One free piece of fruit is just not enough

From the Great Ormond Street children's hospital annual lecture by Gillian Pugh, the chief executive of Coram Family, the children's charity

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Very few children spend the whole of their childhood in the traditional families beloved of advertisers in the 1960s, where two children lived with father as breadwinner and mother as home-maker. The speed of change and the adjustments that so many children have had to make have been considerable. More mothers are working, but overall unemployment remains high. Every day, more than 600 children see their parents divorce, and the pain and dislocation that this brings with it for all the members of the family cannot be overestimated.

Very few children spend the whole of their childhood in the traditional families beloved of advertisers in the 1960s, where two children lived with father as breadwinner and mother as home-maker. The speed of change and the adjustments that so many children have had to make have been considerable. More mothers are working, but overall unemployment remains high. Every day, more than 600 children see their parents divorce, and the pain and dislocation that this brings with it for all the members of the family cannot be overestimated.

But where are children's views, needs and voices in the health service? A recent review of health improvement plans in 87 health authorities found that only one in six referred to consulting with children; and perhaps even more alarmingly the recent NHS plan made almost no reference to children, except to say that they should eat a piece of fruit each day. Advocacy for children is an issue on which Professor Aynsley Green has been taking a lead with his recent article with colleagues in the BMJ, and I am glad to be part of a group taking some of the issues he raises forward. Who does speak for children in the NHS? Why are children not seen as a specific client group? Where are the child-centred services?

The major health problems facing children are no longer acute illness, but increasingly, chronic illness, physical disabilities, and mental-health problems, and with advances in clinical practice, most of these are best treated within the community. Over the years, I have become particularly interested in how vulnerable families access services, and have become convinced of the value of providing specialist intervention wherever possible within an open-access community service. This is a model we are currently developing at Coram Family.

Most adult illness and disease has its roots in experiences in childhood, and we could do much to prevent expensive and disabling interventions in adult life if we put a higher priority on children's health. Most of the dramatic improvements in health have been made through preventive measures in public health - safer sewerage, cleaner air and water, better diets and housing and so on.

I have spent a considerable amount of time over the past 20 years working with central and local government on the development of more cohesive policies for children's services and do not underestimate the difficulty for professionals of working together across agencies. I am also conscious that health has not been around the table at local level as often as it should have been, and the Department of Health seems not to be involved in the Government's new Children's Unit. Co-ordination or integration means building bridges and sharing resources and defining common targets. And where children and families gain, it may mean that individual professionals lose part of their budget or their empire.

We must press for an NHS framework with children and young people's health at the centre, a dedicated health commissioner for children in every health authority, a children's rights commissioner, government guidance to ensure children and young people's health is a priority in every health authority and a much stronger emphasis on preventive, community-based, multi-agency work, such as that we are pioneering at Coram Family.

I hope that what I have said this evening will have made some small contribution to the wider national debate about how as a nation we create an environment for children which can lead to their optimal well-being. There is a huge amount of additional funding going into children's services at present, and the Government is committed to joined-up solutions to joined-up problems. But there is still a long way to go. I have argued that responsibility for children's health and well-being goes far beyond the realms of the health service.

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