Meeting documents

            Meeting: Health Scrutiny Sub-Committee (County Hall, Durham - Committee Room 2 - 05/07/2004 10:00:00 AM)

                  Item: A4 Scrutiny Report-Pre-School Health in County Durham

         

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Health Scrutiny Sub-Committee 5 July 2004 Scrutiny Report: A Review of Pre-School Child Health in County Durham
Report of Head of Overview and Scrutiny

Purpose of the Report

1 To explain the attached report about pre-school child health in County Durham.

Background

2 The Sub-Committee, for its first major project, decided to look at pre-school child health promotion in County Durham. This is a theme which fits well into the Strategic Vision for the County.

3 The report in Section 11 suggests that the Health Scrutiny Sub-Committee should arrange a local conference about child health promotion in County Durham to seek to heighten awareness and promote continuous improvement. It is suggested that the conference should cover the themes investigated in this study - breast feeding, smoking, protection for young children, good practice in SureStart schemes, immunisation, Looked After Children, fluoridation, a joined up approach and the role of local authorities.

4 If this report is approved by the Sub-Committee, the aim will be to circulate it widely and to use the contacts we have developed to promote the proposed conference.

Recommendations

5 You are recommended to agree the Scrutiny report and the recommendations it makes.

Contact: Ian Mackenzie Tel: 0191 383 3506

2004


A REVIEW OF PRE-SCHOOL CHILD HEALTH


CONTENTS

SECTION	CONTENT	PAGE
1	Introduction and Background	4
2	Position Statement by Dr. Tricia Cresswell	7
3	SureStart Schemes	8
4	Immunisation	14
5	Looked After Children	17
6	Evidence from Directors of Public Health	19
7	Child Health Summit	26
8	Pre-School Education	27
9	Exercise and Diet	27
10	Summary of Issues	29
11	Recommendations	31

FOREWORD

The Health Scrutiny Sub-Committee decided to look at the health of children under five in County Durham. This recognised the importance we saw in looking to the future of the County. The health of children determines the health of the adult population. This was referred to recently by Professor Alan Craft, Head of Child Health at the University of Newcastle at the Child Health Summit held in Durham. He made it clear that health in childhood determines adult health. By looking at the health of children under five in County Durham, we hope we are being forward-looking in seeking to influence the health of people in the County in the future.

There are about 25,000 children under five in County Durham at present. This report demonstrates that there is much good practice in evidence in County Durham to improve the health of these young children. We have made some suggestions to seek to promote child health more widely. Part of our role is to heighten awareness of issues and we hope that this report does provide a catalyst for a wide cross-section of services to consider child health as a priority.

I would like to warmly thank all members of the Working Group who have participated in this project. Particular thanks go to all the witnesses who have given evidence. We were very grateful that each Director of Public Health for our PCTs gave evidence personally.

Councillor John Priestley

1. INTRODUCTION AND BACKGROUND

1.1 Following a number of workshops as part of the preparation for Health Scrutiny, the area of Child Health Promotion was chosen as a key area for scrutiny.

1.2 Because of the interest in this matter, all members of the Health Scrutiny Sub-Committee were given the opportunity to be involved in a Working Group to look at this issue.

1.3 The Health Improvement and Modernisation Plan for County Durham and Darlington 2002-5 refers generally to children and young people and to family health services but does not specifically deal with children under 5. Reference is made to the need for a National Children’s Service Framework to pull together the various strategies in relation to children. This will be introduced in due course.

1.4 Each Primary Care Trust now produces its own plan. The position in each Primary Care Trust was explained by the relevant Directors of Public Health and appears later in this report.

1.5 The health of residents in the north east of England is generally considered to compare unfavourably with many other parts of the country. Statistics from the Association of Public Health Observatories indicate that the north east has a high proportion of wards which are assessed as ‘deprived’ (in the top 10% in the Index of Multiple Deprivation). The prevalence of obesity is highest in the north east. These statistics indicate some of the issues that influence the health of people in County Durham. Some further statistics appear in the next section.

S OME S TATISTICS

1.6 County Durham - Children Under Five
( From the Office of National Statistics as at 2002)

	Total	Males	Females
County Durham	25,194	12,961	12,233
PCTs:-
Chester-le-Street & Durham	6,713	3,396	3,317
Dales	4,308	2,225	2,083
Derwentside	4,441	2,273	2,168
Easington	5,085	2,497	2,488
Sedgefield	4,647	2,470	2,177

PCT AREAS

	C HESTER-LE- S TREET AND D URHAM	D ALES	D ERWENTSIDE	E ASINGTON	S EDGEFIELD
P ERCENTAGE OF CHILDREN ‘IN POVERTY’	28%	31.6%	39%	46.4%	37.7
Conception rates for women under 18 per 1,000	38.7	44.5	43.7	61.9	54.8
Proportion	15.3% -	17.1%	19.9%	23.4%	20%

of the population currently

(NB This may be under reported. The north east average in 2001 was 29%)

smoking
Proportion of the population having a BMI greater than 30 (obese)	13.8%	17.4%	15.1%	19%	17.2%
Proportion of the population eating five or more portions of fruit and vegetables a day	18.4%	17.9%	15.4%	12.5%	16.4%
Proportion of the population taking no exercise	7.7%	8.2%	7.6%	10.2%	9.2%

1.7 HEALTH I NEQUALITIES

In 2003, the Department of Health published a programme of action to tackle health inequalities. This programme indicated that to tackle the underlying determinants of inequality, action was required across all government. The actions likely to have the greatest impact over the long-term were:-

All of these issues have an impact on the health of young children.

1.8 In relation to infant mortality, the key short term interventions include:-

1.9. T HE C HIEF M EDICAL O FFICER’S A NNUAL R EPORT

There are some issues identified in the Chief Officer’s Annual Report for 2002 which are relevant for this project. The Annual Report highlights the impact of second hand smoke on public health and raises the issue of introducing bans on smoking in public places, promoting smoke-free workplaces and raising awareness. The public sector is encouraged to take a lead in this. Mothers smoking in pregnancy have a major impact on child health.

Another theme highlighted by the Chief Medical Officer is obesity. He suggested a number of strands to a national strategy to address obesity particularly in relation to children. This included the following issues:-

S TRATEGIC V ISION FOR C OUNTY DURHAM

1.10 Under the Local Government Act 2000, every local authority must prepare a Community Strategy “for promoting or improving the economic, social and environmental well-being of their area and contributing to the achievement of sustainable development in the United Kingdom”. The Community Strategy for County Durham was adopted in February 2004 and is entitled “The Strategic Vision for County Durham”. Each District Council has its own Community Strategy which is linked to the County Vision.

1.11 The Strategic Vision is the basis to a local authority’s power to do anything which they consider is likely to achieve the promotion or improvement of the economic, social and environmental well-being of their area.

1.12 The Strategic Vision which has been the subject of wide consultation, sets out twelve challenges to make County Durham a great place to live, work, visit and invest. One of the Challenges - Challenge 7 - is to:-

“Improve health to match the national average by tackling the underlying causes of poor health which includes poverty and unemployment, poor housing and environment, educational under-achievement, unhealthy lifestyles and poor access to services”.

1.13 To address these issues, the Strategic Vision indicates that an action programme is to be developed to support partnership working to achieve each of the challenges.

1.14 Over the next five years, the aim is to reduce the number of unwanted teenage pregnancies, reduce smoking and raise levels of physical activity and improve people’s diet.

1.15 The Strategic Vision provides the policy framework to the aims of this project to assist in the health improvement of very young children in County Durham. Indeed, to assist those who, by 2023, will hopefully be the beneficiaries of the vision.

2. A POSITION STATEMENT BY DR. TRICIA CRESSWELL

2.1 Dr. Tricia Cresswell, the Director of Public Health for the Durham and Chester-le-Street PCT had an over-arching role in relation to children’s health promotion throughout the county. In this role, she provided an overview for the Working Group.

2.2 Tricia explained how tackling inequalities in health was a major agenda for the Government. A recent multi-department publication Tackling Health Inequalities: A Programme for Action had emphasised the importance attached to this issue. Health Scrutiny was requested to pursue this agenda. Tricia also drew attention to the recent report from the Save the Children Fund indicating that more than one million people in England were still living in extreme poverty.

2.3 Tricia explained that whilst there were improvements in child health, the health gap between children from the poorest families and those from the most affluent families was widening. Tackling child poverty remains a key issue.

2.4.1. In her presentation, she pointed out that children and young people were generally defined as up to the age of 18 but for some duties of care this definition included 18 year olds.

2.4.2. There was no doubt that health was improving. Comparing the situation with 100 years ago, infant mortality was in the range of 250 per 1,000 live births and that this was now down to about 5 per 1,000 live births, but there was still a lot of work to be done.

2.4.3. She drew attention to the comparison of infant mortality rate in other European countries. The Scandinavian countries had the lowest infant mortality rate.

2.4.4. She pointed out that the single most important issue in relation to infant mortality was stopping mothers smoking during pregnancy particularly during the last six months of pregnancy. This was because smoking was likely to produce children with lower birth weight. Children with lower birth rates were statistically more likely to die. In speaking to young girls, it was difficult to get across to them the importance of not smoking during pregnancy. From the point of view of some of the young girls, they had a perception that smaller babies appeared to have advantages. This was not medically supported

2.5.1. Tricia highlighted the health needs of certain highly vulnerable groups. For example children of homeless families living in ‘bed and breakfast’ type accommodation were at much higher risk of accidental and non accidental injury.

2.5.2. She also mentioned that there was not much evidence that two parents were better than one in terms of the health of young children if income was at a reasonable level. However outcomes are poor for children of young, single mothers on low income.

2.5.3. In relation to under-18 conception, the rate in this country was decreasing, but did not compare well with many European countries. She suggested that young women generally did not get pregnant if they saw a future for themselves. Those who perceived that they did not have prospects tended to be those who were involved in early pregnancies

2.6 Another interesting issue was that children were not playing outside as much as they used to and that this was an important element of a healthy childhood.

2.8 There were also issues in the County about sexually transmitted diseases and drugs. In particular, drug misuse in ever younger children/young people and also alcohol misuse in younger children was increasing. This was particularly challenging because the health services did not have appropriate treatment arrangements for such young people.

2.10 Tricia was particularly enthusiastic about breakfast clubs which she thought were very cost-effective in improving child health. There were difficulties, however, in terms of funding such breakfast clubs particularly in areas where there was no Neighbourhood Renewal Funding.

Terms of Reference

2.11 In terms of the scope of the project, it was suggested that the terms of reference should be as follows:-

A review of some important elements of pre-school child health promotion in County Durham covering

Surestart Schemes, family support, breast feeding, smoking cessation in pregnancy and immunisation

with a view to considering any recommendations for improvement.

3. SURE START SCHEMES IN COUNTY DURHAM

P RESENTATION B Y F RANK F IRTH, S TRATEGY & S PECIAL P ROJECTS OFFICER, E DUCATION D EPARTMENT

3.1 Frank Firth gave a presentation about the Sure Start schemes operating in County Durham. 3.2 He described the purpose of the schemes and their principles. There are twelve full scale schemes and two mini programmes in Durham. They commenced in 1998. Each scheme was based on an area in the lowest 20% in the country

based on the index of multiple deprivation. In response to questions, Frank explained that, in general, the schemes could not be financed outside these areas

3.3 A number of targets had been set on a national basis and there were also local targets for the numbers of programmes and children participating. The current position in County Durham needed to be monitored. There were national monitoring arrangements and also the County Council was now the local monitoring body.

3.4 At the moment, Sure Start schemes cover 53 out of the 85 wards in the lower 20% of the index of multiple deprivations.

3.5 Frank explained that there was a need to expand the services in the child care sector to meet this growth industry.

3.6 In response to questions about the cost of child care, it was explained that for those on benefits, 70% of child care was covered by Child Tax Credit. The remaining cost had to be paid for by the parents.

3.7 Frank also explained that for parents aged 14-19, there was a sum of £5,000 available under the Care to Learn scheme which allowed child care for those with young children wishing to work.

3.8 The services under Sure Start were very much centred on the client. Clients were picked up at an early age and services from relevant agencies were available to the client as necessary.

3.9 In relation to the cost of services, Mark Gurney from the Social Care and Health indicated the importance of the Welfare Rights Service which was critical in ensuring that clients made appropriate claims for welfare benefits. Social Care and Health’s approach was that Sure Start was holistic and that those families with problems could be identified at an early stage with a view to anticipating and preventing problems for a family.

3.10 In relation to County Durham, there were three different accountable bodies for schemes although Durham County Council was predominantly the accountable body. There were also eleven different lead agencies. The issue of equality of service was one for consideration.

3.11 Frank explained how Sure Start was to be over-taken by children’s centres in relation to children between 0 and 5. In County Durham, there would be 85 wards in which children’s centres would be set up. These would be integrated facilities to support families with young children. The expectation would be that most children’s centres would be developed from existing Sure Start local programmes. The long term Government aspiration was that all children in the 20% most disadvantaged wards would have access to children’s centre services.

3.12 In relation to children’s centres, the total revenue funding expected between 2004/6 was just over £1.5 million with over £5 million worth of capital. The aim was to reach 11, 440 children between 0-5 by 2006. This was to be extended to 17,600 by 2010. There would be a need for 765 new child care places in the County between 2004/6.

3.13 Gill Eshelby from the Youth Offending Service explained how her service was involved in Sure Start. She raised issues about the benefits of support between 0-4 but expressed some concern about the continuation of services after children reach 4. Frank Firth explained the philosophy of extended schools which were intended to ‘wrap round’ children with difficulties as part of an extension of Sure Start.

3.14 Discussion took place about children in families were there was criminal activity. Reference was made to the ‘Head Start’ scheme in the United States. The results of this scheme had suggested that social problems declined significantly if issues are tackled at an early age. This would apply to those in prison as well as those in the community.

3.15 The need for the group to consider monitoring of schemes was raised. The wider remit of trying to encourage young people to stay in the County and provide them with job prospects was also seen as a long term strategy to address the ageing population within the County.

3.16 It was agreed that the Working Group would visit a scheme within the County to consider this at first hand.

Visit to Peterlee Surestart/Children’s Centre -
3^rd December 2003

3.17 A number of members of the Working Group made a visit to Peterlee SureStart on 3 ^rd December 2003. Brian Brown, Programme Manager for Peterlee SureStart, gave Members of the Working Group an explanation about the SureStart initiative and some details about the scheme in Peterlee.

3.18 The Group was reminded that SureStart is a Government initiative to provide opportunities for families with children under four years. The schemes are targeted on those areas in the bottom 20% of the indices of multiple deprivation. The Peterlee scheme is based on three sites - Eden Hill, Dene House and Acre Rigg.

3.19 Two of the SureStart units are purpose-built to a high standard. Brian Brown explained that the schemes were developed very much in conjunction with parents who live in the community who had a ‘hands on’ approach to designing both buildings and the facilities. The third unit was under development.

3.20 In explaining the history of the SureStart scheme in Peterlee, Brian pointed out that whilst in the three wards there were at the time 850 pre-school children, there were very few nursery or pre-school places. 43% of children going into school in this area had evidence of developmental delay.

3.21 Direct discussions took place with parents about developing the scheme. They made a very strong point that they wished to build up a relationship with any professionals providing services and wanted them to be dedicated to their area.

3.22 Parents were fully involved in running and developing the scheme on a partnership basis. The core staff team consisted of the programme manager, five health visitors (full time equivalents), one part-time and two full time midwives, nine nursery nurses, one portage worker, one librarian, one part time community psychiatric nurse, a domestic violence support worker and a speech and language therapist together with three administrative and clerical support officers. The annual budget was in the region of £736,000 with staffing costs of approximately £400,000 annually.

3.23 Every parent within the SureStart area was contacted to seek to involve them in the scheme. To date, one-third of the targeted children were participating. Brian Brown pointed out that, in talking about the parents and children, they did not use the words “deprived and disadvantaged” because parents did not like these terms. They preferred “high need areas” or “poorly served areas”.

3.24 The Peterlee scheme was the first programme nationally to be accredited as baby friendly by UNICEF. This was seen to be a very worthwhile process which other SureStart schemes might be recommended to follow.

3.25 The Peterlee scheme had recently been designated as the first children’s centre in County Durham. This would be the fore-runner to many other schemes in the County. The Peterlee scheme itself would be expanding into other areas of the town.

3.26 The Eden Hill site had a nursery and a primary school in close proximity. This seemed to be a positive configuration. Dene House did not have a nursery and Acre Rigg premises were not purpose-built which provided a contrast to the customised premises which provided a high quality environment.

3.27 One of the main strengths of SureStart was real joined up working engaging parents in a meaningful way and bringing professionals together in a multi-disciplinary team with a common aim. This theme of multi-disciplinary working was carried through to the library which had been set up at Dene House. This had been developed specifically for SureStart in conjunction with the County Council’s Cultural Services and Leisure Service. Children became library members by joining the SureStart library.

3.28 There were other joined up approaches in relation to seeking employment for parents with JobCentrePlus and Easington Action for Jobs. On-site facilities were provided to assist parents in securing employment. Those in employment had the opportunity of a period of free child care at the start of their employment. The full cost of child care was £100 per week. Those on benefits received assistance to subsidise this cost.

3.29 There were a number of initiatives in relation to breast feeding, depression screening, smoking cessation, diet and fitness. Breast feeding had increased to 45% of those participating in the last twelve months from 23% prior to the SureStart scheme. The benefits of breast feeding in terms of bonding and physical health were explained and also the need to ensure that mixed messages were not sent to parents by products advertising artificial feeding. Support was also given to parents who bottle feed.

Monitoring of Surestart Schemes -
Are they making a difference?

3.30 The County Council is now the formal monitoring body in relation to SureStart schemes in that it has the strategic responsibility to ensure the delivery of the SureStart agenda across County Durham. This responsibility was only devolved on 1 ^st April 2004. Accordingly, no current statistical monitoring information is available but the attached table sets out some of the most recent information

G OVERNMENT T ARGETS BY M ARCH 2006

NATIONAL TARGET	COUNTY DURHAM POSITION
A 12% reduction in the proportion of young children living in households where there is no-one working. Reduction in the number of children in low-income households by at least a quarter by 2004 as a contribution towards halving child poverty by 2010.	On track. Most of the earlier wave programmes are on course to reaching this target. Later wave programmes have not yet produced statistical evidence of progress towards this target but milestones are in place for each of these programmes in order that they reach the prescribed target.
To create 250,000 new childcare places for at least 450,000 children and 180,000 places in the 20% most disadvantaged wards. To create 95,000 new high-quality out-of-school childcare places.	On target. By March 2006, Sure Start County Durham will create 1276 new childcare places in the 20% most disadvantaged wards. 252 new high-quality out-of-school places will also be created.
All families with newborn babies in Sure Start areas to be visited in the first two months.	On target. Sure Start Local Programmes record details of all families that are contacted via Health Visitors who promote Sure Start services to parents within the first two months following the birth of the child. Most promote Sure Start prior to the birth of the child via midwives.
A 6% point reduction in the proportion of mothers who continue to smoke during pregnancy.	Variable results - most programmes report that they exceed this figure whilst one in particular has voiced concern that they are not likely to achieve the reduction. This mirrors the national picture however and continues to be a concern to the SureStart Unit. Programme Managers are working alongside colleagues within the Health Services and in some case a Smoking Cessation Advisor has been appointed to address particular concerns.
Information and guidance on breast feeding, nutrition, hygiene and safety to all families with young children.	On target. This information is given to all parents who reside within a Sure Start area and is provided by health visitors and midwives. All programmes offer a scheme to raise the awareness of home safety equipment, which includes either, free of reduced price equipment such as smoke alarms, safety gates and wall socket covers.
Reduce by 10% the number of children aged 0-4 in SureStart areas admitted to hospital with gastro-enteritis and lower respiratory infection or a severe injury.	Hard to measure as Accident and Emergency Departments do not record this information. However, local programmes have created their own annual targets and are expected to achieve or exceed the national figure by 2006. Reporting mechanisms are built into each programme area and statistics are gathered via Health Visitors.
Ante -natal advice and support to all pregnant women.	Achieved. All Local Programmes employ or buy-in midwifery services via the Health Authority and all report that antenatal advice is provided by matter of course for any parent-to-be.
The number of children under 4 years with active membership of a library.	All programmes employ a library worker to promote the benefits of library membership and this also helps to deliver Book Start and Story Sacks to families.

3.31 In general terms, the SureStart approach is evidence based and delivers a ‘double dividend’ for children in that it improves children’s life chances and parental opportunities. The development of the SureStart Children’s Centre agenda which is the next stage of the SureStart initiative is to build up successful integration of services and bring together good quality early education, child care, health and family support. This is starting in areas where there are particular needs to reduce inequality and tackle child poverty. The aim is to reach children at an early stage through integrated services to address the inequality of life chances being blighted. This depends upon working together to achieve better outcomes for children and families. The Peterlee scheme appears to be a good example of what can be achieved.

Summary Of Issues From Surestart Visit

3.32 The strong messages from this visit were the benefits of:-

P RESENTATION BY D R. D EB W ILSON, C ONSULTANT FOR

C OUNTY D URHAM AND D URHAM H EALTH PROTECTION UNIT
9^TH D ECEMBER 2003

4.1 Dr. Wilson explained that she was employed by the Health Protection Agency which, since the 1 ^st April 2003, provided a service in County Durham and Darlington in relation to communicable diseases. This work was carried out on behalf of the Primary Care Trusts in County Durham. This service was ultimately accountable to the National Board of the Health Protection Agency in London.

4.2 Dr. Wilson tried to put immunisation into context. Immunisation was not new. Indeed, it started over 1,000 years ago. She explained the fairly recent incidence of polio and smallpox. These serious conditions had virtually been eradicated by immunisation. The general view was that:-

No other measure taken by man, apart from the provision of safe drinking water, has saved more lives than immunisation. Immunisation is a key measure to allow us to stay healthy in a world competing with micro-organisms.

4.3 She also pointed out that immunisation is the only medical intervention to have eradicated any disease, namely smallpox. The seriousness of diseases such as meningitis, measles, mumps, rubella, diptheria and tetanus were pointed out. Immunisation had had a dramatic effect on these diseases but they could easily return if the immunisation schedule was not maintained.

4.4 The routine childhood schedule for immunisation was pointed out. Primary immunisation took place between two and four months involving vaccine to deal with diptheria, tetanus, whooping cough and polio. Between 12-15 months, the first MMR1 vaccine was given - meningitis C, measles, mumps and rubella. Between 3-5 years, there was a pre-school booster dealing with measles, mumps, rubella, diptheria, tetanus, whooping cough and polio. Between 10-14 years, BCG was administered and then between 13-18 years, school leaving boosters were available for diptheria, tetanus and polio.

4.5 Children at increased risk of vaccine preventable infections were treated as a priority. It was also pointed out that some vaccines could prevent illness even after a child had been exposed to infection.

U P-TAKE OF I MMUNISATION

4.6 Child immunisations were currently recorded by GPs, a parent’s hand-held record and school-held records. In County Durham, there were currently four child health information systems as follows:-

North Durham covering Durham, Chester-le-Street and Derwentside.
South Durham covering Sedgefield, Wear Valley and Teesdale.
Sunderland covering North Easington.
North Tees and Hartlepool covering South Easington.

These systems were historical rather than related to the current Health Trust areas. There were difficulties in the reliability of information in South Easington. This was being addressed by the Easington PCT which was devising its own health information system.

4.7 There were quarterly and annual reports provided to Primary Care Trusts about the take up of immunisation. The up-take was measured quarterly and annually in relation to children who have reached the age of 12 months, 24 months and 5 years. The national system called ‘Cover’ provided information about children registered with GP practices. In discussion, it was noted that there were some children who were not included, such as Travellers children and those children who moved regularly. There was a need to take particular care with children who are looked after. The issue of asylum seekers was not an issue for County Durham.

4.8 The general position in County Durham was that at all relevant ages, County Durham’s up-take was in excess of both the national and the north-east average. For example, in relation to diptheria, tetanus and polio, the English average was 90.7% take-up, the north-east average was 92.9% and the County Durham average was 95.7%.

4.9 In comparing the figures in relation to each Primary Care Trust, the position for the 24 month cohort this year was as follows:-

PCT	MMR1 %	DIPTHERIA, TETANUS, POLIO %
Durham Dales	82.1	98.0
Easington	82.2	86.4
Sedgefield	95.3	98.6
Derwentside	85.3	99.0
Durham/Chester le Street	85.6	97.2
AVERAGE	84.2	96.8

4.10 It was clear from the statistics that the position in Easington required further attention. Dr. Wilson’s view was that the take-up in Easington was similar to other PCT areas and there was no suggestion that in Easington the position was significantly worse.

4.11 In relation to childhood immunisation, the Working Group was encouraged to ask PCTs whether this was now an indicator which they considered.

4.12 Whilst the figures for County Durham appeared to be favourable compared to other areas, it was pointed out that even 3% of children not receiving a vaccine was of concern. This was noted and Dr. Wilson indicated that considerable attempts were made to follow up those parents who had not arranged for immunisation for their children. This, however, was not a mandatory scheme and parents were entitled to refuse.

4.13 It was noted that there was an assessment made in relation to each GP practice to ensure that all children were getting equal opportunities to take advantage of immunisation.

4.14 The general position in County Durham was that there were very few cases of measles or rubella. In terms of mumps, again there were few cases, although recently there had been a small number in Easington and an even smaller number in Durham.

4.15 It was explained that to ensure that these diseases were tackled appropriately, immunisation needed to be at a level of 95% or more.

4.16 In relation to MMR, it was noted that there was reduced take-up and all attempts were being made to ensure that parents had true information on which to make judgements as to whether children should be immunised.

Summary Of Issues About Immunisation

4.17 The message from Dr. Wilson was that vaccines are one of the most important ways to protect children from serious illness. Vaccines were safe, many billions of vaccinations had been given safely and every vaccine meets strict safety requirements. The risks of disease far outweigh any risks from vaccines. As far as County Durham is concerned, children have a higher up-take of routine immunisations than the average child in the north-east of England or in England generally. However, there was no room for complacency, particularly around MMR immunisation. There is a wide range of advice available for parents to support their making an informed choice for their child.

PCTs should be asked whether immunisation for children was a current indicator. Social Care and Healthshould be asked about the position relating to looked after children. Those sections of society such as Travellers who might not be well-covered by immunisations should be monitored. Easington PCT should be asked about the reliability of information about immunisation.

5. THE HEALTH OF LOOKED AFTER CHILDREN

Mark Gurney, Operations Manager in the Social Care and Health Service of Durham County Council, explained how the health of children looked after by the local authority was delivered. The definition of looked after children is set out below:

“ A child is looked after by the local authority if he/she is in their care by reason of a Care Order or is provided with accommodation for more than twenty-four hours either by parental agreement or if subject to Emergency Protection.”

The primary duty of a local authority is to safeguard and promote the welfare of a child who is looked after. Regulations provided that a looked after child must be provided with health care including any recommended immunisations and any necessary medical and dental attention.

The Local Authority had collective responsibility for promoting good parenting for all Looked After Children. This involved ownership and leadership at senior officer and member level. Their role was to be an advocate on behalf of children in their care and to promote positive outcomes in health education and life chances for such children.

S TATISTICS

National Statistics - All Looked After Children

In terms of the national position for England, the Department for Education and Skills have indicated that, in September 2003, there were 44,900 children who had been Looked After continuously for at least twelve months by English local authorities. There were no available national figures specifically for the under-5 age group.

The national figures for all Looked After Children were:-

Annual Health Assessment	75%
Immunisation	72%
Dental check	75%

The County Durham figures for this period which were collected by sample were:-

Annual Health Assessment	72%
Immunisation	72%
Dental check	72%

A national children’s performance indicator requires local authorities to provide information about the percentage of all children Looked After who had a dental check and health assessment in the last twelve months. (Indicator C19). County Durham compares reasonably well in these national statistics with performance at 76% for last year. The target for the current year is 80%.

County Durham Statistics - Under 5s

In County Durham, in March 2004, there were a total of 502 Looked After Children. 120 of those children were under five years. During 2004, the number of children Looked After under five has, we understand, increased significantly.

The health of Looked After Children was a partnership approach involving health services. There were two health advisers to assist with Looked After Children and also three dedicated paediatricians. Indeed, the links with health were being strengthened particularly in the areas of health promotion for Looked After Children covering issues such as teenage pregnancy, sexual health, smoking cessation, substance misuse, healthy eating and exercise.

Mark Gurney explained that a new regional initiative was to be introduced in May 2004 called the National Healthy Care Standard. This was a multi-agency partnership approach to set out a number of broad principles of health care standards for Looked After Children.

The Working Group requested specific information about the statistics in relation to health assessments, dental checks and immunisations for Looked After Children in County Durham. Mark Gurney explained that some of the recording arrangements relating to Looked After Children were being reviewed to ensure that accurate information was available. The statistics might not reflect the actual position.

At the time of writing this report, the County Durham figures for under 5s were as follows:-

Health Assessment	70%
Immunisation	63%
Dental Check	70%

The performance indicator for all Looked After Children has a target of 80% for this current year.

The Working Group understands that considerable efforts are being made to ensure that both the provision and recording of the necessary checks for all Looked After Children in the County are treated as a priority.

Summary of Issues about Looked After Children

6.1 Each of the Directors of Public Health for each Primary Care Trust in the County was asked to provide evidence to the Working Group. Presentations were given by:-

Tricia Cresswell Durham and Chester-le-Street PCT
Anna Lynch Easington PCT
David Landes Dales PCT
Anne Low Derwentside PCT
Alyson Learmonth Sedgefield PCT.

A summary of their evidence is set out in the following table:-

TO VIEW THE TABLE PLEASE REFER TO HARD COPIES HELD IN CORPORATE SERVICES OR THE COUNTY RECORD OFFICE Summary of Issues Raised by the Directors of Public Health

6.3 These presentations raised the following issues for consideration:-
7.1 A Child Health Summit took place at the Ramside Hotel in Durham City. The keynote speaker was Melanie Johnson, the Minister of State in the Department of Health. This summit drew attention to the inequalities in child health particularly in the north east. There were a number of identified factors in child health inequalities as follows:-
7.2 Professor Alan Craft, Head of Child Health at the University of Newcastle indicated that:-

“It is now more than ever clear that health in childhood determines adult health. Smoking in pregnancy and obesity are key targets.”

7.3 This short quote indicated that the topic chosen by the Working Group was a particularly important one which was a key to the future health of residents in the County.

8. CHILD HEALTH AND PRE-SCHOOL FACILITIES

8.1 A request was made to review the initiatives in relation to child health improvement for children in pre-school facilities. This broadly covered nursery education both public and private and also, to an extent, child minding services.

8.2 Requests were made for an overview about this issue from the Education Service and the Social Care and Health Service. It became clear that whilst there are many initiatives taking place in relation to the promotion of health of young children in the County, the co-ordination of such work was undergoing a change.

8.3 Following the recent Green Paper - ‘Every Child Matters’ and the Climbie report, the Children’s Bill had now been introduced into Parliament. There would be major changes in the way in which services provided for children were to be planned, delivered and co-ordinated and also new accountability provisions. In the circumstances, it was considered more appropriate to simply note that monitoring and general strategy issues relating to the health of young children was undergoing substantial change.

8.4 As far as the Working Group is concerned, this development was to be welcomed. If progress is to be made in relation to the improvement of the health of children in the County, clear lines of accountability, a robust co-ordinating role, and a transparent monitoring role would represent a significant step forward.

8.5 Future services in relation to individual children and their families will require the development of a real multi-disciplinary model of service designed to achieve better outcomes for children and families. There is evidence that there is enthusiasm to achieve this aim.

9. EXERCISE AND DIET

9.1 The Government is giving a high priority to the promotion of good health. In the recent report from Derek Wanless - ‘Securing Good Health for the Whole Population’, the challenges faced by the Government to achieve improved health for the nation are set out. A key role for Government has been proposed in ensuring that the public has proper information on which to take decisions regarding their health.

9.2 A Government Consultation Paper was issued in the spring of 2004 entitled ‘ Choosing Health?’. This consultation document makes it clear that good health and well-being is fundamental to us all enabling us to live active, fulfilled lives. The importance of safeguarding health and preventing illness and disease by promoting healthier and longer lives is a key theme.

9.3 In relation to children, it is pointed out that one in five children does not eat any fruit in a week. The proportions in County Durham are below the national average and, in some cases, significantly so.

9.4 The report also points out that in the north east, people are nearly three times as likely to be out of work and on sickness/disability benefits as those in the south east. This generally has an impact on the health of those affected, particularly young children.

9.5 The impact of physical activity and its relationship to health, the Chief Medical Officer in May 2004, published a report entitled ‘At Least Five a Week’. This evidence based report indicated that for children, a total of at least 60 minutes of at least moderate intensity physical activity each day, is required to support good health. Also, at least twice a week, this should include activities to improve bone health, muscle strength and flexibility. The report makes the point that achieving the weekly recommendation is not the preserve of sports activities. This recommended physical activity could be achieved by all.

9.6 The benefits of physical activity in childhood are carefully explained in this report. This includes healthy growth and development, maintenance of energy balance, psychological well-being and social interaction. Activities for early years could include baby massage, water based activities for babies and infants and their parents, toddler gyms, supervised play and learning through play.

9.7 The evidence shows that nationally two out of ten boys and girls do less than thirty minutes activity per day. The position in County Durham appears to be below the national average.

9.8 It was also clear that obesity levels in England are high and rising. In 2002, just over 30% of boys and girls aged between 2 and 15 years were overweight and 16% of these boys and girls in this age group were obese.

9.9 Children who are obese are more likely to have heart disease and develop diabetes. There are indications that children now spend more time involved in sedentary pursuits such as television watching or computer games.

9.10 There is also significant debate underway in relation to diet for young children. The promotion of a healthy diet is seen to be a key to good health.

9.11 A further consultation document has been issued related to choosing a better diet. This covers consumer choice including improved food labelling and health food promotion, tackling food production to reduce salt, total and saturated fats and added sugar and increasing fruit, vegetables and fibre in food, improving food supplied by retailers and caters in the workplace, improving nutrition in schools, the NHS and local communities.

9.12 A particular theme which is relevant for this project is improving nutrition in pregnancy and the early years. The proposed goals for this action area are:-
10.1 The Government is giving improved public health high priority. The latest consultation document indicates that:-

“Good health and well-being is fundamental to us all, enabling us to live active, fulfilled lives. The Government is absolutely committed to achieving better health for everyone which is why we have put record levels of investment into the NHS.”

10.2 The Government also draws attention to the following statement from Sir Liam Donaldson, the Chief Medical Officer:-

“Strengthening public health means that we need to inspire, we need to explain, we need to communicate, we need to create a commitment to change amongst all of society, that builds on the impetus already gathering in communities, and nationally.”

Health Scrutiny can be a catalyst in encouraging this theme.

General Issues

10.3 A number of general issues have emerged from this investigation. Many relate to the role of communicating and seeking commitment. The issues are:-


Surestart

10.4 A number of issues arose in considering SureStart schemes:-

Immunisation

10.5 A number of issues arose in considering immunisation:-

Looked After Children

10.6 A number of issues arose in considering Looked After Children:-
11.1. Promotion of good health is identified in the Strategic Vision for the County as an important element of the challenges facing the County.

11.2 The guidance to Health Scrutiny Sub-Committees from the Department of Health indicates that:-

“The Overview and Scrutiny of Health is an important part of the Government’s commitment to place patients and the public at the Centre of Health Services. It is a fundamental way by which democratically elected community leaders may voice the views of their constituents and require local NHS bodies to listen and respond. In this way, local authorities can assist to reduce health inequalities and promote health improvement.”

11.3 The Health Scrutiny Sub-Committee, therefore, should act as a lever to improve the health of local people and should act as a catalyst between health bodies and the community.

11.4 Many of the issues which have emerged from this investigation will rely on communication and commitment if there is to be a consistent approach in the County to achieve the Strategic Vision and make Durham County a healthier place to live.



MAIN RECOMMENDATION

11.5 It is suggested that the Health Scrutiny Sub-Committee should act as a catalyst by arranging a local Conference to heighten awareness of child health promotion issues and to seek to assist in the preparation of the action programme envisaged in the Strategic Vision with themes which arise from this investigation. The themes are set out below with suggested directions from the Health Scrutiny Sub-Committee .

i. P ROMOTION OF B REAST F EEDING

The evidence received by the Working Group indicates that breast feeding does have a beneficial impact on child health. The evidence from the SureStart schemes in the County indicates that much good practice is already in place to encourage breast feeding.

The Working Group would like to see this good practice shared across the whole County. This is a theme which many organisations have taken up but the Working Group would like to try to heighten awareness of its importance in promoting child health in the County.

ii. T HE I MPACT OF S MOKING ON Y OUNG CHILDREN’S H EALTH AND S MOKE FREE AREAS

There is no national legislation which empowers either Government or local authorities to impose smoking bans. Nevertheless, there may be issues that can be pursued to seek to heighten awareness of this issue and take incremental, responsible steps in this sensitive area.

The evidence suggests that the single most important issue in relation to infant mortality is stopping mothers smoking during pregnancy particularly during the last six months of pregnancy. Also, exposing pregnant mothers and young children to second hand smoke in work places and public places carries the same risk to health as actual smoking. The Working Group considers that, in its role as a catalyst to promote good health in the County, it should encourage initiatives across the whole of the County to seek to reduce the exposure of young children to tobacco smoke.

There is currently an initiative within the Durham and Chester-le-Street Primary Care Trust area to promote smoke free public places and work places by a number of approaches. One initiative is to introduce a smoke free award scheme to provide incentives for business and local employers to introduce smoke free buildings. We suggest consideration is given to extending this initiative across the whole County. This is particularly important bearing in mind the role of health scrutiny in identifying health inequalities. We would like to look forward to a situation where young children, particularly, were protected in County Durham wherever possible from exposure to tobacco smoke which damages their health.

There are also national initiatives such as the National Clean Air Awards which are pursuing aims to promote smoke free areas. It was noted that discussions are underway about a regional approach to a ban of smoking in enclosed public places. Recently, Liverpool City Council has been considering policies to encourage smoking bans within the City. A national template has been developed giving guidance about how local authorities can play their part in introducing such initiatives. We suggest that there should be a debate in County Durham about whether a more concerted effort should be made to introduce measures across the County to encourage smoke free environments focusing on young children.

In particular, local authorities need to consider their own public buildings and vehicles that they operate. It is important that the public sector is seen to set an example. They can also be an important in encouraging public debate and heightening awareness about this issue. There also needs to be consideration of the interests of smokers. Any policies must also be supportive to those who choose to continue to smoke, although not to the detriment of young children. As mentioned, there is no legislative power to impose smoking bans. Accordingly, a staged approach is necessary if progress is to be made in this area. We would encourage a local action plan being considered for the County setting out the steps which would be realistic for organisations to take in County Durham.

We have noted that Durham and Chester-le-Street PCT are exploring options to appoint a smoke free public places project worker for their area. We think that it would be a positive step if consideration were given to widen this on a countywide basis.

Accordingly, the Working Group suggests that the Health Scrutiny Sub-Committee should encourage a countywide strategy to protect young children from tobacco smoke and that consideration be given to linking such a strategy in County Durham to the emerging regional tobacco control strategy.

iii. P ROMOTION OF GOOD P RACTICE IN SURE S TART SCHEMES AND C HILDREN’S C ENTRES

The visit to the Peterlee Scheme was very valuable. The scheme is promoting child health in an holistic way which provides a good example for others. The adoption of the UNICEF baby friendly accreditation is a helpful initiative which other schemes might wish to consider.

We note that monitoring by the County Council is in its early days. It is pleasing that many of the national targets are on track locally. There are still issues about smoking reduction during pregnancy which need to be addressed.

The joined up approach of library membership for children under four years was a particular area which pleased members of the Working Group.

Good practice should be identified as part of the monitoring role of the County Council and recommended in schemes across the County. Monitoring of smoking reduction for pregnant mothers should be a particular focus.

IV. I MMUNISATION - M ONITORING OF S TATISTICS IN E ASINGTON

Children in County Durham have an above average take up of protective immunisation which was particularly pleasing. It was noted that the reliability of statistics in Easington was an issue but this was being addressed actively by the PCT.

The work underway to improve the reliability of statistics in the Easington PCT area should be monitored when this project is reviewed.

v. L OOKED A FTER C HILDREN

Members of the Working Group expressed some concern about the health checks for Looked After Children. It was recognised that Looked After Children often became the responsibility of the local authority in circumstances where their lives have been chaotic. It was noted that particular effort was being given to ensuring that records for young Looked After Children were accurate. The current target for annual assessment, immunisation and dental checks are 80%. In general terms, there was a view that, for Looked After Children, the aim should be 100% although there needed to be realism about the practicalities. This is a particular area to which the Working Group will need to return in the review of this project to ensure that the required improvement is introduced.

The work underway to address the recording and provision of health checks for Looked After Children should be monitored as part of the review of this project.

VI. F LUORIDATION

The evidence received by the Working Group suggests that fluoridation does have a significant impact on tooth decay for children 0-5. Fluoridation is a sensitive issue which is led by the Strategic Health Authority. Bearing in mind the evidence, the Working Group suggests that this is an issue for further debate. In the interests of very young children, there are clearly benefits for oral health.

Further debate about fluoridation should be promoted.

vii. J OINING UP I SSUES

A standard countywide approach to healthy eating policies for 0-5s should be considered and PCTs should also be asked to consider any significant differences in practice in relation to the 0-5 age group within the County with the aim of promoting good practice consistently across the County. Particular emphasis should be given to promoting smoking reduction measures for pregnant women and prevention of teenage pregnancy and supporting teenage parents.

PCTs are encouraged to identify good practice in this area and seek to apply this across the whole County.

viii. T HE R OLE OF L OCAL AUTHORITIES

In looking at the health of young children, local authorities have a significant opportunity to influence and promote better health. In particular, following the evidence of this investigation, it is clear that they can influence:-

Local authorities should be encouraged to provide a more co-ordinated focus on the health of young children in the County in line with the Strategic Vision which looks forward to significant improvements in the health of County Durham residents.



MEMBERS OF THE WORKING GROUP
Chairman: Councillor Priestley

Councillors: Agnew, A. Armstrong, J. Armstrong, Burnip, Carroll, Cordon, Crosby, Gray, Harker, Harrison, Howarth, E. Hunter, Lee, Marshall, Mitchell, Proud, Pye, Raine, Simmons, Smith, Stansfield and Watson.

Co-opted Member: Gill Eshelby



Attachments

 Item 4.doc;
 Scrutiny - A Review of Child Health - 5 July.doc