the community pharmacist has an important role to play here. It should never be forgotten that he or she is much more likely to be the first contact that the parent and child have with the medical team than anybody else and his or her counter prescribing is immensely important, as is his advice and counselling. We hope that one consequence of the Nuffield reforms, when they are implemented, is that the pharmacist will be able to perform this role so much more effectively.

Reference has been made to social and material deprivation and the health problems from which children suffer as a result of that. With regret, that is unavoidable. The National Children's Bureau Report states::
"We do wish to point out that there is a clear-cut link between … deprivation and many of the health problems from which children suffer. Rates of perinatal and infant mortality, child abuse, cigarette smoking and drug addiction all go up in direct proportion to rates of unemployment, homelessness and poverty. Poor perinatal care and immunisation failure are also more common among the most socially disadvantaged groups"
as the noble Lord, Lord Trafford, pointed out. The report continues:
"We would be failing in our duty if we did not point out that improvement in social conditions would make a greater impact on child health than is likely to occur as the result of any reorganisation of professional work".
There is little doubt, for example, about the correlation between unemployment and ill-health, including especially mental health. Where the doubts arise are about what causes what. One view is that unemployment causes ill-health and therefore affects the health of the children of the unemployed; of course unemployment could be regarded as directly damaging in this as in so many other ways. But the alternative view of this correlation is that the causation runs the other way; that those who are more prone to ill-health are more likely to be made unemployed. However, if anybody tries to find comfort from that it merely serves to underline even further how unfair unemployment is, especially for the children of those who are affected.

It is sometimes said that everybody is sympathetic. No doubt the Minister in his reply will say that. But the words are always added, "This is all a matter of resources". That is somehow supposed to provide an excuse for doing nothing, given the sympathy. Resources are scarce; Lecture 1 in every economics course starts that way. But we are told—in particular from the Front Bench opposite yesterday—that this country is now doing extremely well economically. If that is true, surely we can afford a much enhanced health service especially for the children of this country.

4.59 p.m.

My Lords, I am also very grateful to the noble Lord, Lord Lovell-Davis, for initiating this useful debate. I should like to say that I entirely agree with what the noble Lord, Lord Peston, has said about the relationship of parents and children. I entirely agree, as always, with everything that my noble friend Lady Faithfull has said.

Before I speak perhaps I should declare an interest. Like many of your Lordships I am a parent; and like all your Lordships, I have been a child. It never occurred to my parents (nor indeed to my husband and myself) that, having brought children into this world, we were not the people responsible for giving those children as healthy and happy a childhood as we could, which for anyone is the most secure basis for a happy and healthy future. Neither I nor my children were particularly grateful for all the immunisation injections we had nor the visits to the dentist. But they obviously prevented what was called in the 18th century "kink-cough and total toothlessness".

During the past 30 years there has arisen a feeling that "they" should do something. "They" should pay. "They" should look after our children. "They" should absolve us from all responsibilities. Everybody has a "they" in his life, sometimes not altogether desirable. My grandmother had a "they" who stole her sugar and butter so that she kept it locked in her wardrobe. But in reality there is no "they". "They" is us. It is we, the parents, who are responsible for our own children.

One of the main points made by Professor Graham of the National Children's Bureau in his report is that parents are the most important primary healthcare givers. The report suggests that children's health records should be kept by the parents because they are less likely to lose them than the public authorities. There should be much closer co-operation with parents who can sometimes observe when something is going wrong with a child. Parents should also see about immunisation. In France, East Germany, Saudi Arabia and the United States non-immunised children are not allowed to attend state schools. Something on these lines on a voluntary basis might encourage British parents to see about the immunisation of their own children.

Of course, sadly, there are families without love; there are families in very poor circumstances; there are one-parent families and there are orphans. In all of these cases the children are at risk and need the help and support that can be given to them by doctors and by professionals. Not only do some children require professional help but sometimes in the case of a severely disabled or disturbed child it is the parents who do. Parents, being closer to their children, can always detect something that is not quite right and which, being caught in time, may be cured that much more easily. The policy review group of the National Children's Bureau has laid much stress on the involvement and responsibility of parents in the health of their own children. It is particularly keen for parents to keep the health records of their own children.

Inside each of us is the child we once were and the loving care which we received from our own parents. How important it is that that same love and care should now surround each and every child in Britain today.

5.4 p.m.

My Lords, I, too, should like to congratulate and thank my noble friend Lord Lovell-Davis for initiating this important debate on a vital report. A number of Members have naturally mentioned the fact that it was very sad to see free milk go from our schools. It is a remarkable coincidence. Winston Churchill said that to give British children free milk was a noble idea. Mrs. Thatcher thought so much of that statement that she abolished free milk.

Here we are today discussing the problems of children and only this week Mr. Moore, masquerading as a minister for health, said that he would not increase child allowances. I find that rather distressing. What is this peculiar Conservative quirk to have these orgiastic attacks now and then on British children? We have witnessed it on milk; we have this vital debate today and this is the day that the Minister tells us "No more money for children's allowances".

The report by the National Children's Bureau, a private organisation on child health service, is long overdue. But why did not the DHSS undertake the review? Perhaps when he replies the noble Lord, Lord Skelmersdale, will tell us why. The review has found a lack of commitment by Government, by health authorities and by local authorities to be concerned for the care of children. I find that to be a devastating comment in this day and age.

In 1982 the area medical and area nursing officers for child health were abolished by this Government. That is care for children for you! Just abolish that important group of specialists. At the same time there was a reduction in the child health budgets which caused professional disenchantment among child health specialists. These are all very serious charges which cannot be denied or explained. All the Government have to do is to reinstate the situation that pertained before they inflicted these appalling cuts and attacks on British children.

The Government give the impression that they have no role to play in improving social conditions. Bad social conditions are a danger to anyone's health; bad social conditions are especially a danger to children's health.

I agree that parents throughout the country should, as is recommended in the report, possess standardised records of each child's health. There is also a very important submission in the report from the Health Visitors' Association. Health visitors play a vital role in all facets of health, particularly in children's health. Their record before the First World War was admirable. I have to declare an interest. I am very proud to be a vice-president of the Health Visitors' Association. Its report stressed the importance of the school nurse and the need for a policy statement on her role and function. I hope that the noble Lord, Lord Skelmersdale, will also comment on that.

I turn briefly to the remarks of the report on adolescents who, it says, are in need of improved services. I do not have time to go into what all those improved services may be, but I am sure that most Members of the House understand what they are. The report underlines that there are not enough hospitals with special units and special wards for adolescents. How do the Government intend to tackle that? They have a smashing idea—they want to abolish all the wards, or as many as they can. That is the way in which they tackle these problems. The cuts are bound to worsen the situation that this vital report says exists and is dangerous. The Government's policy is simply to make matters worse.

Pregnant mothers and their children, wherever they live and whatever their economic circumstances, are entitled to the best facilities and treatment within the National Health Service. Here again the report points out that there are ways in which we could improve on the situation for mothers having their children and bringing them up for the first few months, but nothing is being done about it. That is not true. Something is being done about it: the situation is being made worse again. The Government are doing so much in this field, but it is always the wrong thing and above all it is a bad thing.

Preventive and curative medicine are in need of improvement. It is, despite all we have to draw on, important that a register of immunisation should be provided at school entry to ensure protection. I repeat, a register of immunisation should be provided at school entry to ensure protection. We do not do it. In the United States it is the law. I hope the noble Lord, Lord Skelmerdale, will comment on that as well.

We should make much more use of computers, particularly as regards surveillance and preventive procedures carried out on children. By all these endeavours we contribute to a good caring society and hence the cultivation and enlargement of individual life. If a child is neglected in its early years it sometimes carries that neglect throughout the rest of its life. We should take much more advantage of preventive and curative medicine, for that is the base for all other health endeavours. Preventive medicine is health by collective action.

Long before I was born—indeed in the latter part of the last century—a massive contribution was made to the health of this nation, and especially to the health of children, by sanitary inspectors and by medical officers of health. For a century they have played a vital role. Their work meant the creation of social codes that have collective well being as their aim. The sanitary inspector and the medical officer of health recognised the magnificent contributions of people such as Pasteur, Simpson, Jenner, Lister, Semelweis, Fleming, Domagd and RÖntgen. We have a wealth of knowledge, ability and endeavour to draw on to protect our children in matters so vital to the future of our nation.

I should like to make an appeal before I sit down. Let us join with the report and reaffirm that henceforth our purpose will be to promote optimal health for all children living in the United Kingdom for their future as well as for their children's future.

5.12 p.m.

My Lords, I too should like to start by echoing the gratitude which other noble Lords have expressed to my noble friend Lord Lovell-Davis for giving us this opportunity to debate this challenging report by the National Children's Bureau. The bureau, its policy and practice review group, Professor Philip Graham and Dr. Kurtz are to be thanked for their valuable contributions. We have heard that this report is the first review of health services for children since the Court Committee reported in 1976. It has been produced by professionals involved with children's health and their voice is therefore authoritative. Thanks to the report we now know that it was high time that the whole field of child health was reviewed.

The broad picture which emerges is that, nowithstanding the progress made in some sectors of child health care—and ante-natal and perinatal care were mentioned by the noble Lord, Lord Trafford—health care for the children of the poor and the needy has not improved during the past 10 years and indeed has declined for many such children. That I believe is the report's main conclusion. It is a matter of considerable sadness that the authors of the report were driven by the evidence of their own eyes and ears to draw this appalling conclusion. We are entitled to ask the Government where they stand in relation to this finding.

The review group makes a large number of recommendations, but their significance has to be adjudged against its central message (which emerges on page 10 of the report) and which has been referred to more than once this afternoon. That central message is that improvements in social conditions would make a greater impact on child health than is likely to occur as the result of any reorganisation of professional work. In our submission that message overshadows all the other recommendations although they are excellent recommendations. Again we are entitled to ask: when will the Government listen to this message? When will they do those things that need to be done and can only be done by government. Surely there must be some limit to the Government's inactivity in this field.

It is in a sense a matter of commitment. This key word is used by the authors of the report. On page 9 the authors identify the existence of a lack of commitment to the health needs of children at central government level, local authority level and health authority level. If the Government have created the impression that they have no real commitment to improving health services for children, it is not surprising that there should also be a lack of commitment lower down the line and that children are to be found at the tail end of planning. This in turn produces the disenchantment which the review group found to have grown among many of the professionals involved with children's health.

Limited by time and resources the review concentrated on the three main areas outlined by my noble friend Lord Lovell-Davis but even so it produced about 40 detailed recommendations. The press has already highlighted the recommendation that a personal medical record card should be maintained by parents in respect of every child. This recommendation has been supported by many speakers in your Lordships' House this afternoon and we fully support it for two reasons. It involves the parent with the health of the child. Parent involvement is right and we are glad that it is slowly happening. We agree with the review group and with the Health Visitors Association that this recommendation would give further encouragement to parent involvement. My noble friend Lord Peston is right to emphasise that professionals too must change their attitudes towards parent involvement. This would help them to do just that.

We support it for another reason. As health authorities are finding it difficult to keep track of the medical records when parents move from one health district to another and change doctors and clinics, the personal medical record card held by the parent would be an invaluable aid. I have been sent the child record book produced by the community unit of the Nottingham health authority. It has a column for vaccination records, a column for details of hospital treatment; and a page for recording illnesses. It seems to me that this is just what the review group had in mind. This recommendation could be adopted quickly and cheaply by all health authorities. Does the department propose to ask the authorities to implement this simple recommendation.

The report urges a strong push on vaccination and this has also been well supported by the press and in the House this afternoon. Far too many children are still unprotected from measles and whooping cough. Avoidable deaths are still occurring. A Welsh Office health Minister addressing a health conference in Cardiff in September told his audience that this was the time for action. Do the Government have any action in mind apart from exhortation? I have read that the Health Visitors Association has suggested that it would be helpful if the Government could introduce a no fault compensation scheme for vaccine damage. Is this matter receiving Government consideration? I will be interested in the Minister's answer to the question posed by the noble Lord, Lord Winstanley, as to when a safe vaccine will become available.

We have heard that the report contains a number of important recommendations on surveillance and prevention. A great deal has been said about the recommendations and I want to touch on two of the detailed recommendations under this heading. It is recommended that the primary health care team should take over complete responsibility for the delivery of surveillance and preventive procedures. Professor Philip Graham has subsequently explained that he has in mind that it may take about five years before this recommendation can be fully implemented.

We clearly recognise that the GPs have an important part to play in child health. I am sure that the department will pay careful consideration to what has been said by my noble friend Lord Rea and by the noble Lord, Lord Hunter, in relation to this recommendation. Nevertheless there could be difficulties with this recommendation at least in the short term.

I make no apology for referring once again to the Health Visitors Association. My noble friend Lord Molloy is right to point out that they are very much in the front line. I understand that the association is somewhat concerned about this recommendation in the short term, fearing that some of the GPs may not be competent to provide a service comparable in quality to that provided by the health authority, child health doctors in partnership with health visitors, and health workers.

I believe that the Health Visitors Association is here saying something important. I have just been looking at a profile of 214 GPs working in an area covered by one of the inner London health authorities. Of the 214 GPs so employed, 29 are over the age of 70, 54 are over the age of 65, while only 21, who have recently been in the medical schools, are under the age of 34. Moreover, 91 of those GPs are in single-handed practices. That being the position, I would gravely doubt whether many of the doctors in this particular profile would be in a position to undertake training to enable them to carry out the new responsibilities assuming that they wish to be so involved, and that may be an important assumption.

I would not generalise on the basis of this particular profile. We appreciate that the DHSS has commissioned a national project to consider all aspects of the organisation of community child health services, and they will no doubt deal fully with the GP perspective on child health. I should mention that I have read with considerable interest and sympathy a summary of the Secretary of State's statement to the Society of Family Practitioners Committee on 16th October. We just wonder how he proposes to encourage greater GP involvement in child health.

I welcome wholeheartedly the emphasis placed by the review group on the role of the consultant community paediatrician. This consultant was recommended by the Court Report. It has been recommended in your Lordships' House this afternoon. He has a valuable role to play. Without having a committee at his command he would be a link between the hospital and the community. He would go out to the community, attract other professionals concerned with child health services, and together they could generate the necessary driving force and get things off the ground. This has not happened to the extent hoped for.

We understand from the report that there are about 75 such consultants in post whereas ideally we would require about 350 in post. In Wales we have merely one such consultant in post who provides merely half his sessions to community paediatrics. Can the Minister tell the House why so few appointments have been made? Is it the case that the department is at the mercy of the district authorities and that it cannot insist that these appointments should be made?

We support another major recommendation that the school health service should be revitalised. The review has produced at least nine recommendations under this heading. Travelling around the country we hear of dissatisfaction among teachers with the school health service. We hear that there is inadequate communication between teachers and doctors, and vice versa. If the Government cannot today accept the majority of these recommendations then, on the evidence of this report and on the evidence of the report on inequality in health published earlier this year, and notwithstanding what the noble Lord, Lord Hunter, has said, we would urge the Government to investigate the school health service in depth.

The other major recommendation relates to the inadequate health services for adolescents, and here we speak of the young people who, through some misfortune or some difficulty in development, cannot fit themselves into the world we live in, and who need treatment and guidance to help them on the road to maturity. There has been virtually no movement to improve health services for adolescents during the past 10 years. My noble friend Lord Lovell-Davis has gone into the details of this recommendation and I do not propose to add anything to what he has said so eloquently. I am glad that my noble friend Lady Ewart-Biggs referred to the report, Where are the Children? That is a report that is worthy of the department's consideration. I am grateful that the noble Lord, Lord Winstanley, has referred to nutrition. This is not referred to in the report. We should be interested to know what role school meals will henceforth play in a nutrition policy.

The noble Baroness, Lady Faithfull, who is so clearly associated with the National Children's Bureau, and whose commitment to the welfare of children and young people is deeply and widely respected throughout the country, has come up in the course of the debate with another major recommendation. She recommended that periodically the three major departments of state involved with child health should produce a joint report on the impact of their policies and present it to Parliament. We wholeheartedly support that recommendation.

It seems to me that the report would do at least three things. It would identify the problems which are the cause of concern; it should help to ensure that the three departments are not pursuing conflicting aims; and it would help also to ensure the convergence of policies and the co-ordination of policies. We hope this recommendation from the other side of the House emanating from the noble Baroness, Lady Faithfull, supported by the noble Lord, Lord Trafford, and supported by ourselves should be acceptable to the Government, whether or not it is acceptable to the three departments.

The report presents a considerable challenge to the Government and to the professionals concerned. In ending my speech I am left wondering whether there can be any significant advance in the short term unless children's needs are bracketed together with those of the other three priority groups: the old, the mentally ill, and the mentally handicapped. However, this is a point that has already been made by my noble friend Lord Lovell-Davis.

5.28 p.m.

The Parliamentary Under-Secretary of State, Department of Health and Social Security
(Lord Skelmersdale)

My Lords, at 5.38 p.m. on 16th February 1977 the noble Lord, Lord Lovell-Davies, rose to call attention to the Court Report on child health services. Today, 10½ years later, it falls to me to congratulate the noble Lord on providing the House with a valuable opportunity for a much overdue discussion on child health—I agree with the noble Baroness, Lady Ewart Biggs—and to do so in the context of the timely report from the National Children's Bureau on this subject. I should like to congratulate the bureau for what, by any standards, is a comprehensive look at a number of aspects of children's health services.

Let me say at the outset that the Government remain fully committed to the principles of the Court Committee's findings. As everyone agreed then, full implementation of the proposals would be achieved in the longer rather than the shorter term. But it would be wrong to say that nothing has happened. The Court Committee reported at the end of 1976. There was consultation; then a departmental circular was issued in 1978. Credit is certainly due to the last Labour Government—when it is due, I think it oughtto be respected—and to this Government, too. We have not been idle, as I shall seek to show. In the following year district handicap teams were set up and there were other developments to which I shall come later.

The central recommendation mentioned this afternoon by virtually every noble Lord has been consistently rejected not only by this Government but by that of the party opposite. Nothing in that respect had changed. But this afternoon something did change. We heard a most interesting and thoughtful speech from my noble friend Lord Trafford, who asked, why bother with a joint report? Why not have a report from my noble friend the Secretary of State for Social Services, contributed to by whoever my noble friend thinks appropriate? I shall examine that proposal most carefully.

In the last Parliament we gave additional impetus to progressing the report's philisophy by the funding of a number of projects about which I shall speak later. A great deal has been achieved since the committee reported. Today's debate gives the Government the opportunity to put on record what these achievements are. Prevention has always been an essential part of this Government's policy. I certainly agree with the noble Lord, Lord Rea, that—and I précis—prevention is cheaper than cure.

The Court Report was particularly significant in that it sought for the first time to change people's attitudes and to emphasise the importance of prevention rather than later treatment. Early detection of treatable conditions is vital if the full benefits of services available are to be used to the best effect. 1980 saw the DHSS paper Prevention in the Child Health Services which outlined the Government's policy in this area and suggested a basic programme of child health surveillance for health authorities from birth to school leaving age. The importance that the Government attaches to these services was further re-affirmed in 1981 when Care in Action was published. I do not agree with the condemnation by the noble Lord, Lord Lovell-Davis, ofCare in Action which sets out in detail the Government's policies and priorities for health and personal social services in England.

The functions ascribed to the various posts which were described in Care in Action are still excellent. Each district health authority assigns the functions to a senior doctor and nurse according to its own individual needs. The report of the National Children's Bureau recommends the appointment of consultant community paediatricians. My noble friend Lady Faithfull is right in saying that the primary front line in child health care, as in adult health care, is the general practitioner. I am sure that I have indicated the wrong noble Baroness, but never mind.

Many health authorities have made such appointments in recent years and there are now at least 100 in post. I am able to inform the noble Lord, Lord Molloy, that there were none in 1979. The job descriptions vary from authority to authority reflecting differing local situations. The appointment of consultant community paediatricians can considerably help in co-ordinating health authority services for children with those provided by social service authorities and education departments. The report states that what is needed is a doctor who is in charge in a district, whatever one calls him; someone to whom the social services and education authority could turn in the first instance to ask for health support.

I agree with my noble friend Lord Trafford and I was delighted to be reminded by the noble Lord, Lord Hunter of the refreshing attitude of the BMA to the whole problem. It is necessary to have someone but I am not still convinced that it should necessarily be a doctor.

The noble Lord, Lord Winstanley, called for the re-introduction of free school milk. I have not time to develop the arguments fully but there is a contrary medical opinion, as he will know only too well that it is pre-school and not free school milk that is needed. The Government are studying this opinion. Already, supplementary benefit claimants, families receiving family income supplement who have children under five or handicapped children up to the age of 16 and expectant mothers in receipt of supplementary benefit, receive milk tokens which can be exchanged for milk or powdered baby milk. I think it would be right on another occasion to discuss the changes made by the 1986 Social Security Act.

It gives me great although, as noble Lords will perhaps agree, slightly unusual pleasure to agree with the noble Baroness, Lady Ewart-Biggs, on the subject of immunisation. It is obviously an important aspect. In this country there is a comprehensive and, it should not be forgotten, free childhood immunisation programme. We have targets of 90 per cent. immunisation uptake by 1990 for immunisable diseases. While we have already achieved 85 per cent. for diphtheria, tetanus and polio, the level of whooping cough immunisation was only 71 per cent. in 1986. We cannot therefore afford to be complacent, and renewed effort is needed to reach the targets set. I hope that that will be helped by the proposed introduction of a combined vaccine against measles, mumps and rubella in the near future. It will be given to children in the second year of life as the measles vaccine is now. The Government have set their target high and I shall be addressing a meeting of National Health Service staff responsible for immunisation uptake on 10th November to discuss this subject.

In reply to the noble Lord, Lord Molloy, immunisation has never been compulsory in this country except, I am reminded, in the case of smallpox just after the war. There is no present intention to change that situation. A requirement for children to have been immunised, or to be exempted, before school entry, would not therefore be an appropriate step for a district health authority to take on its own. However, responsible officers in health authorities have been asked to assess the immunisation state of all children about to enter primary school and to offer immunisation to unprotected children.

Although the training of staff is primarily under the responsibility of the professional bodies the Government have funded a number of projects aimed at providing training and training materials on the delivery of child health services. Since 1983, approximately £400,000 has been spent on a variety of such training projects. The Government attach great importance to an effective school health service. Since 1978 we have actively encouraged major improvements in the training of school health nurses. I am aware that there is concern that the full potential of this service is not being realised in all health authorities. The department is keeping the situation under active review and will take any further action that seems appropriate.

Adolescents are recognised as a separate group and since the Court Report teenage wards exist as a feature of children's hospitals and some district general hospitals. However, many others use partitioned areas to meet the needs of that group. Recognition of that recommendation is steadily growing, but I admit that progress in some respects falls short of what we would wish. I believe that the right way ahead is a renewed effort by health authorities to identify areas where improvements are necessary.

Part of this subject is parental involvement. I do not know whether one can be described as a professional parent but, if so, then my noble friend Lady Strange could be so described. She put forward the position of parents very strongly and the House will be grateful to her.

We are aware of initiatives which are being taken at this time, for example research on parental child health records which was a point made by one noble Lord. While I initially thought that that proposal was unlikely to work, it appears, on first analysis, that parents take care of their child's health records. It is early days but we shall be watching closely the outcome of that work.

We are all aware that community child health services are complicated and difficult to organise. They are provided by a larger than usual number of professional staff through home visiting, health clinics, health centres and general practitioner surgeries. Effective delivery is far from easy and requires co-operation between health and local education authorities, family practitioner committees, general practitioners, social services and voluntary organisations. Health authorities in particular provide an important input to social services on matters concerning child abuse, adoption, foster services and the health of children in care.

Obviously, circumstances will vary and the means of collaboration for each locality needs to be worked out locally, not by central government—here I certainly agree with my noble friend Lord Trafford—so that services are both responsive to the needs of the local population and as cost effective as possible. Inevitably, there will be problems of communication and varying degrees of co-operation between the groups. As a result the Government have recently funded a two-year project to seek ways of resolving problems which have been identified in various work by the department on the organisation and delivery of those services. The project is currently under way in four health districts and associated FPCs. The results of the project will be available in about 18 months' time and it is hoped that this will enable us to make available additional guidance and advice on the organisation, management and planning of child health services to the relevant authorities.

The noble Lord, Lord Prys-Davies, mentioned the form and content of child health surveillance. This is under active consideration by a number of professional groups at present, and I welcome the debate. The process of child health surveillance must be set in the context of services to the family, and if I am to look to the future I would see, as did the consultation document on primary health care, an increasing role over time for general practitioners in dealing with the medical component of this activity for the under-fives. We have no reason to doubt that that is the right course.

I do not want to pre-empt anything which our White Paper on primary health care may want to say about this subject, but I hope that we shall hear from the noble Lord, Lord Prys-Davies, in the light of his remarks today.

I am pleased to be able to say that in the past year the professional bodies most concerned with child health have made considerable progress. We have heard today about the BMA forum which earlier this year reached agreement on consultant-led community service. We have not heard about the Faculty of Community Medicine, which has a working party on the integration of child health services. Its report is expected soon.

Again, the British Paediatric Association has called together a working party involving a number of medical and nursing professional bodies, and is looking at child health surveillance for the under-fives. Our own child health service project in four districts will also look at the problems of integration. We shall draw all those threads together Integration of services is important and the Government will play their full part in helping to achieve it. I agree most certainly with the noble Lord who said, "For goodness sake, we do not want any more working parties and reports".

My Lords, does the noble Lord intend to answer my specific question about the statement made by the noble Baroness, Lady Trumpington, with regard to the new acellular pertussis vaccine developed at Porton Down which he told the House was ready for clinical trials? Have the clinical trials taken place, and when will that vaccine be available for general use?

My Lords, I am sorry, but I must have skipped that part of my notes. I shall make an opportunity to write to the noble Lord on that subject.

We have covered a lot of ground this afternoon, during which time I have tried to explain as comprehensively as I can in the very short time available how seriously the Government takes the issues raised by the House this afternoon and the action that we are taking to make progress on them. I appreciate that there are many points, not only that of the noble Lord, Lord Winstanley, which I have not been able to address. Therefore, with the leave of the House, I shall take the opportunity to write on those points which I have not been able to answer.

I hope I have been able to show that the action that we are taking and have taken is coherent and logical, although I am the first to admit that we still have a long way to go. Finally, let me once again express my thanks to the noble Lord, Lord Lovell-Davis, for providing the opportunity for this important debate, which I hope your Lordships will agree has been constructive.

My Lords, I believe that this has been a very valuable debate and I should like to thank all noble Lords who have taken part and made such important contributions to it. I should like to apologise for exceeding my allotted time by about two minutes, but I mistakenly understood that I was permitted to speak for 20 minutes.

As was pointed out during the debate, child health services are not reported on and are seldom debated either in your Lordships' House or in another place. I hope and feel sure that what has been said this afternoon on all sides of the House will be heard not only in your Lordships' House and within government circles but also by a wider audience of professionals, parents and others of our people.

I should like to thank the Minister for replying to the debate and for the courtesy of his reply. We must all welcome what he said about the more encouraging aspects of the Government's view of child health services, limited though they may be. It is good to know that the Government are looking at matters raised in this debate, such as the reporting proposal made by the noble Lord, Lord Trafford, and that they are looking into pre-school milk and immunisation. I was particularly interested to hear what the Minister said about the school health service, and also that the Government will be looking closely at the recommendation for child health records for parents.

I wish to thank the noble Lord, though I could wish he had gone somewhat further in assuring us that amore positive lead in child health services will be taken by the Government. I am grateful to him for what he said. This has been a timely opportunity to raise a vitally important subject. I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.