Healthy Start Scheme and Welfare Food (Amendment) Regulations 2005

– in the House of Lords at 4:28 pm on 17 November 2005.

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Photo of Lord Warner Lord Warner Minister of State, Department of Health, Minister of State (Department of Health) (NHS Delivery) 4:28, 17 November 2005

rose to move, That the draft regulations laid before the House on 3 November be approved [8th Report from the Joint Committee and 14th Report from the Merits Committee].

Photo of Lord Warner Lord Warner Minister of State, Department of Health, Minister of State (Department of Health) (NHS Delivery)

My Lords, the Welfare Food Scheme has played a vital role in providing a valuable safety net for pregnant women and families since it was introduced back in 1940. It is currently serving about 560,000 low income and disadvantaged households. But it now needs updating better to meet the nutritional requirements of present-day families.

In discussions on the enabling powers contained in the Health and Social Care (Community Health and Standards) Act 2003, several concerns were raised about the changes proposed to the Welfare Food Scheme. We have tried to take on board the comments made at that time and have reflected them in the proposals we are now making. For example, we are proposing to introduce the reforms in two stages to test the scheme prior to full implementation across Great Britain.

That is taking up very much the points made during the debate on the 2003 Act by the noble Lord, Lord Clement-Jones, and the noble Baroness, Lady Barker.

We propose to implement Healthy Start in Devon and Cornwall in the first instance. During that first phase, beneficiaries in Devon and Cornwall will receive Healthy Start vouchers, while beneficiaries in the rest of Great Britain will continue to receive Welfare Food Scheme milk tokens. Existing beneficiaries in Devon and Cornwall will be automatically transferred onto the new scheme to ensure seamless provision. Beneficiaries in phase 1 will receive with their vouchers Healthy Start communications providing information about the scheme and useful hints and tips on eating a balanced, healthy diet. Those materials will be part of a larger communications strategy developed to support the introduction of the new scheme. As part of phase 1, we propose to remove provision of low-cost infant formula via the NHS across the whole of Great Britain to families with children under the age of one who receive specified tax credits and have a family income under a certain threshold. NHS clinics in Devon and Cornwall will also cease the provision of all infant formula from the start of phase 1, which will support the department's commitment to increasing the number of mothers who initiate breastfeeding. It is also our intention to remove the exchange of infant formula, as part of the scheme, from all NHS clinics from the start of phase 2. We expect phase 2 of Healthy Start to be rolled out across the rest of Great Britain later in 2006, taking into account the feedback from the evaluation of phase 1.

In the main, beneficiaries currently receiving Welfare Food Scheme milk tokens will also be entitled to Healthy Start vouchers. The scheme will continue to provide, in phase 1, vouchers to all pregnant women and children under five in low-income families on certain benefits—income support, income-based jobseeker's allowance and child tax credit. But we intend to remove entitlement for those pregnant beneficiaries currently receiving tokens because they are in a family receiving pension credit (guarantee credit)—that applies to fewer than 200 women—from phase 1 because of the greater value of this benefit. We also intend to remove entitlement for the small number of disabled children aged five to 16 years not in relevant education as a result of their disability, but we have made a commitment to provide a one-off goodwill payment to those disabled children. The Committee on Medical Aspects of Food and Nutrition Policy concluded that there was no nutritional justification for continuing that element of the scheme.

In contrast, we will provide Healthy Start vouchers to all pregnant under 18 year-olds regardless of their income, because we know that teenagers' diets are often nutritionally poor. Supporting young pregnant women during such an important time can only improve the health outcomes for both mother and baby. From phase 2, we intend to reduce the age limit for the scheme from age five to age four. We have not reduced the age range during phase 1 as that would create inconsistencies and inequalities between those receiving Healthy Start vouchers in Devon and Cornwall and those receiving milk tokens throughout the rest of Great Britain. As a result, we can increase the support that we give to families with the youngest and most vulnerable children by providing double vouchers to most families with children under the age of one.

The new scheme also recognises that premature babies may need extra nutritional support, and so double vouchers will be paid. We propose that the value of each voucher should be £2.80 per week, but regularly reviewed, as was mentioned by the noble Lord, Lord Clement-Jones, in the passage of the 2003 Act. Beneficiaries will receive vouchers in advance in four-weekly cycles, and the vouchers will normally have a four-week expiry date. In circumstances where a backdated payment is made, vouchers may be issued with a longer expiry date. Regulation 8(2) allows for an expiry date of up to six months.

During previous debates on the changes, concerns were expressed, by the noble Baroness, Lady Noakes, and the noble Lords, Lord Clement-Jones and Lord Chan, about the introduction of an application process. Those concerns have been considered but we still regard the application process as an important aspect of the scheme, as it forges closer links with the NHS and the very people who are likely to need the most support. The contact will be between beneficiaries and health professionals, which I think was also supported by a number of speakers in debate on the 2003 Act.

The application process will create opportunities for health professionals to provide information and advice about healthy eating as an integral part of the scheme. Only new beneficiaries will need to complete an application form, to be signed by a health professional, as existing beneficiaries will be automatically transferred to the new scheme. Under the current scheme, pregnant women already complete an application form, so this is an extension of that existing process. We would expect the application form to be signed by either a midwife or a health visitor, as they are most likely to be in regular contact with the beneficiary. That process very much fits in with the current role of midwives and health visitors, as they currently sign applications for the Sure Start maternity grant. We have consulted the Royal College of Midwives and the Community Practitioners' and Health Visitors' Association in establishing the requirements.

We intend to develop and deliver a package of health professional training sessions, as well as other supporting materials, to set Healthy Start in the context of wider health advice and guidance. But I should make it clear that we certainly do not expect health professionals to establish whether a potential beneficiary is entitled to vouchers in any way.

To help and support beneficiaries in making the right dietary choices, we want to make the scheme more flexible by increasing the range of foods under the scheme and providing a fixed-value voucher. Although we intend to expand the range of foods under the scheme, we have kept it relatively simple at this stage, including fresh fruit and fresh vegetables as well as liquid cows' milk and infant formula. That is to avoid confusion at the point of sale—particularly, for example, with frozen vegetables, which could include items such as frozen chips that for obvious reasons we would not want to promote through the scheme. We will consider the range of foods and the "5 a day" initiative as part of the evaluation of phase 1.

We will actively target retailers currently registered with the Welfare Food Scheme, and will seek to recruit further retailers to participate in Healthy Start to ensure that beneficiaries have the widest access possible to a variety of local retailers, including initiatives such as box schemes and farmers' markets. To participate in the scheme, retailers need to supply only at least one of the food types under the scheme—for example, milkmen who stock only milk for their rounds. Retailers will be required to complete and sign a simple application form, which includes a declaration as an anti-fraud measure highlighting to retailers their responsibilities under the scheme. Once registered, retailers will receive a registration pack containing a handy window sticker and a retailer quick reference guide, as well as their first claim form.

The process for reimbursing retailers is designed to be straightforward to ensure unnecessary burdens are not imposed, particularly on smaller businesses. Vouchers will be reimbursed at full face value, so the current and unpopular retailer deduction will cease. That means that, for every £2.80 voucher exchanged by a retailer, £2.80 is received back.

Every scheme is vulnerable to fraud but we have considered carefully the concerns expressed previously by, in particular, the noble Baroness, Lady Finlay of Llandaff, about the potential for abuse of the scheme. We are working with NHS counter-fraud specialists to minimise fraudulent activity, including the establishment of a common Healthy Start contractor database.

Concerns have been previously raised by the dairy industry about expanding the range of foods. We have met several key stakeholders to discuss the changes we are proposing and have agreed to review the scheme and its processes as part of the phase 1 evaluation. But we must reform the scheme if we are more fully to meet the nutritional requirements of those pregnant women and young children who most need it. Beneficiaries may prefer to continue getting just milk with the new vouchers, rather than using the vouchers for fruit and vegetables—that is their choice.

We will undertake a rapid evaluation of the impact and processes for phase 1 before the scheme is rolled out nationwide. I think that that was recommended by the noble Baronesses, Lady Barker and Lady Howarth of Breckland, in debates in 2003. I commend the regulations to the House, and beg to move.

Moved, That the draft regulations laid before the House on 3 November be approved [8th Report from the Joint Committee and 14th Report from the Merits Committee].—(Lord Warner.)

Photo of Baroness Morris of Bolton Baroness Morris of Bolton Spokespersons In the Lords, Education, Family & Children, Health, Deputy Chief Whip, Whips, Vice-Chairman (Candidates), Conservative Party

My Lords, I thank the Minister for explaining the regulations, which establish phase 1 of the new Healthy Start scheme in Devon and Cornwall and amend previous regulations. The Welfare Food Scheme has been in place since the beginning of the Second World War and, however useful its purpose, it is right that it should be reviewed in the light of the vast knowledge and experience that we now have on nutrition and vitamins.

The Government have chosen Devon and Cornwall for this six-month to eight-month trial because of their geographical isolation and demographics in terms of urban centres, medium to small towns and rural villages, and it is understandable why these factors make it a sensible place for the trial. But by their own admission in the Explanatory Notes the Government recognise that there are only small pockets of deprivation in that area. Why did the Government not consider a metropolitan area to be more suitable, or why not trial the scheme in both a rural and a metropolitan area so that the findings could be compared and contrasted?

The current Welfare Food scheme is limited to milk and infant formula. While the scheme's aims of broadening the foodstuffs available and providing greater access to those foods through a fixed-value voucher are worthy, we have concerns. Under the new proposals, all the value of the voucher could be spent on fruit and vegetables. We argued during the passage of the Bill that a portion of the voucher should be ring-fenced for milk. There are many worries that children will lose out on the nutritional value of milk. Will the Minister comment on that and on the strong concerns expressed by dairymen about the knock-on effect on their deliveries? Will he explain how the vouchers will account for the considerable variation in the price of fruit and vegetables around the country, the seasonality of prices and the impact of inflationary rises and falls?

As part of the scheme and in line with the Government's drive to encourage breastfeeding, provision of infant formula will be withdrawn. I am a strong advocate of breastfeeding, the benefits of which are many and well-chronicled. It is particularly important if there is a history of allergies in the family. Breastfed babies receive protection from infections and illness, and there is the added benefit that mothers who breastfeed are less at risk from a number of conditions.

However, not all women can breastfeed. It can be horribly painful and some babies just do not thrive. There was an article in the Sunday Times this weekend by Sarah Smith, who was so embarrassed that she was bottle-feeding her baby, due to her daughter being a lazy sucker, that she pretended to breastfeed. The last thing we should do is somehow to demonise mothers who, for whatever reason, cannot breastfeed. Nor must we make them feel that in any way they are inferior mothers or that they are letting their children down. Surely, the best way to encourage breastfeeding is through education. Is it sensible to withdraw infant formula? Could that not leave some babies undernourished?

The scheme requires a healthcare professional to sign the application form, with the aim of forging closer links with the NHS, so families have access to advice on diet, nutrition and other health issues. Yet during the consultation, as the Minister mentioned, many NHS practitioners felt that mandatory contact would stigmatise the NHS. I am still not sure why the Government decided to go along that route. Will it not add considerably to an already overburdened NHS?

I do not ask such questions to be difficult or to oppose the regulations, with which we are in broad agreement, but to raise genuine areas of concern and to probe the intentions behind government's thinking.

Photo of Baroness Barker Baroness Barker Spokesperson in the Lords, Health 4:45, 17 November 2005

My Lords, there were happy occasions during the passage of the primary legislation when we debated this subject at length with the noble Baroness, Lady Andrews, who gave her customary full and detailed replies. I am delighted to see these regulations before us.

However, it is fair to ask one or two questions about the operation of the scheme. Referring to those debates, the Minister will know that we were concerned that a scheme for so long successful in its universal coverage of children and mothers was about to be disrupted. Therefore, it is beholden on us to test some of the assumptions behind it.

The first point is the value of the voucher, at £2.80. I shall assume that that is based on the price of milk at the moment. Given that fruit and vegetables are now included and, as the noble Baroness said, there are variations by region and by price, will that be monitored? In his introduction, the Minister said that the Government were committed to ensuring that the scheme will be updated. How and when will that uprating happen? Will there be an annual uprating, and will it be in line with inflation?

The scheme as the Minister outlined it will apply to children up to the age of four, not five as with the current milk scheme. Is that because there is an assumption that children will go to school and that their nutritional needs will be met in school at the age of five? Perhaps the noble Lord can confirm whether that is right.

It seems strange to have chosen to pilot the scheme in Devon and Cornwall, as the noble Baroness said. I am sure that there are good reasons for doing so, but to pilot a scheme like this in an area where there are so few members of black and minority ethnic communities is strange. In the roll-out of the scheme—in future it will be rolled out to other areas—will its effect on minority communities be closely monitored?

What will the Government do to ensure that there are enough registered food outlets available within an area, particularly in rural areas, to ensure the scheme is workable in the way that he envisages? If there are not enough outlets, what other proposals will be put in place? The noble Baroness, Lady Morris, mentioned that the scheme is confined solely to cows' milk. Some children are allergic to cows' milk and, therefore, depend on goats' milk or soya milk. There is a perfectly good nutritional reason for those alternatives to be considered, so perhaps the noble Lord would say why not.

Regulation 13(2) states that there will be no refunds when someone presents at a food outlet but does not obtain food to the full value of the voucher. Why is that so? Regulation 13(3) says that if retailers do not have goods available, they will be able to write a note. Does that mean that the system will work like medical prescriptions, when if a pharmacist cannot supply a prescription in full, he writes a note for the person to present on a subsequent occasion.

Perhaps the Minister can explain why children of asylum seekers are not to be included in this scheme. I suspect that he will say that children of asylum seekers and pregnant asylum-seeking women will be dealt with by other authorities. If professionals with knowledge of and concerned about children's welfare and health are concentrated in this scheme, why should asylum seekers not be in touch with those people?

Will the Government keep under review the diversity of the retailers that participate in the scheme? When we discussed this matter under the primary legislation, there was a fear that the scheme may become a means whereby retailers get themselves into a monopoly position with the NHS and have undue influence over the provision of essential food to children. I would be grateful if the noble Lord would answer those questions.

Photo of Lord Chan Lord Chan Crossbench

My Lords, I thank the Minister for his Motion. I shall focus on three issues. First, it is good to know that the scheme will soon be up and running, but I share the concern of the noble Baronesses who spoke for the two opposition parties that the choice of Devon and Cornwall is not particularly helpful to some disadvantaged communities, since the majority of them are in metropolitan areas, as well as the concern of the noble Baroness, Lady Barker, regarding diverse ethnic minority communities. Therefore, will the pilot project be for a limited time—six months or a year—before it is introduced nationally? That would be important.

Secondly, I congratulate the Government on looking at Schedule 3, on Healthy Start foods. It is a Healthy Start diet, but one or two things seem to be missing. I agree that we should, wherever possible, encourage breastfeeding, and I shall return to that in a moment. However, regarding milk, since we are thinking of children up to the age of four or five, I am surprised that yoghurt and other such foods are not mentioned. They would be very helpful for young children as they are easy to eat and digest and are also very healthy.

Regarding breastfeeding, the purpose of the scheme is to assist people who are disadvantaged therefore journalists on the Sunday Times may not be representative of that group. However, if we are to make breastfeeding successful, we need more health visitors and midwives to assist young mothers, as in the case highlighted, to breastfeed. I am concerned that the number of health visitors and midwives is not increasing. Also, the redesign of primary care trusts will make such health professionals even more difficult to find. So how, on the one hand, can we say that we are recommending and encouraging breastfeeding, but on the other hand, the people who will assist young mothers will not be available in the numbers required?

Thirdly, there is the matter of outlets. In metropolitan areas where there are disadvantaged communities, outlets are limited. Therefore, will lesser known shops and private shopkeepers be given the opportunity to register as outlets for the scheme?

Finally, there is the issue of review and monitoring. Not only is fraud likely, but there is also the possibility that bad habits will start if we do not review the scheme regularly. If the vouchers increase in value, they may not necessarily be used on the foods recommended for a Healthy Start diet.

Photo of Lord Warner Lord Warner Minister of State, Department of Health, Minister of State (Department of Health) (NHS Delivery)

My Lords, I shall respond briefly to the points raised in this debate on these important regulations. On the alleged new burdens on midwives and health visitors, they, after all, already see pregnant women now and are best placed to give advice about a healthy diet, which is the purpose of this scheme. We have discussed these issues with their professional bodies. It is worth bearing in mind that, if I may gently say to the noble Lord, Lord Chan, the number of midwives is increasing at a time when the birth rate has been falling. So these issues have been actively considered.

Why Devon and Cornwall? I shall not reply "Why not?". The selection of Devon and Cornwall for phase 1 was based on three main criteria. First, it is geographically self-contained, with borders that do not cut across large urban communities; secondly, it includes a mixture of current approaches to the supply of infant formula through the Welfare Food Scheme; and, thirdly, it includes both urban and rural areas and pockets of deprivation as well as larger identifiable disadvantaged populations. There will be some degree of involvement in the scheme by people from black and minority ethnic groups. We will of course closely monitor that after wider roll-out of the scheme.

On the issue of the value of the voucher—why £2.80?—the amount equates to the average cost of seven pints of liquid milk provided through the existing Welfare Food Scheme. It was decided not to vary this value from the average cost of seven pints of milk to ensure equity with people on the Welfare Food Scheme outside Devon and Cornwall. But, as part of the evaluation of phase 1, the voucher value and the quantity of Healthy Start foods purchased with it are intended to be examined.

Will the voucher amount be increased at the rate of inflation? We intend to regularly review the value of vouchers and we will increase it in line with the increase in the retail prices of foods available through the Healthy Start scheme. Picking up on a point made by the noble Lord, Lord Chan, we will of course look at the types of food that are appropriate.

The noble Baroness, Lady Morris, raised the issue of babies who do not feed well or who may not be able to tolerate cows' milk. Healthy Start, like the Welfare Food Scheme, is designed to meet the nutritional needs of healthy pregnant women, babies and children. If a baby has a specific health problem with the mother, a health professional should be consulted, and specialist infant formulas can be prescribed through the NHS if there is a clear medical need for them. NHS prescriptions are, of course, free for all children.

The noble Baroness, Lady Barker, asked why asylum seekers were not included under the Healthy Start scheme. They are not included because their needs are currently met by the National Asylum Support Service—and this principle has been reinforced by the High Court. We are keeping NASS informed of our plans for implementation of the Healthy Start scheme, so that it can review the support it gives to asylum seekers who are pregnant or have young children, and modify it as appropriate.

Soya-based products are excluded from the scheme on the basis of expert medical advice that they are not as nutritionally adequate as cows' milk. Soya drinks are low in energy, compared with cows' milk, and lack several vitamins and minerals. Never let it be said that I do not bring education to this House.

The issue of retailer monopoly was raised by the noble Baroness, Lady Barker. Registration is open to any retailer selling one or more relevant products, and we will encourage the widest range of retailers to take part, to provide choice and greater accessibility.

Vouchers, in most instances, must be exchanged for goods to their full value in order to ensure that the voucher is exchanged for only Healthy Start foods. Regulation 13 applies especially to milkmen, who may take the voucher and provide milk throughout the week. We understand the concerns of the dairy industry. There is already a decline in the number of milk-round men in general outside the changes proposed by the Welfare Food Scheme, but we will keep things under control.

I believe that the changes set out in these regulations will help us better to support the nutritional needs of low-income families. On those points I have not been able to respond to I will write to noble Lords. In the mean time, I commend the regulations to the House, and I hope that we can approve them.

On Question, Motion agreed to.