Amendment 154

Health and Care Bill - Committee (6th Day) – in the House of Lords at 12:30 pm on 26th January 2022.

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Lord Farmer:

Moved by Lord Farmer

154: Clause 21, page 30, line 1, leave out “may” and insert “must”Member’s explanatory statementThis amendment and others to Clause 21 and Schedule 4 in the name of Lord Farmer would specify that integrated care partnerships consider how to integrate family help services into the provision of health and social care services, as relationships are recognised by research as a 'health asset'. ‘Family help’ is defined in accordance with the Independent Care Review’s starting definition. ‘Family hubs’ are named as key potential sites for delivering integrated paediatric health and family help.

Photo of Lord Farmer Lord Farmer Conservative

My Lords, I will speak to all four amendments in this group in my name. I remind the Committee that I have already declared my interests, especially as regards integrated care and family hubs.

In Committee in the other place, the Minister, my honourable friend Edward Argar, recognised

“that the system has been calling for two different and important types of integration: integration within and across the NHS to deliver healthcare services within a defined locality, and integration between the NHS and local government and wider partners.”

He went on to say:

“The ICP is intended to bring together health, social care and public health to develop a strategy to address the needs of the area also covered by the integrated care board. If”—

I emphasise “if”—

“the ICP wants to go further, it can also involve representatives from the wider system, where appropriate, such as voluntary and community groups, and social care or housing providers. That will be up to the ICP, and we will welcome locally driven innovation to reflect local circumstances.”—[Official Report, Commons, Health and Care Bill Committee, 16/9/21; col. 332.]

I, too, welcome locally driven innovation to reflect local circumstances, as I will emphasise shortly. However, I am genuinely mystified as to why integration between the NHS and local government and wider partners is voluntaristic in the Bill. My Amendment 154 would exchange “may” for “must” and require integrated care partnerships to include in their strategy a statement of how health-related services could be more closely integrated with health and social care.

My Amendment 155 would specify “family help” as a required subset of health-related services, access to which would include through family hubs. This wording avoids prescribing hubs as the sole means of delivery of and access to services. That said, I have been talking to seasoned health leaders in the Newcastle area who say that the current system is simply not working for vulnerable families. Parents need help navigating what is out there; the community-based access point of a family hub would be a game-changer. The Supporting Families programme, appropriately based in the Department for Levelling Up, Housing and Communities, recommends hubs in its systems guide for this reason. Moreover, the Government have invested significantly—around £130 million to 2024-25 —to develop this badly needed infrastructure and fulfil their 2019 manifesto promise to

“champion Family Hubs to serve vulnerable families with the intensive, integrated support they need to care for children—from the early years and throughout their lives.”

The second action area in the DHSC’s The Best Start for Life strategy ensures that families have access to the support they need through a welcoming family hub. As I have already said in this Committee, as well as perinatal and early years healthcare, local authorities in Essex are delivering more extensive paediatric health services to meet the same need for co-ordination identified in Newcastle. Continence, speech and language, and allergy services, among others, are provided in community settings close to families through their integrated family hubs.

Many such health needs are psychosocial and practical. Addressing them needs a whole-family approach, often through early help commissioned by local authorities. This is what integration should look like. I have always insisted that the design of these family hubs should be flexibly and locally determined, not centrally imposed. but flexibility must be geared towards meeting families’ and children’s needs. One key lesson from children’s centres was that health should be fully integrated from the start.

How that is done should be locally decided, including through consultation with local people. Also, the hub is not the place where everything happens—that would need a vast building—but it is the place through which families can access everything. Other government departments are joining up, integrating their policy goals with those of health, by actively citing the delivery of their priorities in and through family hubs. I could give many examples but, for the sake of time, I will limit myself to a couple.

The Department for Work and Pensions is keen to run its reducing parental conflict programme in family hubs, making access to couple relationship support far easier and less stigmatising for low-income families. The Ministry of Justice is funding a pilot family hub in Bournemouth, which will include a specialist family justice programme that links closely to the family court. Separating parents will be encouraged, early in the process, to use the family hub rather than go down a costly and adversarial court route.

The lack of community-based support is one of the reasons why the promise of the 1989 Children Act has not yet been fully realised, as many pointed out in publications to mark its recent 30-year anniversary. I will return to this. I need to keep emphasising that family help, particularly with relationships, is not at all niche but is erroneously treated as such, hence the need for it to be specified in the Bill. The social determinants of health have already been referred to by other noble Lords, and family-level factors in particular can make or break clinical efforts by healthcare professionals. The US Centers for Disease Control and Prevention says that children need “safe, stable, nurturing relationships” to thrive, and UK research, including from UCL, recognises healthy, well-functioning relationships as a “health asset”.

With my Amendments 158 and 167, “family help” in the Bill would mean

“services which improve children’s lives through supporting the family unit and strengthening family relationships to enable children to thrive and keep families together”.

I quote, but in a heavily truncated form, the independent care review’s starting definition, which can be read in its entirety in lead reviewer Josh MacAlister’s The Case for Change. He teases apart how this phrase differs from “family support” in local authority usage, and refers back to Professor Eileen Munro’s 2011 social work reform recommendations and the 2003 and 2009 reviews by the noble Lord, Lord Laming. Both emphasise the need for easily accessible, early help for families if outcomes for children are to improve markedly and tragedies are to be averted in more cases.

I would go even further back than that. In the earliest days of the welfare state, it was recognised that poor family functioning threatens the effectiveness of its other pillars. The ability of health, education and state financial support for families to transform the life chances of children is fundamentally undermined if parents fail to nurture their children emotionally and materially. In 1949, in acknowledgement of this uncomfortable truth, Michael Young, one of the architects of the welfare state, called for child welfare centres. These would, he said, fulfil Beveridge’s principle of the preservation of parental responsibility and deal with the emotional cost to children of high post-war levels of family breakdown.

These began to emerge as family centres in the 1980s. Many were opened by voluntary organisations such as the National Children’s Home, now Action for Children, and many had significant local authority and social services involvement. They helped parents of children of all ages, mainly in disadvantaged areas, ideally before and to prevent the involvement of social services. Family centres were included in legislation—symbolically, given today’s Bill—as part of the then Department of Health and Social Security’s contribution to the Children Act 1989. As family help was a health emphasis in that landmark law, a health Bill is a highly appropriate updating vehicle.

As an aside, in 1994, the National Audit Office, then the Audit Commission, proposed a central role for family centres in developing a more proactive partnership with parents. The commission reported that Section 27 of the 1989 Children Act—the duty to co-operate—was still not progressing well, and emphasised the need for a single point of entry to a range of multiagency support services. Plus ça change, plus c’est la même chose. We can wait until family hubs spread slowly across the country before acknowledging the need for them in legislation, or we can update the Children Act by making it reflect more accurately where more than 30 years of policy-making since then have brought us to.

There is an argument that family hubs are as yet untested, hence the Government funding rollout in only 75 local authorities. However, as I said, the principles that they are based on rest on decades of learning about what families need. We can, and must, refine the model, but hubs—somewhere families can go where someone will be able to help—are a vital missing pillar of our welfare state. I believe that, in time, they will be as indispensable as primary care and schools, because they make such a valuable contribution to their successful functioning.

As it currently stands, the Children Act 1989 is out of date in how it refers to family help in infrastructure. Paragraph 9 of Schedule 2 states that local authorities

“shall provide such family centres as they consider appropriate in relation to children within their area.”

The name “family centres” is too suggestive of a single building, while the phrase “family hub” expresses that this is an access point. It is descriptive, not prescriptive. Many family hubs refer to themselves as children’s centres. Others, such as those in Doncaster, want to shift the culture away from an exclusive focus on the early years, so they do call themselves family hubs.

Moreover, other aspects of paragraph 9 are inappropriate now. Paragraph (c), for example, refers to the family centre being a place where someone will be provided with accommodation while receiving advice, guidance or counselling. That does not happen, hence my rewording to reflect better what the hubs actually do without being overdeterminative. Local needs decided, as I said, in consultation with those who will use them, as well as in the context of integrated care partnership discussions, must be the priority.

Finally, it is with humility that I propose amending the Children Act 1989. Internationally, it is highly respected and much copied. However, the intention of my amendments is to fulfil its key principles: the emphasis on prevention, on keeping children with their families wherever possible and on ensuring that help is available for parents who struggle to nurture their children or provide a safe and stable environment in which they can thrive. I commend these amendments to the Committee.

Photo of Baroness Tyler of Enfield Baroness Tyler of Enfield Chair, Children and Families Act 2014 Committee, Chair, Children and Families Act 2014 Committee 12:45 pm, 26th January 2022

My Lords, I lend my voice to this important group of amendments. I will explain very briefly why family hubs are so important to many of the big themes that we have been discussing in the Bill so far: prevention, early help and integration in particular.

Family hubs have a very important role to play in improving early intervention services and helping with integration and data sharing, as we discussed earlier, among public services and the voluntary sector. Importantly, as the noble Lord, Lord Farmer, explained, the range of services available in family hubs often includes important services such as children’s health services, which are better delivered in a community setting and integrated with other family health services, rather than delivered in a hospital or somewhere that has a much greater focus on acute care.

The Public Services Committee, on which I served until very recently, produced what I thought was a very important report on vulnerable children recently. It put a national rollout of family hubs at the very core of a national strategy for child vulnerability, proposing that the most deprived communities be prioritised in the early stages of any such expansion. In our report, we set out what fundamental characteristics we thought should be at the heart of every family hub, including employing full-time family co-ordinators, offering addiction and domestic violence services, providing support for parents with poor mental health and organising parenting classes. I say that, because I hope that it illustrates the point I made about integration between health services and broader family support services.

I had the privilege as a committee member—I think the noble Lord, Lord Hunt, was with me—to visit Westminster family hub. I sat down and talked to a young mother with two young children who had a lot of very difficult issues that they were dealing with. The mother explained how the help and support she was getting through the family hub, both with her health issues and those of her children, as well as a wider range of issues, were helping her to keep her head above water. I was so impressed with that family hub and the help and support it was giving, and the way it was integrating statutory services and the voluntary sector.

I will make two other brief but important points. First, family hubs will be working with children from birth to 19. I see that as important, because families face challenges at any time, not just when children are very young, and focusing solely on early years and not helping families with older children does not have the same sort of holistic approach. So it is extremely helpful if, during early years, families build up these trusted relationships with people they meet in family support hubs of the type I have described, rather than sever that relationship when the child reaches the age of five. Parents can continue to contact a familiar team and access that trusted source of information and advice.

My final point to emphasise is the importance of family relationships and relationship support. One key thing about family hubs that is very important is the work they do to prioritise help with relationships—it might be couple relationships, parent-child relationships or even sibling relationships. By being able to deliver counselling and various other programmes to address some of the conflict and breakdown that often affects families in these difficult situations, they often help avoid the whole family reaching crisis point, particularly to the extent that parents have to access the courts to resolve disputes. For all these reasons, I very much support the amendments.

Photo of Baroness Wyld Baroness Wyld Conservative 1:00 pm, 26th January 2022

My Lords, I support my noble friend Lord Farmer. I declare my interest as a non-executive member of the board of Ofsted. I apologise for not being able to speak at Second Reading for my own family reasons. I echo everything that the noble Baroness, Lady Tyler, said. It was a real pleasure to serve with her on the Public Services Committee.

I will praise the Government first, which is always wise. They are showing great commitment to family hubs and I believe that they are committed to the rollout. What concerned me when the committee took evidence from certain members of the Government was a sense of a lack of urgency. Everybody agreed that this was a brilliant idea, but different people from different departments had different ideas about how they should work.

We also took evidence from families, in private and in public. The stories we heard over and again were, as others have alluded to, that, “This could have been prevented if it had been addressed in a joined-up way”. We particularly heard from young children, “I had to tell my story over and again.” Imagine the trauma. This could have been prevented under a different model. These situations did not have to happen.

We have the building blocks to make sure that these situations do not happen, but I do not think the legislative framework is in place to help us to address that. For that reason, I am persuaded by my noble friend Lord Farmer and I am happy to support his amendment.

Photo of Lord Mawson Lord Mawson Crossbench

My Lords, I am very supportive of what the noble Lord, Lord Farmer, said. My colleagues and I have been in this space for 37 years and we have built rather a lot of things in it. It has been very interesting to watch what happened in east London, when this new scheme from a new Government arrived in the middle of a group of communities that already had well-established relationships with very vulnerable families, with a whole range of opportunities emerging. I am sure it was unintentional—it is part of the danger of being overinfluenced by the idea that local authorities will sort this stuff out in the same old usual way that they have tried to before—but it was very disruptive for the social enterprise sector, which was already doing this stuff very effectively, with all the numbers to show it. I will not go into the detail now, but when you look at the detail of what actually happened, the present facilities cost £100,000 more than those being delivered by the social enterprise sector.

These ideas are really important. I am happy to take the noble Lord into this in a lot more detail. I encourage him to spend more time in the detail in some real places to look at the unintended consequences of what happens when new government programmes arrive in communities, with the best will in the world, with an overconfidence in what they think the state can deliver. I am very happy to have a further conversation with the noble Lord, but the detail of the long-term relationships with these families really matters.

Photo of Lord Warner Lord Warner Crossbench

My Lords, briefly, I support these amendments, partly from my own experience as a director of social services and Children’s Commissioner, but also because of the points that the noble Lord, Lord Mawson, raised.

I have three key points from history. As a director of social services in the 1980s and 1990s, I offloaded my local authority family centres to the voluntary sector because a survey of parents suggested that they would not come to a service run by the organisation that was likely to take away their children. That was a perfectly rational position and we should listen to what people say about that.

Fast forward to 1999 and parenting orders under the Crime and Disorder Act. We find that compulsion brought parents to the party but, when they actually attended, they found—not so much men but women—that they were being treated and given skills that enabled them to manage children, largely teenage children, much better than they had been. It was a great shame that we used the criminal justice system to bring people to a parenting tuition experience that they should have been given many years before.

This is a final point from history. Michael Gove made me—this was madness on my part, as well as his—children’s commissioner for the failing Birmingham City Council children’s services. Ofsted report after Ofsted report had been telling them of their deficiencies. We found that the group they could not handle, for which they had no effective responses, was teenagers. If we are to make any progress in helping people to help the family unit, we need to address the support given to parents during the teenage years, because they are really struggling, particularly mums.

Photo of Lord Bethell Lord Bethell Conservative

My Lords, I will briefly say that I am extremely optimistic about family hubs. They answer the challenge to solve the complexity around integration incredibly well. My noble friend Lord Farmer made the point that one cannot think of a better example of what integration looks like than family hubs. The noble Baroness, Lady Tyler, talked clearly and persuasively about the journey they have been on.

My noble friend has made the case for these amendments. Other noble Lords have made the case for updating the legislative framework. I ask the Minister to look carefully at what can be done to bring these laws up to date so that family hubs can thrive, as I believe they will.

Photo of Baroness Merron Baroness Merron Opposition Whip (Lords), Shadow Spokesperson (Health and Social Care), Shadow Spokesperson (Digital, Culture, Media and Sport)

My Lords, I am grateful to the noble Lord, Lord Farmer, for introducing this important debate and to other noble Lords who have supported the amendments before us and spoken about how we can improve the support that families will receive through this Bill. As the Family Hubs Network rightly observes,

“prevention is simply listed in the Bill as one of several commissioning requirements of ICBs with no broad mention of children’s health”.

This group of amendments gives us the opportunity to sharpen this.

As we have heard, the issues that families face, in whatever form or shape, do not exist in isolation. In addition to the impact of financial, housing, social and other pressures, the physical and mental health of a child or young person affects the physical and mental health of not just their parents, but their wider family, and vice versa. It makes common sense to facilitate a healthcare system that is designed and resourced to actively take a holistic approach to the many issues that face children and those who care for them.

I cannot help but feel that the points raised today are not new. We have the experience of Sure Start to show us how effective properly integrated family services can be. As the Institute for Fiscal Studies confirmed:

“By bringing together a wide range of early years services for children under 5, Sure Start centres dramatically improved children’s health even through their teenage years.”

Early investment is crucial.

I hope the Minister will be keen to embed change in this Bill to replicate the success that we saw through Sure Start. The first step towards doing this is to make sure that integrated care partnerships are properly required to consider how family help services can be thoroughly integrated into our health and care system, so that family members—no matter what form those families take—are seen as both individuals and groups who have an effect on each other.

Photo of Lord Kamall Lord Kamall The Parliamentary Under-Secretary for Health and Social Care

I thank my noble friend Lord Farmer and all noble Lords who spoke about their experiences. The creation of integrated care boards represents a huge opportunity to support and improve the planning and provision of services to make sure that they are more joined up and better meet the needs of infants, children and young people.

Before I go into the specific amendments, I make it quite clear, as my noble friend said, that the Government set out in their manifesto a commitment to championing family hubs. We want to see them across the country, but at the same time we must give democratically elected councils the choice to shape how services are delivered, bearing in mind some of the points made by the noble Lords, Lord Mawson and Lord Warner, whom I thank for their experience on this.

The Government agree that it is vital to ensure that ICPs work closely with a range of organisations and services to consider the whole needs of a family when providing health and care support. In preparing the integrated care strategy, the integrated care partnership must involve local Healthwatch and the people who live or work in the area. We are working with NHS England and NHS Improvement on bespoke draft guidance, which will set out the measures that ICBs and ICPs should take to ensure they deliver for babies, children and young people. This will cover services that my noble friend considers part of family help.

In addition, the independent review of children’s social care is still considering its definition of “family help”, and the definition published in The Case for Change may well be further refined as a result of ongoing consultation. It would be inappropriate to define the term in legislation at this stage, pre-empting the full findings of the review and the Government’s response to it. Also, it is important that there should be a degree of local determination as to what should be included in the strategies of ICBs and ICPs. In order for them to deliver for their local populations, a permissive approach is critical.

On Amendment 167, we agree that family hubs are a wonderful innovation in service organisation and delivery for families. The great thing about them is how they emerged organically from local councils over the last decade. I pay tribute to my noble friend for the key role he has played in advocating family hubs and bringing this innovation to the heart of government. The Government strongly support and champion the move but we are clear that they have to be effective and successful—they need to be able to adapt to local needs and circumstances. They also need to be able to operate affordably, making use of a diverse range of local and central funding streams.

In both these regards, local democratically elected councils should hold the ultimate decision-making power over whether to adopt a family hub model and how it should function. As such, I regret that we cannot support the amendment, which would place too much prescription on the decisions and actions of local authorities and risk imposing significant new financial burdens. For this reason, I ask my noble friend to consider withdrawing his amendment.

Photo of Lord Farmer Lord Farmer Conservative

My Lords, I thank the Minister for his rather disappointing reply and those who supported these amendments, particularly the noble Baroness, Lady Tyler, and my noble friend Lady Wyld, for giving such clear definition to the services and the advantages of family hubs. I take to heart the advice from the noble Lord, Lord Mawson, about unintended consequences. I would quite happily talk to him about this. I also take the point from the noble Lord, Lord Warner, that it is nought to 19, not nought to five. Families have so many problems with teenagers, as we see on the streets today, and family hubs can be a non-stigmatising place where help can be got.

I agree with the noble Baroness, Lady Merron, about Sure Start. In a way, I have always said that family hubs are building on Labour’s Sure Start centres. However, it is not nought to five but nought to 19—in fact, nought to 25 for children who come out of the care system, et cetera, with special needs.

There might be concern that my amendments attempt inappropriately to set in concrete the policy of family hubs when it is constantly progressing. However, the changes I have described are not just about bringing the latest policy idea into the Bill. Absent of these references to places where families know that they can access help and be connected to the full gamut of local services and support, the Bill will not reflect the overarching direction of travel. Their inclusion requires health to be fully on board, which has not happened in the past, to the detriment of the success of previous policies.

My amendments represent unfinished business from the founding of the welfare state. The family help that they mandate is also essential to the success of the levelling-up agenda and the build back better agenda, which is what this Government will be judged on. I hope that I might be able to speak further with the Minister before Report but, in the meantime, I beg leave to withdraw my amendment.

Amendment 154 withdrawn.

Amendments 155 to 159 not moved.

Clause 21 agreed.

Clause 22: NHS England’s financial responsibilities