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The Parliamentary Under-Secretary of State for Health (Jane Ellison)
It is good to serve under your chairmanship, Mr Amess, and to respond to such an interesting debate.
I shall focus my remarks fairly narrowly on the subject of the debate, because I have a feeling that I will get the chance to talk about smoking in cars quite a bit in coming weeks. I have had the chance to discuss today’s subject many times with my hon. Friend the Member for South Northamptonshire (Andrea Leadsom), and her passion and knowledge have shifted parliamentary opinion in that important area. I remember sitting through a late-night debate which, unusually, attracted double-figure attendance; she has moved the dial for political discourse about the importance of early years. She has a positive and constructive relationship with several Departments’ officials, who enjoy working with her on that agenda; I think that will continue.
The debate has been fairly consensual. I accept that there is some challenge with respect to numbers to do with Sure Start, and funding issues; but, to be honest, whoever was in power would have faced the same issues over the past few years. I shall therefore focus on what we are doing in response to the manifesto “The 1001 Critical Days”. I shall try to pick up on points that have been made. I am standing in for the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter), who is the lead Minister and is at present in a Bill Committee. He is sorry not to respond to the debate in person, but my hon. Friend the Member for South Northamptonshire will know that the issue is close to his heart and is the focus of much of his work. However, it is an honour for me to sit in on such an amazing debate, with so many excellent contributions.
Like the shadow spokesman, I pay tribute to the other hon. Members who contributed to the manifesto, and to the hon. Member for Nottingham North (Mr Allen) for his tireless campaigning on early intervention. I have had several stimulating and fulfilling conversations with him on the subject. He is passionate about the issue. What he has done to formalise matters through the Early Intervention Foundation—and the information, knowledge and evidence base that has been established because of that—will be extremely important. Evidence is important in this context because, to pick up the point about pressure on resources, the more evidence that can be presented to show that interventions work, the easier it will be to persuade people that such interventions are a good investment of public money, when that is in relatively short supply.
A clear case has been made, and the manifesto has support from across the political spectrum. The message is clear and simple: prevention and early intervention can improve outcomes and transform the life chances of children. Several hon. Members ably explained where the costs pop up in the system when people suffer damage and how much better, safer and kinder it is to make interventions early in people’s lives, to prevent such problems. That message sits well with the Government’s pledge to improve the health outcomes of children and young people so that they become some of the best in the world. That is a challenging goal, but the Government are determined to rise to it.
I want to touch on the risks associated with pregnancy. A healthy pregnancy provides the best foundations for a healthy life. Poor diet, smoking, using illicit drugs and consuming alcohol at that time can all have an impact on the child’s later cognitive functioning and on their health and well-being. As my hon. Friend the Member for South Northamptonshire said, a fetus exposed to extreme stress in the womb will have higher levels of the stress hormone cortisol, which can create higher levels of stress later in life. There is a highly relevant example of that in another part of my portfolio. Domestic violence can peak during pregnancy and, as a very significant stress factor, it can cause the very conditions in the womb that have long-term consequences for children.
Hon. Members have articulated the early years risks very well during the debate. There is a growing consensus about the agenda and the fact that early years intervention offers the greatest opportunity to create secure, happy and healthy adults. Moving forward in accordance with that shared agenda is the key. I will mention one or two of the risk factors. Smoking in pregnancy is highly relevant to much of my work in public health. It can lead to low birth weight, which is linked with heart disease later in life. The key messages on smoking in pregnancy are getting through to many people, although not to everyone. We still have some way to go, but in 2012-13, 12.7% of mothers were smoking at delivery. That is lower than the 2009-10 figure of 14%. However, the regional variation is extraordinary. Figures that recently came across my desk showed enormous regional variation, and responding to that is a challenge that I have put to public health directors in the regions. It is a good example of the way that a regionalised public health system can focus intensely on problem areas.
Experts are still unsure exactly how much alcohol it is safe to drink during pregnancy, so the safest approach is not to drink any at that time. Drinking heavily in pregnancy can lead to low birth weight and damage brain development in the womb. Fetal alcohol spectrum disorders are a range of cognitive and functional disabilities that can be caused by exposure to alcohol in the womb. In short, smoking and drinking alcohol while pregnant can cause irreparable damage to a child and make them more susceptible to illness throughout life. The manifesto highlights the numbers of babies affected by those issues, and I reassure the House that those are on our radar.
Perhaps less obvious is the impact of events in early childhood on later health and well-being. A drive towards wider understanding of that, among parliamentarians and in local government and the voluntary sector, is very important. I think that initially it is difficult to take on board the detail of the issue, and that is why it is so important that my hon. Friend the Member for South Northamptonshire has persisted in making the case to colleagues, and explaining it in detail, with the evidence to back it up. Many of us now have a wider understanding of what may not be as intuitively grasped as messages about not smoking or drinking during pregnancy. Traumatic emotional experience in childhood can translate into a greater risk of disease and mental health problems. Many hon. Members focused on that during the debate. We have, I think, learned that the old adage that time heals all wounds is not true. Adverse events in early childhood can resonate down the years.
According to the emerging research, growing up with exposure to multiple adverse childhood events can have a lasting impact. For instance, growing up in a household where the mother is treated violently, where a parent is chronically depressed, mentally ill or suicidal, or where someone uses drugs can increase a child’s risk of a range of conditions. Those who experience multiple adverse childhood events achieve less educationally, earn less and are less healthy. All those consequences were articulated in the debate. The hon. Member for East Lothian (Fiona O'Donnell) spoke of some sad examples, and about sitting with very young children and talking about their personal experience.
One of the saddest papers that I have read as a Minister was one that I submitted to the Chair of the Select Committee on Home Affairs, about gang violence. It was about the early lives of children who, at a young age—under 10—were on the fringes of being drawn into gang violence. I set myself a challenge, before reading the attached case history, of guessing what was happening in the child’s life. Every guess I made about the factors that were present was right, and I am sure that other hon. Members would have made the same ones. The case history showed that a child much younger than 10 was already showing signs of post-traumatic stress disorder. There is a lot of emerging evidence to show that such children are far more likely to be drawn into gangs. Good work is being done, particularly in London, on understanding how to diagnose that. It all goes to support the case being made through the debate for intervening very early; otherwise, children grow used to high levels of stress and aggression.
High-quality care during pregnancy is crucial and we want women to receive excellent maternity services that focus on providing the best outcomes for them and their babies. There has been significant investment in maternity services. Since 2010 the midwifery work force has grown by 6.9 %—that is 1,380 additional midwives. I of course understand the challenge, in that there is always a call for more midwives; that is an important area. There has been £35 million of capital investment in the environment where maternity care is provided and where women give birth to their baby. We are working with NHS England to ensure that women receive better care during pregnancy, with every woman having a named midwife responsible for providing personalised antenatal and post-natal care. Women can now make more informed choices about their care. Again with the support of Health Education England, we have increased the number of midwives and are working to ensure that specialist mental health support is available in every birthing unit by 2017.
The NHS does an excellent job in nearly every case of delivering babies safely, but it is crucial, as has been highlighted, to ensure that we do more to look after mothers’ mental health. More than 10% of women will have a mental health problem or mental illness during pregnancy, and we must ensure that we provide all-round support for women to detect and treat such conditions. Again, Health Education England is taking forward work with a range of partners to ensure that training is available for health care professionals in perinatal mental health. It is working with the Nursing and Midwifery Council and the Royal College of Midwives to ensure that midwives’ undergraduate training includes a core module focusing on perinatal mental health and with the medical royal colleges to provide postgraduate training on maternal mental health by 2015.
For a relatively small number of women, specialist perinatal mental health services are required. Through maternity and children’s strategic clinical networks, NHS England is supporting the development of maternity and perinatal mental health networks, as recommended by guidelines from the National Institute for Health and Clinical Excellence on antenatal and post-natal mental health. The networks will develop action plans and collaborative working to drive improvements in access to and quality of care.
Andrea Leadsom
As I understand it, NICE guidelines still only approve video interaction guidance, which is an effective but quite short-term intervention, and cognitive behavioural therapy as talking therapies for the perinatal period. There is a wealth of evidence that parent-infant psychotherapy, a psychodynamic form of therapy, is far more effective in parent-infant situations. As randomised controlled trials are the only acceptable evidence base to NICE, and as psychodynamic therapy does not lend itself to that, there is a bit of a chicken-and-egg situation. How do we improve the availability of specialist parent-infant mental health services if NICE will not approve them because they do not undergo randomised controlled trials?
Jane Ellison
If my hon. Friend does not mind, I will write to her after the debate to respond in the level of detail that she asks for, as that is not in my brief. However, I can reassure her that I think there are trials, supported by Government research funds, to consider some of the areas that she is interested in. I think that there is room to give her encouragement in that regard.
To return to the networks that I was describing, for women at risk of poor mental health during pregnancy and following childbirth, services do exist. Ministerial colleagues have visited excellent services in Blackpool, for example, that support women who have or are at risk of developing mental health or substance misuse problems in pregnancy or post-natally.
The key messages on smoking in pregnancy are also getting through. We have some way to go, but as I have said, the figure is beginning to drop. Teenage pregnancy can, of course, lead to poor outcomes for both teenage parents and their children. Teenage mothers have three times the rate of post-natal depression and a higher risk of poor mental health for three years after the birth. They are three times more likely to smoke during pregnancy and 50% less likely to breastfeed, with consequences for their children. It is imperative that we reduce the numbers of young women and girls getting pregnant and mitigate the impact of having a child when young.
The good news is that our rate of teenage pregnancy now stands at a historic 40-year low. In 2011, the last year for which we have figures, our conception rate for young women under 18 was 30.7 per 1,000, down from 35.4 per 1,000 in 2010. That is due to a lot of hard work, dedication and passion from our health care professionals, many of whose efforts have been described by Members in this debate. I pay tribute to their efforts and the important results that they are yielding.
Reducing conception by under-18s is one of a basket of indicators in the public health outcomes framework and our sexual health improvement framework, which was published in March 2013, to drive continual improvement. Despite our best efforts, though, some young women and girls will become pregnant, and we must do our best to mitigate the risks to those young mums-to-be and their babies. Several hon. Members, including my hon. Friend the Member for Winchester (Steve Brine), have paid tribute to the family nurse partnership, a preventive programme for vulnerable first-time mothers under the age of 20. It offers intensive and structured home visiting delivered by specially trained nurses from early pregnancy until a child is two. There are now more than 80 teams covering 91 areas across England, and the Government are committed to increasing the number of places on the programme to 16,000.
The family nurse partnership successfully engages with disadvantaged young parents, including fathers, to pick up a point mentioned by my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton), who is no longer in his place. Of those who are offered the family nurse partnership, 87% enrol and a high proportion continue to engage until their child reaches their second birthday. My colleague the Under-Secretary of State for Health, the hon. Member for Central Suffolk and North Ipswich, witnessed—other Members have referred to this during the debate—the transformational power of the programme, and he met family nurses and their clients in London in 2013.
Thankfully, we have 30 years of evidence from the USA and elsewhere that shows that the family nurse partnership programme improves outcomes for mothers and children in the short, medium and long term. That includes health and behaviour during pregnancy, reduced child abuse and neglect, improved school-readiness for the child and improved economic prospects for the mother. That list is the mirror image of all the different threats to health and wealth that have been articulated during the debate. It shows that the impact of some of these powerful early interventions can ripple down the generations, as other hon. Members have said.
To pick up a point made at the start of the debate, such interventions have also made great savings to the public purse in health, social care and the criminal justice system. I am glad that my hon. Friend the Member for Winchester mentioned the US research. We are undertaking a large-scale independent randomised control trial that will rigorously evaluate the programme’s effectiveness in the English context, and the initial findings will be reported later this year. I am sure that hon. Members present will be interested to see that, because it will be useful to see those data expressed in an English context.
The Healthy Child programme is a universal evidence-based preventive programme to improve the health and well-being of all children and to identify and treat problems early. Effective implementation of the programme should improve many of the outcomes highlighted in the “The 1001 Critical Days” manifesto, including the strong parent-child attachment, positive parenting, better social and emotional well-being among children and care that helps to keep children healthy.
Fiona O'Donnell
The Minister speaks about bonding between mother, father and baby in the early days. May I draw her out on the issue of maternity and paternity pay being included in the cap on benefit spending announced by the Chancellor in his autumn statement? Will she give an undertaking that that will not lead to a freeze or a reduction in maternity and paternity pay?
Jane Ellison
The hon. Lady will understand that that is not in my portfolio, but I am happy to draw her concerns to the attention of colleagues in whose portfolio it rests. I undertake to do so after the debate.
The Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich, has asked Public Health England to commission a rapid review of the evidence base for the Healthy Child programme, with a focus on primary prevention. The Department of Health is also working with the WAVE Trust, which was instrumental in developing the evidence base for the manifesto, with the Early Intervention Foundation and with others to explore how valuable work in prevention can be built upon. We will be interested in the outcomes of that evaluation.
Mark Durkan (Foyle) (SDLP)
The Minister has referred to looking at the issues by drawing on data and evidence that are available in the English context. As well as sharing that, importantly in this context, will she ensure that questions in the “The 1001 Critical Days” manifesto are addressed at the level of the British-Irish Council? That would enable all eight Administrations throughout these islands who face such challenges in common to share their experience, good practice and piloting. The work could be elevated to that level rather than all the different Administrations trying to do the same things back to back.
Jane Ellison
The hon. Gentleman makes a good point, and I have regular dialogue on matters in my portfolio with Members of the devolved Administrations. I am happy to look into that point after the debate, because some of the lessons to be learned are universal across different countries in the UK.
There has been a lot of interest in health visitors. They and their teams lead the delivery of the Healthy Child programme, and of course they are the bedrock of our children’s public health services. They are often the first professionals to recognise that a mother is depressed or that parents are struggling with the negative effects of many sleepless nights; we have had a few descriptions of those from colleagues in this debate. Through their work, health visitors can have an impact on the well-being of the whole family. Because of their vital preventive role, the Government are committed to growing the health visitor work force by 4,200 by the year 2015 and to transforming health visiting services to improve outcomes and reduce inequalities in the nought-to-five age group.
Taking up the point about whether recruitment is on track, and weaving in the point made by my hon. Friend the Member for South Northamptonshire, we believe that we are on track. There have been a couple of challenges in one region, to which we are now responding, but the rate of increase in health visitors will increase. It is determined by training intakes, which determine the rate of qualification and entry into the profession. We are happy that that is on track. I give that assurance to the shadow Minister. The latest health visiting work force data that we have, which are from October 2013 and were published this month, show that the total number of health visitors nationally is 9,770 full-time equivalents. Overall, there are 1,678 more health visitors than the May 2010 baseline of 8,092. That is a growth of 21%, but we intend to grow that number more, as we have said, because we think it is so important and crucial to the aims of the manifesto.
On troubled families, we know that some families have multiple problems and cause problems in the community around them. I will not go into a lot of detail, but there is clearly relevance and read-across from some of the early years issues that we have been discussing in this debate. In particular, I have seen the Troubled Families programme in my area encouraging critical working together and getting everyone around the same table to consider people and families as a whole.
That programme will have done a great deal of good to embed that idea and approach as good practice for many local authorities. There is a strong read-across to the other things that we are discussing about earlier years, and in some cases, of course, they will be the same families, depending on the nature of the family. I have certainly seen in my area, and in lots of the other pilot areas, how services have embraced the opportunity to stop working in silos and consider a whole family’s needs instead. I hope that that will become orthodoxy in how we move forward with Government policy in numerous areas and in the local government approach to things.
The Government are increasing local authority budgets by £448 million over three years on a payment-by-results basis to support troubled families across England. Again, my ministerial colleague is meeting those involved in the Troubled Families programme to discuss the health contribution to this valuable programme, and he can then address some of the points to which I will draw his attention as a result of this debate.
I do not have time to go into much detail, as I am aware that I have already made a long speech, although I am drawing to the end of it. I have many points to respond to, but I wanted to touch on the points about social mobility made by my hon. Friend the Member for East Hampshire (Damian Hinds), which I have heard him articulate before. He discussed how to support parents. I think that my hon. Friend the Member for South Northamptonshire was present when Alan Milburn, presenting his most recent social mobility report, urged Government and politicians generally to break what he called one of the “last taboos” of public policy, which is telling people how to be good parents and supporting them to be good parents. That is an interesting challenge for us all to consider and respond to, because it is undoubtedly difficult terrain for both Governments and individual politicians.
Andrea Leadsom
I would just like to make the point that although politicians attempt to say, “Family and the first couple of years are really private, and you mustn’t interfere,” often, in my experience of 15 years’ work with charities, people are actually desperate for help, and they do not know where to go. It is completely the opposite. It is not as though we were trying to ram support down people’s throats and tell them how to live; it is that they are desperate for it. I have lots of meetings with people who have set up charities to support mums who are desperately depressed or tearful or who cannot cope. They do that because they themselves went through it and there was nobody there to help them. I think it is the exact opposite. We kid ourselves if we think that we are interfering. We are not; we are simply providing support that people desperately want.
Jane Ellison
I think that is right. My experience mirrors my hon. Friend’s. I suppose the sensitivity is always about people being tempted to stray into saying how everybody should live their lives, but I agree with her. My experience is just the same as hers. Most people are crying out for support. I guess that the key thing is how that is delivered and how people are asked whether they would like to receive it. There are ways of doing that, and I think we are close to breaking that taboo. It is all about how the support is offered. Rather than telling people, it is about saying, “We are here to support you and we think that we can nurse you through this difficult time,” so I think she is right. Common sense dictates that that is nearly always the case, but it is not an area that Governments have previously dealt with. It is an area that people have been nervous to go into.
I am glad that my hon. Friend mentioned charities. I want to touch on some work done in the area, because giving people the best possible start in life is not only a job for parents, the NHS and Government. Charities such as the WAVE Trust—Worldwide Alternatives to ViolencE—and the Early Intervention Foundation, which is funded by the Government, are contributing to, even leading, the debate in crucial areas about early child development. The Big Lottery Fund is working with both those charities and many others on the “A Better Start” initiative, where it will invest £165 million over the next 10 years to stimulate new and innovative preventive approaches in pregnancy and the first three years of life, again to improve life chances. I congratulate it on that work, and Ministers and parliamentarians will want to keep in touch with that significant programme of work and look at the outcomes it achieves.
Before I move off charities, I pay my own tribute to Home-Start and many other charities like it. I am privileged to be the patron of Home-Start Wandsworth, so I have seen at first hand the great work that it does, which I know is mirrored up and down the country. I have spoken to many mums who said that Home-Start were the people who stood by their side when they felt they had no one else to help them. They talked about the difference that it made to them at a difficult time in their lives.
On the points about integration, we can definitely do more to look at ensuring that all those initiatives are joined up. My ministerial colleague the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich, is hosting a round table on the subject of integration, with a specific focus on the early years. That will look at what more we can do to ensure that children and families get that integrated support. A number of Members have mentioned that.
That is only one part of the system, however. The challenge of data sharing was brought up in earlier contributions. The sharing of information between NHS services and across the health, education and care system underpins good integrated working. It is not really possible to do it without that, and it is important for promoting good outcomes. In recent years, there have been a number of attempts at a national level to improve information sharing, including through specific work in foundation years services.
As my hon. Friend the Member for South Northamptonshire and other Members will know, the Government commissioned Jean Gross, a former communication champion for children, to explore ongoing barriers to information sharing in early years and to identify examples of good practice. I reassure my hon. Friend that Ministers from the Department for Education and the Department of Health welcome that report and its excellent analysis of the issues on information sharing. Much local good practice is outlined in it, and we are working with places such as Wigan, Warwickshire and Hackney to move that agenda forward through the programme to introduce integrated assessment of children aged two to two and a half. We know that there is variation across local areas, but we are working to try and understand how to reduce that.
The Department for Education’s statutory guidance for children’s centres is clear that health services and local authorities should share information, such as live birth data, with children’s centres on a regular basis. The Department of Health is taking forward work with NHS England and others, including the Health and Social Care Information Centre, to explore how regular updates of bulk data on live births can be provided to local authorities, including the benefits of local sharing versus sharing nationally held data. My hon. Friend the Member for East Worthing and Shoreham said in an intervention that sometimes there is a culture of using it as an excuse. As highlighted in the Caldicott reviews and reports, we know that culture and relationships need to change, and we need to make sure that there is an understanding of the existing framework in law that supports much greater information sharing than perhaps is always undertaken.
Jean Gross’s report also made recommendations about training on information sharing. We are working with the Royal College of Paediatrics and Child Health and with the DFE’s strategic partner, 4Children, to explore how an e-learning package on information sharing can be developed that is accessible to and appropriate for both health and early years professionals. We are hoping to see progress there.
To summarise, system-wide change is required to achieve all of this. Each part of the system, at each level, has a vital contribution to make. As the response to the debate has illustrated, work is going on across different Departments, and how we integrate them is critical to it. All of us see the manifesto “The 1001 Critical Days” as a rallying point for all those who have an interest in ensuring that, as the Government state in their pledge, we improve the health outcomes of children and young people so that they become among the best in the world.
The manifesto comes at an exciting time, because the evidence on the importance of a healthy pregnancy and on the early years is growing. As I have said, the evidence is becoming clearer, which makes it easier to make the case. It makes it easier for those who make decisions about how to structure services to do that with the confidence that they are doing something that will make a real difference, and that the consequences of a poor start for long-term physical and mental health will be addressed. Government, the NHS, charities and others are working well together to take the agenda forward, and I know that my hon. Friend the Member for South Northamptonshire will continue to champion it in Parliament and continue to improve the understanding that we all have of this important agenda.
I pay tribute to everyone who has taken part in such a good debate. I will follow up a number of points, and I will of course report back to the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich, on the debate that we have had. I look forward, as do officials in the Department of Health, to ongoing, dynamic and constructive relationship working to take the objectives of this important manifesto forward into the future.