Published: 05/02/2004, Volume II4, No. 5891 Page 24 25
Margaret Hodge is passionate about the potential for integrated services to improve child health and well-being. She wishes more GPs felt the same
Margaret Hodge seems to thoroughly enjoy being the minister for children.
Running late and slightly frazzled, she has the politician's art of focusing all her energy onto the person she is talking to. A sometimes loose way with detail is cloaked by enthusiasm.
Her role has not always been comfortable. Indeed, since she was given the newly created job in the newly created Department for Education and Skills last June, she has faced continual media and political attacks over her child protection record while leader of Islington council in the 1990s.
Apologies and compensation have quietened those calls, and now Ms Hodge seems freer to concentrate on the present rather the past - last week she gave keynote speeches to two conferences.
Both addresses were about integrating children's services, and particularly protection. Last August, she told Local Government Chronicle readers that, in no uncertain terms, social services directors needed to place children higher on their agenda - and fast. Does she think the same of health managers?
'I talk to individuals engaged in health and you get some real positivism. Equally, I meet a lot of cultural and professional resistance to moving out of your silo and recognising that by working across the boundaries the whole is greater than the sum of its parts.'
She says it is the health visitors and school nurses she meets who really impress with their enthusiasm. The question remains whether this enthusiasm communicates itself up to senior managers - a concern of chief nursing officer Sarah Mullally.
Ms Hodge says: 'I often ask, when I meet chief executives of primary care trusts, how much they spend on children's services?
They often do not know. And if they do know, It is a minute amount.'
This 'mixed bag' of enthusiasm and apathy is inevitable and 'not depressing', according to the minister. She explains: 'The pathfinder [children's] trusts are hardly off the ground.We haven't got the new statutory responsibilities that will require people to cooperate.'
One of the frustrations, as well as appeals, of the children's trust agenda is local flexibility - some are pooling budgets, some are not; some include services such as physical disability that others do not; some combine commissioning and provision, some do not.
Ms Hodge seems to favour pooled budgets 'so that people are really having to work together', but stops short of advocating it explicitly.
'We think a route to better outcomes for children is joint working. There is a range of levers which will encourage [it]. We are thinking rather carefully now, for example, about the targets we set for local authorities. How do we align those to national service framework-type targets or to our own targets [agreed with] the Treasury?'
She also emphasises the importance of joint inspection. Ofsted (the Office for Standards in Education) will lead the inspection regime, 'first among equals' as Ms Hodge puts it. Ofsted will work with the Commission for Social Care Inspection and the Commission for Healthcare Audit and Inspection.
'There are huge issues to grapple with; CSCI and CHAI have got their own legislative framework and have only just been established. Both come from a very different tradition of how they inspect. Ofsted goes in, inspects and withdraws; CSCI goes in and has a much more developmental improvement role. CHAI is the inspection regime I know least well but, from what I understand, will do much of its inspection based on statistics and doesn't do as much inspection in situ.So We have got to see what's the best for inspecting a setting which will provide multi-agency services.'
The Every Child Matters green paper says that children's trusts will 'normally' sit within local authorities - a word which might alert the wary. If joint authors Ms Hodge and community care minister Stephen Ladyman want councils to have them, why not just say that?
'There is a tension between wanting people to take local decisions and national standards and We have just got to recognise it.'
But how much variation is she willing to put up with before the reality of an integrated universal service is lost?
'I've got a vision. And in my vision it would all be together. I would actually have all the child and adolescent mental health in there, certainly all the school nurses, all the youth-offender teams, Connexions. There is an interesting issue about acute paediatric services as well, which I haven't really thought through.
'My ideal is all encompassing; I have equally got to recognise that people have to evolve on their own. But I am not going to lose my vision.'
So that means an ideal in the sense of something to be worked towards in reality rather than a never-to-be-achieved perfection?
'There is a direction of travel and people will move at different paces, ' she replies. She adds that although the government is 'not going to legislate', she 'expects' children's trust to be universal by 2006. 'I can't see another way of doing it.'
Ms Hodge stresses that the 'allin-one' vision is based on a lead professional controlling assessments. 'The other day I met a 10 or 11-year-old child with a lot of physical disabilities who is in a mainstream school. Her mother told me she's had 18 different professional assessments. Crackers!'
So is common assessment one of the non-negotiables; one of the cornerstones of good outcomes?
'What's a non-negotiable? I think you're tying me down too much and being too prescriptive.
But if you want to put the child at the centre, it makes sense for everyone to work together and That is about planning, commissioning and pooling resources. It makes sense to have a common assessment framework.
'Sharing of information is an area where I think we will probably be more prescriptive than other areas. The reality is we would be much better with a national system for professional information sharing.'
However, Ms Hodge said she has 'shied away' from following this route as she feared she would 'still be discussing it in 20 years time'.
Instead, the DFES has chosen to use a series of local hub-andspoke systems, rather than a national one shared by all agencies. This would involve each local authority drawing in information from social services, primary care, schools and so on. Each child would have a unique identifier, possibly - but not necessarily - an NHS number.
GPs would flag concerns about a child with the 'hub'.Of course, the controversy is what constitutes concern (do you 'report' a mother who smokes heavily? ; a stepfather who uses drugs? ) and what the response should be. 'It is another question We are asking ourselves, ' Ms Hodge says.
One of the concerns of local systems in this context is that it tends to be the most vulnerable children who move between local authority boundaries most often. For that reason, Ms Hodge says there needs to be 'some commonality across the country'.
'So I think We are going to be more prescriptive [though] It is a very difficult area of public policy.
GPs, interestingly enough, are the most reluctant to share information and hide, often, behind the data protection legislation.'
She says that the responsibilities of GPs will be made 'clear in the legislation'.
The logical conclusion might appear to be that GPs should face a statutory duty to share information, but Ms Hodge will not be drawn further on the subject.
However, in her speech to an HSJ conference last week, she said that GPs would have duties through legislation to protect children.
She is happier talking about the growing evidence of the success of early interventions. This covers issues like obesity and diabetes, and the idea that young families are ripe for engaging with wider health improvement.
So should this success be reflected in the key children's targets for 2005? And should the new raft of school-based children's centres be their vanguard?
'At the moment we are talking about what is the most appropriate, because We are trying to cut down on targets.What is the most appropriate health target that we can devise for now - we can always revise it in three, four or five years. And should it be around the mother's health or the child's health. If so, what indicator should we use?
'We are all keen to develop evidence-based policies, and one of the frustrations is that the data is so slow in emerging. In February I'll be getting data for teenage pregnancy based on 2001, or something like that.
'So even now, we can't really judge. If I am absolutely honest, We are putting a lot of money into the teen pregnancy strategy but we can't judge which of our interventions is being really effective. You can see regional variation, but you do not know what it is that makes the difference.'
But she is patient on this issue as with others - a number of times she emphasises that time will bring reward. For a minister who only a few months ago seemed to have a pretty short-term future herself, Ms Hodge seems now to be happy concentrating on the long term.