Children and Families Bill

Baroness Eaton Excerpts

Wednesday 30th October 2013 Grand Committee

[Baroness Hughes of Stretford]

My Lords, I shall speak to Amendment 112, standing in my name; to Amendment 118, tabled by my noble friend Lady Wilkins, to which I have added my name; and to Amendment 114, tabled by the noble Lords, Lord Low and Lord Ramsbotham.

All the amendments reflect the strong view that the local offer should be strengthened to ensure that it is a statement that parents, children and young people can rely on and for which, particularly—the noble Lord, Lord Low, stressed this—the local authority can be held accountable. In order to do this, the amendments would create the minimum standards that have been called for both by the SEN sector and by the Education Select Committee.

It is right to acknowledge that in the lead up to the Bill arriving in this House, and, indeed, while it was in the other place, there was considerable debate across the sector as to whether minimum standards for the local offer were a good idea. People tried to evaluate the impact of having minimum standards or not. It is also fair to say that the broad and strong consensus now is that minimum standards are necessary to ensure reliability and accountability, otherwise there is a danger that we may end up with a postcode lottery of services. Again as the noble Lord, Lord Low, said, this is not about being prescriptive with local authorities but rather ensuring that no child or young person is left behind or suffers from a poorer service because of where they live.

The Government have said, and probably will say again, that they feel that minimum standards will create a race to the bottom, that they will constrain parents’ and young people’s ability to influence the local authority to increase service provision, and that that is to be avoided. The opposite is true. Equally one could argue that if you do not set a minimum there is a risk that councils will deliberately weaken their offer and undercut other councils to avoid families moving in because of resource constraints. There is a real risk that the quality of service locally will be entirely dependent on budgets and will be reduced.

Some organisations within the sector, for example, the RNIB, NDCS and Sense, have said that in the absence of any expectations on minimum standards, local authorities with better provision could reduce it in line with poorer neighbouring provision, and that too many services—I agree with this—are already at the bottom or below what parents should reasonably expect. The Government should move on this.

[Baroness Eaton (Con)]

My Lords, I seem to be a lone voice in the Committee today as I support Clause 30 in its current form. We should resist making any further amendment to the clause that would make the measures more prescriptive than they are already. To do so would needlessly hinder local provision for local issues that are not foreseeable from a national point of view. I therefore cannot support Amendment 118 and the others in the group which seek to introduce minimum standards for the local offer.

It is of concern to me that by introducing central prescription we would reduce the flexibility of local authorities to allow for local solutions. Government departments are unable to see the detail that is based on the daily contact and conversations with parents and young people and are unable to respond to individual and local needs. They cannot do that in the way that a local authority can. With a variance in funding for education, including SEN provision, across the nation’s local authorities such prescriptive measures could damage in a very real way the ability of local government to cater for the needs of local residents.

SEN provision varies between local authorities due to the nature and size of the local population, with greater needs for levels of service in some areas and much less requirement in others. By allowing local authorities to control their own provision, which these amendments would restrict, those authorities will be better able to provide those required specialist services. I always think of the example of a child with severe autism, who may require ballet lessons which would not be part of an offer. If a local authority is stretched to provide financial support for the things that it has to do, this removes its flexibility to deal with individuals on the basis of their need.

A serious concern regarding these amendments is that they would place duties on local authorities to secure a minimum level of health provision, when the body responsible for this is not the local authority but the National Health Service. It is entirely understandable that local authorities should be very wary of being responsible for provision over which they have no direct control. I agree with the references made earlier to the Minister’s view that too much prescription can severely limit flexibility and innovation in service provision.

We often heard negative comments today about local authorities’ provision. There is of course always room for improvement but with so many good quality provisions being made and so much work going on with parents and children in local authorities, our view should be that the aim of local authorities in this area is to provide a good service. We should not set expectations at a level that just will not be available but allow flexibility, and allow local authorities to create the right services for the people in their locality.

[Baroness Howarth of Breckland]

My Lords, the noble Baroness, Lady Eaton, is not alone in having some reservations about setting minimum standards as they may well stifle innovation and individual programmes. Perhaps more thought could be given between now and Report to how we ensure that local authorities provide a range of services. I know that the code says quite a lot about this. My great worry is that if you do not have something which can be inspected and monitored, and an expectation of a range of services, some local authorities might end up with very little indeed in their local offer—and it will be a postcode lottery. There is a real dilemma in how you maintain that flexibility yet ensure that families have something they can turn to which is monitored by either Ofsted or the Care Quality Commission. It would be quite useful to give some thought to this between now and Report so that we can come up with a better solution than a rigid framework, but with something ensuring that the services are there.

Health and Social Care Bill

Baroness Eaton Excerpts

Monday 5th December 2011 Lords Chamber

[Earl Baldwin of Bewdley]

My Lords, I support what the Government are doing here, though with some reluctance, for reasons that will not surprise the noble Lord, Lord Hunt. I am reluctant for two reasons that lie at the heart of a fluoridation policy: the scientific evidence for it and the medical ethics. It will pay to revisit those briefly this evening.

It is now 15 years since I started putting down Questions to the Government, chiefly on the evidence surrounding fluoridation. In the late 1990s the previous Government conceded that the studies they relied on were old and not of very good quality. Sir Iain Chalmers, a leading healthcare scientist who was then director of the UK Cochrane Centre, joined me in pressing for a high-quality systematic review. The Government agreed. That review, which came to be known as the York review, was conducted by the NHS Centre for Reviews and Dissemination at the University of York. I served on its advisory board as it examined 50 years of the world literature. The results, published in 2000, surprised many people.

Not one good-quality study could be found. This meant that nothing could be stated with clear confidence: not efficacy in preventing caries—though that did appear likely—not safety, and significantly not the hoped-for evidence that fluoridation might even out the inequalities in dental health between social groups. So poor was the evidence for that question that the four senior research scientists who were involved in the review described it in a letter to Health Ministers at the time as “weak, contradictory and unreliable”.

I know from the previous amendment that it is dangerous to quote the noble Earl, but I was interested to reread the speech of the noble Earl, Lord Howe, on the regulations of the Water Act in 2005, and to read that he, too, was impressed by the lack of good evidence as shown by York. I emphasise that the York review was not just any old review—there have been plenty of those. This was a Rolls-Royce systematic review, conducted to the highest international standards, the only one of its kind in the field. A more recent Australian systematic review has been unable to find anything that would change York’s conclusions.

I wish I could say that this better understanding of the evidence had influenced policy. Having accepted York’s findings, through gritted teeth, governments have downplayed them and, at times, subverted them. For the past 10 years the York scientists, when they had the time to do so, and I have been trying to point people back to what the known evidence shows. In the face of deeply held beliefs, this has been quite an uphill task.

The question of ethics, which is my second objection, can be put in a nutshell. In our society, a person faced with a healthcare intervention is free to accept or reject it. This is the principle of individual informed consent. We find it in case law and in pronouncements from all kinds of medical bodies. Fluoridation is invasive and unavoidable. Therefore fluoride designed to protect teeth should not be delivered by this method. I could say much more, as indeed I have many times in your Lordships’ House, but now is not the time or the place. These twin objections, evidence and ethics, are what motivate most of the large number of people who oppose community water fluoridation.

Given, however, that such schemes exist, and that the Government are determined to provide for new schemes, how best should they be structured? I believe that what the Government are proposing here is a significant improvement on what went before. The old system where water companies had a veto over new schemes was clearly not ideal. Since the Water Act 2003, strategic health authorities have been in the driving seat. Curiously enough, the All-Party Group against Fluoridation that I subsequently chaired was given an assurance by Health Ministers in the previous Government that they would put elected local authorities in charge, as is now proposed. However, when it came to their Water Act, it did not happen.

The problem with the unelected SHAs was—is—that they almost inevitably reflected the dominant medical view. Fluoridation was a classic case of premature consensus, on weak evidence from the 1950s and 1960s, and it became a kind of sacred cow, resistant to new evidence, as I have indicated with the York review. The regional director of public health who advised the SHA that recently decided to fluoridate Southampton, against the expressed wishes of its population, described fluoridation correctly as the “professional orthodoxy”. Sir Iain Chalmers, who knows more about medical evidence than most people, has described it publicly as a “religion”.

A most unfortunate feature in all this is that so many prominent bodies should have signed up with the National Alliance for Equity in Dental Health as campaigners for fluoridation—not just supporters, campaigners. The website of the British Fluoridation Society shows the British Dental Association, the British Medical Association, the Faculty of Public Health Medicine, the NHS Confederation, the UK Public Health Association, among dozens of other such bodies, including some royal colleges and about 60 primary care trusts. If you have signed up to a campaign, not only are you compromised in terms of impartial advice but it is very hard to draw back. It is much easier to keep going forward with your professional peer group. And, if you are the people whose advice is being sought and heeded, there is likely to be only one outcome.

While fluoridation continues, these clauses may offer the least worst way forward. In parenthesis, referendums would show more clearly what local people want. There have been quite a number in America, but as they have tended to reject fluoridation the Government may be wary of them. Even here, to have your healthcare treatment decided by a majority vote of your neighbours is not a principle known to medical ethics. At least local authorities are accountable to the populations they serve and, while quite properly taking advice from all quarters, should be better able to gauge than the SHAs have been what is right for their communities. People should not have to accept what Big Brother, or rather Big Doctor, thinks is good for them. I broadly support these clauses, but the devil will be in the regulations.

I conclude by putting three questions to the Minister. First, will she consider providing for a neutral body to set out the current state of the evidence in any future public consultation? This was suggested by Iain Chalmers back in 2003. Some of the misstatements during the Southampton consultation were pretty terrible. Secondly, will she include in that a revision of the Chief Dental Officer’s guidance letter of February 2008 to decision-makers over fluoridation? I think that the noble Earl, Lord Howe, suggested to me that this would happen. Thirdly, will she give the undertaking, given by the previous Government during the passage of the 2003 Act and the regulations in 2005, that no new scheme will go ahead unless the local population is in favour? If so, will she ensure that any undertaking given—the noble Lord, Lord Warner, who is not in his place, was one who gave it at the time—will not be watered down in the regulations so as to lose its effect, as happened last time?

[Baroness Eaton]

My Lords, like the noble Earl, Lord Baldwin, I feel that there is an improvement in the fact that fluoridation of the water supply should be determined locally. Local authorities are democratically accountable bodies, and surely they are the best placed to make decisions on behalf of the local population.

My concern, not just about this section of the Bill but about the amendment of the noble Lord, Lord Hunt, is around consultation and the ethical issue, which we have already heard mentioned, about the fluoridation of water and what that creates. I would appreciate hearing whether the processes by which the public are consulted about the fluoridation of water could enable communities to reject proposals to do so.

Members of the public are very cynical about consultation. They believe that, whenever their opinions are requested by any public body, no one takes action based on those opinions. It is important that communities are consulted and that the results of those consultations are taken notice of. The effect of fluoride on teeth may be a matter for dentists, just as the effect of fluorides on the rest of the anatomy may be a matter for scientists or doctors, but the question of whether it is right to use public water supplies to convey to the entire population a medication that is intended to influence the bodily development of 0.4 per cent of the population—that is, children whose teeth are forming—is surely an ethical question. The views of water consumers should carry just as much weight on this matter as the views of dentists and scientists.

I would be grateful if the Minister could reassure the House that consultation as referred to will actually have meaning and that local authorities, consulting on the matter of water fluoride with the residents, should be bound by the results of such consultations. It appears that the Bill allows the Secretary of State to ignore the results of consultation. Would the Minister explain this and give examples of where she envisages the Secretary of State taking decisions that disregard the results of the consultation?