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Westminster Hall

Thursday 7 February 2002

[Sylvia Heal in the Chair]

Child Health and Maternity

Motion made, and Question proposed, That the sitting be now adjourned.—[Jim Fitzpatrick.]

2.30 pm

The Parliamentary Under-Secretary of State for Health (Yvette Cooper) : I welcome the debate this afternoon. Maternity and child health is a vital issue. It forms a huge part of the work of the national health service and has a wide Government and community purpose. Improving the health of our children was part of the motivation for establishing the national health service and it has been important over centuries of public health. The well-being of our nation's children is of particular importance to the Government, who are committed to giving each child the best start in life.

The health and well-being of a child are the key to helping that child achieve his or her full potential. Each child and young person deserves the best possible start in life and to be brought up in a safe, happy and secure environment. Children deserve to be consulted, listened to, heard and supported as they develop into adulthood and maturity. By investing in the health of our children, we will have healthier adults.

Children's health is closely linked to, and impacts on, many other aspects of children's lives. Perhaps more tangibly than at any other stage in our lives, social, emotional and educational development are closely linked to health in childhood. That is especially true throughout pregnancy and in the years when children are very young. Health in the early years can affect health throughout life, and health problems that develop in childhood can haunt people throughout their lives. Deep-rooted health inequalities in society often stem not only from childhood but from what happens in pregnancy.

The Acheson report was commissioned soon after the 1997 election to examine health inequalities across the board. It was the first time that such an assessment had been carried out for 20 years. It concluded:

Fundamental inequalities impact on the health of young people. The blunt truth is that a boy born to a low-income family at the end of the 20th century can expect to live, on average, seven years less than his classmate from a professional background. Babies born to low-income families are more likely to have low birth weight, which will have an impact on their health and education for many years. For example, low birth weight babies develop high blood pressure by the age of 11, thus increasing the risk of heart disease later in life.

Improving health in pregnancy and childhood involves the NHS, public health and wider initiatives from the Government and the community. Substantial progress has been made in all those areas, but we still

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have considerably more to do. I shall refer to some of the key areas where progress has been made. I wish also to highlight some of the challenges that will face us in the future. Maternity and child health is a massive subject, so I do not pretend that I can cover all the issues involved comprehensively. However, I shall be happy to respond to any particular worries that hon. Members have.

The main measure under which improvements can be made to maternity and child health in the next few years is the national service framework—the NSF—for children. NSFs have been developed in respect of coronary heart disease, mental health and cancer. They are the mechanism for improvement, reform and investment in the national health service, and they establish national standards and set out priorities for change. That is why I am so pleased that we are now developing the NSF for children.

In July last year, the children's national clinical director, Professor Al Aynsley-Green, was appointed to spearhead the development of the NSF. Like other national service frameworks, it will be developed by teams of people drawn from social care, the voluntary sector, the national health service and parent groups. Young people will also be involved in establishing the priorities and national standards as part of the NSF.

The NSF will implement many of the recommendations in the Kennedy response to the Bristol tragedy that specifically relate to children and hospital services. Because the NSF has such a wide range of topics to cover, we decided to adopt a modular approach. The module dealing with hospital services will be delivered this year. The NSF offers the most important opportunity in terms of future developments, but it must build on the progress that we have already made. I will outline some of the areas in which progress has been made, but important challenges lie ahead.

Wider issues that go beyond the NHS have a huge impact on children's health. One of the most obvious of those is the child poverty target, which falls outside much of the work done by the NHS. However, meeting that target and taking every child out of poverty within a generation will probably do more than anything else to improve children's health and tackle health inequalities.

Other direct programmes and measures supporting children and children's health also go beyond the NHS. For example, the sure start programme, which aims to improve the health and well-being of families and children from before birth through to the age of four, also looks ahead to their futures.

Sandra Gidley (Romsey): I welcome the sure start programme, so I hope the Minister will not think that I am carping. However, I feel very strongly about how my constituents are affected. My constituency contains an area that would easily qualify for the sure start programme if it were bigger, but because it is only part of one ward, it is difficult for the people living there to access any services or sure start money. They face an uphill struggle. Will the Minister introduce a scheme to ease that problem?

Yvette Cooper : The hon. Lady makes an important point. The current sure start model applies to areas of a particular size. They tend to be urban and are assessed

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on the basis of the level of deprivation. The programmes are community based and look at different services operating together and concentrate on working with parents to improve opportunities for families with children under the age of four. This is the first time that there has been a real focus on the under-fours that examines how the different agencies work together. That could have a huge impact on those children.

The hon. Lady is right to suggest that the main sure start model that is implemented throughout the country applies only to certain types of communities—those of a particular size or level of deprivation. One of the challenges facing us in terms of where we go next with sure start is to determine what we can do about smaller pockets of deprivation and about those who live on low incomes in wealthy areas. Such people may also suffer from disadvantage and deprivation.

Sure start currently reaches a third of children under the age of four who live in poverty.

2.39 pm

Sitting suspended for a Division in the House.

2.54 pm

On resuming—

Yvette Cooper : To continue the discussion on sure start, I believe that problems are faced not only by families who live in pockets of deprivation but by low-income families in other areas. Sure start will reach one third of children under four who live in poverty. Many children who live in poverty do not reside in poor areas—or in poor areas that are large enough to conform to the current sure start criteria.

To address that problem, we have begun piloting work in smaller pockets of deprivation and in rural areas. Thirteen sure start programmes are currently operating in rural areas and they are addressing the different challenges posed by deprivation in such communities. We are also investing £22 million to establish 15 mini sure start programmes that are intended to reach 7,500 children under four years of age who live in rural areas or pockets of deprivation. I will happily write to the hon. Lady to give her more details about how that initiative will develop. However, she also rightly referred to the longer-term challenge. Sure start has been very successful, and its principles must now be mainstreamed, so that we can offer effective support to families on low incomes throughout the country.

In addition to sure start, action is being taken to prevent teenage pregnancies. They are a reflection of social inequality. The risk of becoming a teenage mother is almost 10 times higher for a girl from a poor family than it is for a girl from a wealthy background. In 1999, almost one in 20 girls in England aged 15 to 17 became pregnant. That has huge health consequences, because the infant mortality rate for babies born to teenage mothers is more than 50 per cent. higher than the average, and the rate for babies born to mothers of under 18 years of age is more than double the average. There is also an increased risk of maternal mortality.

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The teenage pregnancy strategy has operated throughout the country, providing local partnerships to reduce teenage pregnancy. The early signs are positive. Teenage conception rates are falling. The conception rate for girls aged under 18 has been falling for the past eight quarters. It fell by 4 per cent. in 1998 and 1999, and the conception rate for girls aged under 16 years of age fell by 7 per cent. in that period.

Another programme operating outside the NHS that works to improve children's health is the children's fund, which will provide £450 million over three years. It supports a wide range of services that help to prevent children and their families from suffering the consequences of poverty. Bad health is one of those consequences.

There is much to be proud of in the programmes that I have mentioned. Work in local communities is starting to have a positive impact on the health of children and families. One of our challenges for the future is to integrate that work with other services and support for children and young people. Another challenge is to apply those programmes—and the lessons that they teach us about the strategies that make the greatest difference—to every area in the country. I have already referred to that objective in my remarks on sure start.

I shall now consider how the NHS can play a greater role. Pregnancy is an issue in which I have had a personal interest over the past few years. The interesting thing about being a pregnant Member of Parliament—as I am sure that other hon. Members who have been in that situation will testify—is that one experiences maternity services in different parts of the country. When I was heavily pregnant, I started to work out where the hospitals and maternity units were located along the GNER route between London and my constituency just in case I were to require rapid admission to one of them.

Access to supportive antenatal care during pregnancy is essential. It can make a huge impact on subsequent health. Evidence of that is provided by the recent confidential inquiry reports into maternal deaths and into stillbirths and deaths in infancy. It suggests that there is a direct link between poor antenatal care and poor outcomes for mothers and babies, including premature birth and low birth weight. Although such babies often suffer from complications immediately after birth, they also frequently suffer from far-reaching health and developmental problems.

Pre-term births are most common where mothers are very young, have poor health, are poorly nourished or smoke during pregnancy. Almost half neonatal deaths are linked to conditions of immaturity, which is why we must work to continue to improve antenatal services across the board and address risk factors, such as smoking during pregnancy.

Sure start programmes are doing much to improve maternity services and outreach for neonatal care, especially for people in low-income areas. Additionally, specific support is available for the many pregnant women who wish to give up smoking. The NHS pregnancy smoking helpline has been set up to give advice and support to women who wish to give up smoking. Dedicated support is being developed in every area. In sure start areas, programmes aim to reduce the number of pregnant smokers by 10 per cent. by 2004.

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Of course, we must improve not only antenatal care but care during labour and the critical post-natal period. The Government are working with the Royal College of Midwives to expand the number of midwives who work in the NHS, and to improve women's choices and control over their care during pregnancy and labour. Our most recent survey showed that nine out of 10 women were happy with the services that they received during pregnancy and childbirth. However, we know that there are wide variations in the care that people receive.

We recognise that we need more midwives in the NHS. We are committed to recruiting and training an additional 2,000 midwives over the next five years, and 500 of them should be working in the NHS by the end of the year. The NSF will build on that.

In addition to improving standards of clinical care, we are investing £100 million over two years in a capital programme to improve the environment in more than 200 maternity units. The money will pay for major refurbishments, new facilities for fathers and families, and the modernisation of antenatal units. More than 80 units will receive better bereavement facilities.

National standards on inductions, caesareans and other matters are being developed through the National Institute for Clinical Excellence.

Mr. Gareth R. Thomas (Harrow, West): I hope that I am fortunate enough to catch your eye, Mr. Beard, to make a speech in which I shall suggest how the Minister may allocate some of the money to expand maternity services. I flag up the real problem of recruitment of maternity nurses and midwives in London. Can she throw any light on further initiatives that her Department, perhaps in collaboration with other Departments with responsibility for public sector workers, may introduce such as rents-to-mortgage packages or other residential accommodation?

Yvette Cooper : Recruitment is a serious issue. My hon. Friend knows that many of his concerns apply not only to midwives but to nurses. There are areas in the south-east, especially London, in which the cost of housing and living is high, and such areas may suffer the greatest pressures. An immense amount of work has been done to improve recruitment, and that has been successful in recruiting additional nurses. We must apply the lessons that we learned from that to midwives. Work has been under way in the past year or so with the Royal College of Midwives to ensure that we apply to midwives the techniques that were successful for nurses. If my hon. Friend wishes, I shall say more about that when I wind up.

As part of the NSF, we must build a framework of national standards for our maternity services and the care that women, their new babies and families receive. That has huge potential. Many people who are involved in care or who have used services throughout the country are participating in drawing up and developing the maternity services module of the NSF.

There are excellent examples throughout the NHS of the provision of greater support and information for women and their partners. However, we know that some families are greatly frustrated because they do not receive the care that they want.

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We must build on the work that is being done to improve screening for children, such as the introduction of newborn hearing screening during the first few days of a baby's life. The programme is being piloted with a view to rolling it out nationally. Early detection of deafness allows parents and children to obtain the treatment and support that they need at a much earlier stage. That can help a person's development throughout childhood and later life.

Mr. David Drew (Stroud): I declare an interest inasmuch as several of my children were born at Stroud maternity hospital so I have some expertise in the subject. I attended the retirement of one of the midwives, Jo Moon, a week ago. Stroud is unusual in that it has one of the two remaining midwife-led units in the south-west. How does my hon. Friend view the debate about what women want—the choice to use midwife-led services—and safety and other issues that consultants tend to push in more acute child delivery settings?

Yvette Cooper : My hon. Friend is right. Midwife-led maternity care has huge value. There is a focus on midwives and their work in all maternity units, whether they involve consultants or are separate. The role of midwives in leading care can be critical. There are examples throughout the country of midwife-led units that are hugely popular with the women and families who attend them, who receive the choice and care that they want in maternity services. We need to increase choice for women in maternity care, and midwife-led units are an important part of that. That is one of the issues that we shall consider as part of the maternity services element of the national service framework.

In advance of that, we have a maternity work force working group that involves members of the royal colleges—the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists, the Royal College of Paediatrics and Child Health and the Royal College of Anaesthetists—and representatives of maternity groups, including the Maternity Alliance and the National Childbirth Trust. One of the issues that it is examining is how to provide safe, high-quality care in different settings and establish standards that apply in different settings in order to ensure that whatever the setting and the arrangements we can ensure that women and their babies and families receive the high-quality care that they need. I hope that that will provide a more secure framework for the development of different models of care that allow for women's choice.

Immunisation is a further important aspect of child health. We have made huge progress in the eradication or decline of some terrible diseases that in previous centuries killed hundreds of children in this country. Our immunisation programme has been largely responsible for the most immense improvements in children's health, and we should be proud of it. It has saved many lives and prevented much serious morbidity throughout the country. Living at the beginning of the 21st century, many of us take for granted those health improvements and not having to worry about the infectious diseases that haunted families in previous centuries.

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Hon. Members will be aware of the current debate about MMR—the measles, mumps and rubella vaccine. I shall say a couple of words because it is so relevant, but I shall not dwell on it unless Members want to discuss it, and I shall return to it in my reply.

The strong medical advice given to the Government is that MMR is the safest way to immunise children against some very deadly diseases. We are advised that the evidence considered by countless independent committees shows no link between MMR and autism. Of course research must always be thoroughly scrutinised and examined by independent committees, and it is. Along with the royal colleges and medical experts from all over the world, 90 countries recommend MMR as the safest way to immunise children.

Sandra Gidley : I support the MMR programme. Does the Minister accept that there may not be a statistically proven link, but there is powerful anecdotal evidence of a link between administering the vaccine and the development of autism? That tiny risk, if there is one, must be considered in the context of the risk of death from measles and other childhood diseases if children are not vaccinated. It is a comparison of risks that—

Mr. Nigel Beard (in the Chair): Order. This is becoming a rather long intervention.

Yvette Cooper : The medical evidence that I have received does not say that. This is not simply about balancing the risks presented by particular diseases; it is about examining all the evidence. The clear advice from the chief medical officer and the Royal Colleges is that the evidence shows that there is no link between MMR and autism.

Dr. Ashok Kumar (Middlesbrough, South and Cleveland, East): Is it not dangerous to get into anecdotal evidence? The scientific evidence demonstrates amply that there is no link in 99 per cent. of cases, and MMR has been recommended by people in the medical profession. We should take their wise counsel on this. Does my hon. Friend agree that it would be dangerous to suggest for even a nano-second that we should be guided by the anecdotal evidence?

Yvette Cooper : My hon. Friend has made an extremely important point. In the end, all that we can go on is the evidence that we have. In some matters the evidence is limited and we have to be careful about what we say and not protest too much or claim that we know things when we simply do not. For example, there is simply not enough evidence to make claims about how safe or unsafe it is for children to use mobile phones, which is why the chief medical officer has given cautionary advice to parents on that. However, there is considerable evidence about MMR. No Government can ever give guarantees about any form of medical treatment, but we can look at all the evidence, which, according to our best medical advice, shows no link between MMR and autism.

Ms Julia Drown (South Swindon): Is it not true that a rise in autism occurred before the MMR vaccine was

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introduced and there was no change after its introduction? One of the things that fuels the concerns is that people start to notice autism in children at exactly the same age as the vaccine is given. Autism is an awful thing, and one can understand parents wanting to attach something to it. That may be why we are having this debate when, as the Minister says, the scientific evidence clearly favours MMR as the safest option.

Yvette Cooper : My hon. Friend is right. The number of diagnosed cases of autism was increasing before MMR was introduced. It has continued to increase since then and, even though the levels of MMR have remained stable, the number of reported cases of autism has increased. She is also right that problems can start to emerge and be diagnosed at a similar age to the age at which children receive the MMR vaccination.

One important point that can get lost is that we need to know more about the causes of autism. We have quite a bit of evidence about MMR and autism, which has concluded that there is no link. We need more evidence on what the other causes might be because there is too much anxiety, albeit completely understandable, about autism among parents, particularly those with children suffering from autism. The Medical Research Council has done a major review of the research into autism to point out where further research is needed. That research is taking place. That is an important part of the work that we do here.

Mr. Gareth R. Thomas : May I ask the Minister to comment specifically on autism? We need more research into how autism develops and what are the best solutions for carers of children with the condition. More funding is needed for packages of support for carers and children.

Yvette Cooper : My hon. Friend is right. There have been many discussions about the causes of autism and about the right kind of treatment, intervention and support that families with autistic children need. Autism is one of a small number of key issues that we want to trace through the national service framework for children. Maternity and other services should be considered not in isolation but in the light of case studies of conditions such as autism, which would benefit hugely from being tackled through the national service framework.

Other forms of immunisation have made a big difference. The meningitis C vaccination programme was a huge success and is a great tribute to the NHS. School nurses, GPs, health visitors and nurses throughout the country delivered the meningitis C vaccination programme at immense speed. The UK was the first country to develop the vaccine and the first to implement it so rapidly.

In 1998, meningitis C caused an estimated 1,500 cases of meningitis, with 150 deaths, mainly of young children and teenagers. The new vaccine has resulted in a reduction of the disease of up to 90 per cent. in the main immunised groups.

Improving children's health means considering issues involving diet, nutrition exercise and health in the early years. The national school fruit scheme will offer every infant school child a free piece of fruit each day in

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school. More than 80,000 children between the ages of four and six are already benefiting from the scheme, which will cover all of the west midlands region in the summer and later be extended throughout the country. It is the most ambitious programme to improve childhood nutrition since the introduction of free school milk in 1946. Experts say that children should eat five portions of fruit and vegetables a day, but on average they eat only two portions and children in low-income areas eat one or none.

Mr. Drew : Does my hon. Friend acknowledge the benefit of measures to reduce food poverty? Governments get nervous about targeting and targets, but if there was more joined-up thinking and action between health, education and other Departments we could eradicate child poverty. It would improve people's quality of life if they could eat better food.

Yvette Cooper : My hon. Friend is right. There is a potential for health services to work with others, perhaps as part of local strategic partnerships, especially in neighbourhood renewal areas, and that could make a huge difference. There are some good examples from the five-a-day programme and community-based programmes to improve access to healthy food. They will be expanded using funding from the new opportunities fund in the next few years.

For older children, improving health can be part of personal, social and health education in schools, and the healthy schools programme can help them to avoid the risks of drugs, alcohol and pregnancy later on. We need to consider not only the needs of healthy children and how to keep them healthy but the needs of children who become sick. Most children will suffer some illness in their lives, perhaps one of the common childhood illnesses, which can be handled by parents or with the help of the primary care sector, but some, sadly, require more intensive and specialist care in hospital. I know from personal experience that NHS Direct can be a huge reassurance for parents. The 24-hour nurse-led telephone helpline assists callers to access the right service at the right time—perhaps at night or during the weekend. Five to 10 per cent. of the calls relate to children under 12 months and 20 per cent. relate to children under five. That is a hugely useful resource for anxious parents who want advice on the necessary care when a child is ill.

When children become critically ill, they need immediate attention from those skilled in caring for children. Improvements began to be made in paediatric intensive care with the introduction of the paediatric intensive care strategy in 1997, and an additional £60 million has since been invested in the strategy. Key improvements have been the development of lead paediatric intensive care centres for the most critically ill children and of retrieval teams to collect children and take them to those specialist centres, which have staff expert in caring for sick children. However, we need to go further by expanding our capacity and also considering neonatal intensive care.

Children with life-limiting illnesses require particular specialist support. They may be ill for many years and need constant care day and night. Eight Diana nurse teams provide a range of palliative care support to children at home. In addition, children who need

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palliative care will shortly benefit from £48 million that has been made available from the new opportunities fund to provide respite care in the home, the community and hospices.

Disabled children are a priority in the "quality protects" programme. I am talking about work with some of the most disadvantaged and vulnerable children in society, who may need additional support from social services, education services and local authorities.

It is not simply a question of physical illness. We must ensure that mental health and well-being are maintained and promoted in schools and elsewhere. A recent survey shows that 20 per cent. of five to 15-year-olds have a mental health problem, and 10 per cent. of that age group have a mental health disorder that significantly affects their ability to lead a normal life. Access to high-quality mental health services is essential for those children. The NHS plan and the mental health national service framework have set out an ambitious programme of change, which will have a major impact on child and adolescent mental health services. However, we are starting from a low base, and services need to be expanded. That is why it is vital that the children's NSF take forward the work that has been done to make a real difference.

There is much to do across the NHS, social services and the community to improve children's health and to involve parents, children and young people in their care. The NHS needs to work in a spirit of openness, as the tragedy at Bristol and Professor Kennedy's report have again highlighted. Special efforts and new thinking will be required to implement many of his general recommendations in services for children. The quality of care must be improved, which is why the work of the paediatric cardiac review group, which is picking up on the Kennedy report, is particularly important. The group is due to report this spring.

We have made substantial progress in improving children's health, but we need to recognise that new problems and challenges emerge and that we can do much more. The NSF provides us with a great opportunity to take forward the good work that is being done, but which is often too fragmented. That is vital for children and parents, as this week has shown.

There have been immense improvements in children's health in terms of the dreadful childhood diseases that killed so many in the past. We have improved treatment, diagnosis and vaccinations. In the past, childhood cancers killed many, but this country is now expert in treating them and leads the world in many respects. We must not turn the clock back. We have made huge progress, but we have a long way to go. I hope that the next few years will provide a great opportunity to improve maternity services and children's health.

3.23 pm

Tim Loughton (East Worthing and Shoreham): I welcome you to the Chair, Mr. Beard. I think that this is the first time that I have spoken in Westminster Hall under your chairmanship and I am sure that it will be a pleasure.

I echo the Minister's words of welcome for this debate on child health and maternity. I cannot speak as a pregnant Member of Parliament, but I can speak as the husband of a previously pregnant MP's wife. Indeed,

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I was speaking in the Chamber when my pager went off to tell me that my wife was going through the first pangs of producing one of our children, so I know the cut and thrust of this place and how it affects our family existence.

It may be slightly ironic that I am speaking for the Opposition today as a representative of Worthing, which has the oldest population in the country and might be thought the furthest away from child and maternity matters. However, I am a father of three children and I have two excellent hospitals—the Worthing and the Southlands—in my constituency, so I speak with some experience.

It is appropriate that our debate takes place just a week before Valentine's day, when Great Ormond street hospital celebrates its 150th birthday. Few better centres of excellence for child care exist anywhere and the hospital is internationally renowned.

As the Minister said, this is an enormous subject, to which neither the Government or the Opposition will be able to do full justice. I shall focus on maternity services, the sure start programme, the national service framework— particularly with respect to mental health—and, more topically, immunisation.

I stress from the outset that we welcome the NSF for children's health. The test of its success and thoroughness, however, will not be how many committees sit to arrange and organise it or how many tsars for children's health are appointed, but the real health improvements during children's crucial early stages that result from it. As the children's tsar, Professor Aynsley-Green, said, we have possibly the best chance in 50 years to put children's lives and health at the centre of Government policy. We welcome that, though it is a considerable task to live up to. The NSF is comprehensive, embracing maternity and social services; prevention, care and treatment; support for children with disabilities; transition to adult services, which are a particularly grey area; and children and adolescent mental health services.

I am pleased that the Minister spent some time dealing with that difficult mental health sector, which the NSF covers. This country has a big gap in mental health services, especially for children and adolescents. The United Kingdom population includes about 14.9 million children and younger people under 20—some 25 per cent. of the population—and it is estimated that at any one time, 20 per cent. of them experience psychological problems. The majority who experience such problems face difficulties that could be made much better by early intervention, which does not happen enough.

A consensus exists among professionals that substantial increases in the psychological disorders of youth—not just in this country but worldwide—have occurred since the second world war. Risk factors such as poor education outcomes and antisocial behaviour overlap considerably with later mental health difficulties, but we face big gaps in provision for dealing with those problems. Young people who are caught in the gap between services for children and those for adults acutely feel the lack of specialist provision across the spectrum of child and adolescent mental health services.

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Difficulty gaining access to specialist health care is a problem. Young people with mental health problems can be placed on adult hospital wards because they are the only provision available in the area. The young people often describe that experience as frightening and disorienting. Excessive use of drugs as a chemical cosh—instead of the one-to-one personal care that they desperately need—is another major problem.

For some time mental health provision in this country has been too patchy; mental health services for children and adolescents leave a great deal to be desired. We now have an opportunity to deal with the vast gaps in children's provision.

As vice-chairman of the all-party parliamentary group on autism, I welcome the inclusion of autism in the NSF. I shall not go into further detail, however, because we debated the subject a few weeks ago to celebrate the start of national autism awareness year.

The hon. Member for Harrow, West (Mr. Thomas) made a comment about better services for carers. Early intervention is absolutely essential. We have no standard detection system in this country to pick up cases of autism and provide appropriate care at an early age. As the hon. Member for South Swindon (Ms Drown) rightly mentioned, autism has been increasing for many years or, rather, detection of it has because we now know more about it. However, we still do not know nearly enough, and we need to spend more time and resources finding out about it. There is no obvious link between vaccinations and incidents of autism.

There are three problems with maternity services. There are big variations in the standard of service across the country, there is still a shortage of midwives, and there are moves towards greater use of caesarean section, which has caused increasing alarm.

We welcomed the "Good Birth Guide"— an interesting title for a report; it is not quite the "Good Wine Guide"—which was produced in January. It gives a guide to maternity hospitals and is by Dr. Foster, an independent group. It is interesting that it is not just big city hospitals with midwives who have heavy work loads that experience problems. The report reveals that there are 21 hospitals in which more than one baby is born per delivery bed a day. That means that some pressured units are operating in conditions of substantial overcrowding. Roger Taylor, the editor of the guide, said:

Ipswich hospital was top of the league table, and has a delivery rate of 1.3 babies per bed a day. That overcrowding gives many maternity departments in hospitals a production-line feel. That is not the only consideration when measuring the effectiveness of such departments; in many cases, the delivery rate reflects the efficient intervention of midwives at home with mothers who arrive at hospital only when they have reached the advanced stages of labour.

I speak from experience. I took my wife to Chelsea and Westminster hospital for the birth of our second child, and we were caught on the underground car park ramp with the "car park full" sign blazing when things were getting close. I had to reverse up the ramp with cars behind me to dump my wife. When I returned, having

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parked the car, she was in labour and gave birth some 20 minutes later, so I know that there are different ways of giving birth. I am sure that the Minister did not experience such alarming incidents.

The criticism has been made that general practitioners tend to book women into the nearest big hospital, and do not always discuss with them the availability of smaller community hospitals and midwife-led units, which are to be greatly praised. The hon. Member for Stroud (Mr. Drew) referred to such a unit in his constituency. Big is not always best. There is still too much of a maternity lottery in the provision of services.

I think that it was the Minister who last summer announced a shake-up of maternity services, which would result in continuous one-to-one care for every woman during childbirth. We welcomed that. That was to be done, first, by means of a £100 million plan to recruit 2000 extra midwives and modernise childbirth services—perhaps an ambitious target. Secondly, national standards were to be set up by 2003, giving women maximum choice in type of delivery and support. Thirdly, there were to be improved facilities to enable fathers to play a full role in births, and more sensitive treatment for bereaved parents in maternity wards. We praise those objectives.

It had been announced previously—on 2 May 2001—that there were to be more midwives and more money for maternity. It was said:

On 10 October 2001, the Minister of State, Department of Health, the hon. Member for Redditch (Jacqui Smith), announced that maternity units would receive £100 million. Was that a treble announcement of the same money, or was new money being announced on each of those three occasions? I should take a stab at the former solution.

There is a crisis in midwife recruitment in maternity services. It might be better to judge the work load of maternity services by the number of babies delivered by a midwife in a year. It is generally agreed that the maximum figure should be 35. At Wexham Park hospital, the figure is as high as 51. At St. Peter's hospital, Chertsey in Surrey, it is 49 and, at the King George hospital maternity department, it is 45. That means that there is a greater possibility that a midwife will have to deal with more than one woman in labour at any one time. Research shows that women do better with one-to-one care. Last month, Louise Silverton, the deputy general secretary of the Royal College of Midwives, said that the figures showed how precarious and under-resourced the service was. There are still few returners to midwifery. The Minister put forward an ambitious bid to recruit 2,000 new midwives.

Mr. Andrew Lansley (South Cambridgeshire): Did my hon. Friend notice that the Minister made no mention of the return-to-practice scheme that was launched in February 2001? Many of the representations that I have received make it clear that work load pressures are one of the reasons why some midwives have left the profession. It is important to ensure that such pressures

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are dealt with inside the profession before that return-to-practice scheme is successful. Clearly, it has not been successful over the past year.

Tim Loughton : My hon. Friend makes a valid point. It is all very well trying to recruit new midwives as, indeed, we need to do, but far greater efforts with nursing generally need to be made to retain experienced midwives. Genuine, practical moves must be made to make the profession more attractive to experienced midwives who may wish to return. Louise Silverton said that returners were few, and that remains the case.

Will the Minister confirm my figures? In 1997, the number of whole-time equivalent midwives was 18,050. At the end of 2001—the last date for which figures are available—that figure was unchanged at 18,050. We were still 2,000 short. Even the head count, which is the Government's favoured measure, does not deal with the problem. If more midwives are working shorter hours, the problem still exists. In 1995, the head count was 20,020; in 2001, it was 23,080. However, the whole-time equivalent is the crucial figure.

Let us consider the qualified nursing, midwifery and health visiting staff numbers and break them down into areas of work, as the Government do. In the September 2001 NHS work force census, the whole-time equivalent figure in 1996 was 23,190 and, in 2001, it had fallen to 22,680. Worryingly, those figures show not only that there have been no increases in the number of full-time midwives but that there has been a fall in the number of staff in related midwifery services. It certainly casts doubts on the ambitions of the Minister.

There are especially big shortages in certain parts of the country, not least in London and the south-east. The average age of midwives is getting older, and that suggests that there is a problem with new recruits entering the profession after training. Does the Minister have the latest recruitment figures for London and the south-east? What improvements of choice are now available to women in maternity wards? What special considerations have been made for women from ethnic minorities in London? Perhaps the Minister could comment on what help has been received in the south-east for housing for maternity staff and say whether any of them have been included in the keyworker housing scheme.

The Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of Anaesthetists and the National Childbirth Trust published a report on caesarean sections in October last year. It revealed that 21.5 per cent. of women were giving birth surgically. That is an alarmingly high figure. In Northern Ireland, the figure was 23 per cent.; in London and Wales it is as high as 25 per cent. That is a six-fold increase since the 1970s, when the average figure was about 4 per cent. It is nearly double the figure that was recommended by the World Health Organisation. More than half the obstetricians surveyed admitted that caesarean section rates in their units were too high. Mary Newburn, head of policy research for the National Childbirth Trust, says:

Why, then, are rates so high? Of the total number of caesareans, 7 per cent. are elective—a trend increasingly encouraged by celebrities such as Victoria Beckham and

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Patsy Kensit. There is something of a culture of women who are "too posh to push" and who opt for the convenience of choosing the time to produce their baby before returning to work, a drinks party or whatever it is that is far more important to them. Also, more women are giving birth later in life, when there is a greater risk of needing an operation. More worryingly, many hospitals fear lawsuits if difficult births go wrong. As Bill Dunwoody from the Royal College of Obstetricians and Gynaecologists says:

That is not a good reason for promoting caesarean section.

There is evidence that electronic foetal monitoring has increased caesarean section rates without any long-term benefit to babies, suggesting that it is over-sensitive and inaccurate and that most women should not have it during labour. There is also a suggestion that pressure from doctors in under-staffed hospitals lacking midwife support and reassurance also discourages women from having natural births. My constituent was quoted in The Sun recently. Jenny Lesley now works for the NCT. She wanted to give birth naturally, but ended up having all three of her children by caesarean section. She says:

The Minister mentioned sure start. In many ways, it is one of the better regeneration schemes. I visited a scheme in Hastings last year and saw a travelling play bus and a mobile health clinic. Several flats in a block had been knocked into one to create a centre for mothers in the middle of a deprived estate. At the centre, mothers could use the nursery facilities, see the district nurse or get medical help. It was very impressive. Although it had been open for only a few weeks when I visited, it was already a seething mass of people and was obviously appreciated.

As with most regeneration projects, sure start schemes, as the Minister said, are concentrated in urban areas. I hope that she will make a more detailed comment on the extension of the scheme to rural areas. As the hon. Member for Romsey (Sandra Gidley) said, under the current classification system, there are small wards of deprivation that do not qualify for such schemes because they lie side by side more affluent areas. That is a particular problem in parts of the south of England and around my constituency.

The sure start programme has targets to reach by 2004. The first is to reduce by 20 per cent. the number of children aged nought to three in the 500 programme areas who are re-registered on the child protection register within 12 months. That is a laudable aim but, as those of us who considered the Adoption and Children Bill know, the number of looked-after children has risen over the past few years and currently stands at 58,000. We therefore have an urgent task.

A second objective is to achieve a 10 per cent. reduction in the number of mothers who smoke during pregnancy. Again, we applaud that aim, but why is the gap widening between the number of young men and women smokers? It is much harder to persuade young women to give up smoking, so resources should be targeted to help with that problem.

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Thirdly, sure start aims to achieve a reduction of 5 per cent. in the number of children with speech and language problems requiring specialist intervention by the age of four. There is an acute shortage of speech therapists, and that is one of the biggest gaps that we face. It is also difficult to determine which body is responsible for the provision of speech therapists—the local health service trust, social services or the education department attached to local county councils. Something of a vicious triangle, or buck-passing, exists between those three parties. We need joined-up thinking, especially given the intense pressure on social services departments throughout the country. They are spending £1 billion more than the Government think they ought to be spending and are given credit for in the standard spending assessments.

I welcome some of the targets and the thrust behind the sure start programme. However, will the Minister tell us the basis on which the success of sure start will be judged? Are the targets realistically attainable? What progress has been made to date?

I shall now consider immunisation and, especially, the MMR debate that is raging at present. I agree with everything that the Minister said on the subject, and I welcome the progress that has been made over the past 20 years on immunisation programmes, such as meningitis C and the other programmes before that. We have a good record of which we should be proud. That is why the current problems with MMR vaccinations are worrying.

I was surprised by the comments of the hon. Member for Romsey, who spoke on behalf of the Liberal Democrats, because the Liberal Democrat health spokesman seemed to say something different yesterday when he referred to an element of risk. The Minister is right to say that the issue is not about balancing risk, because there is no scientific evidence to suggest any link between the MMR vaccination and autism or other side effects.

The Minister and I are on record as saying that our children have had the MMR vaccination, and I have no difficulty repeating that point. As vice-chairman of the all-party group on autism, I say that it is imperative that parents should accept the MMR vaccination for their children. It is the best alternative on offer. It is not 100 per cent. risk free, but nothing is 100 per cent. risk free. The Minister drew a good analogy with mobile phones. Parents who have any doubts should be encouraged to give their children the MMR vaccination. That has always been our position, and it categorically remains so. We share the confidence of the British Medical Association, the royal colleges and the 35 European, north American and other countries that use the vaccination.

Sandra Gidley : Will the hon. Gentleman give way?

Tim Loughton : I shall if the hon. Lady is willing to clarify her party's position.

Sandra Gidley : I was actually going to ask the hon. Gentleman to clarify his party's position. I think that the shadow Secretary of State for Health, the hon. Member for Woodspring (Dr. Fox), is on record as saying that

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there should be open access to the individual vaccines. That seems to be at odds with what the hon. Gentleman said.

Tim Loughton : That kind of misrepresentation is not helping the present debate. The fundamental point—this has always been the position of the Conservative party and its health spokesmen, and remained as such yesterday when we made a further announcement—is that no vaccination provides a better alternative to the MMR vaccination. We want all our constituents' children of a suitable age to have the MMR vaccination. We offered the Government a bipartisan approach two years ago when some "rogue" reports that cast doubts on the safety of the MMR vaccination were published. We offered to promote the message about the safety of the MMR vaccination and to point out that the dangers for a child who was not vaccinated were much greater than those for a child who had received the vaccination. We said that the MMR vaccination was as safe as it could possibly be, and that there was no concrete evidence to the contrary.

The simple reality is that the hon. Members in this Chamber do not need convincing. We must convince the public outside. The Government have given assurances over the past few months, but mixed messages have come from Ministers and, especially, from the Prime Minister, and those messages have led to misinformation and disinformation. The public have lost confidence in what they are told, and they are voting with their feet to such an extent that the vaccination rate is below 70 per cent. in parts of London.

Yvette Cooper : I have listened to the hon. Gentleman carefully. I welcome his support for the medical advice that we have received about the importance of the MMR vaccination as the best way to immunise children. Does he believe that the Conservative party's call—not only this week, but over the past 12 months when records show that for much of the time coverage was 83 per cent.—for the introduction of separate jabs has contributed to what he described as a decline in confidence in the MMR jab?

Tim Loughton : The hon. Lady is wrong. Until yesterday, our party's policy was that MMR was the only option. That remains the policy but, as from yesterday, we have said that single jabs should be available for those people who are not being vaccinated. That was not the position before yesterday when what we said was purely a response to the dangerously low take-up of the MMR vaccine.

Yvette Cooper : Does the hon. Gentleman deny that a year ago, before the last election, Conservative spokespeople called for separate jabs to be made available on the NHS?

Tim Loughton : Members on both sides of the House have called for separate jabs. Official Conservative party policy was to support MMR. Now, however, levels of cover are so low that a choice must be made available. MMR or nothing is not a choice. The difference between 70 per cent. and 95 per cent.—the former level, which needs to be achieved again—of 591,000 children leaves a gap of 25 per cent. That could mean that, according to

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the prevailing figures, 148,000 or so children are not being vaccinated. That is the simple reality. Whatever the hon. Lady's assurances, and whatever the attempted assurances of the Prime Minister, which have patently failed, a number of children are not being vaccinated at the moment and have no cover. That is why something needs to be done.

Ms Drown : The hon. Gentleman said that different information was coming from the Government. I have seen nothing that is inconsistent. I should be grateful if he would clarify his remarks, because if he believes that there has been inconsistency, we need to clarify what he means. All the information has been absolutely consistent in saying that MMR is the best thing.

The hon. Gentleman himself recognises that MMR is the best thing. Does he not realise that, by saying that people should be allowed single vaccines, he is fuelling their concerns? A responsible Opposition would say exactly what he said earlier—that MMR is clearly the safest way of protecting children.

Tim Loughton : The hon. Lady misses the point. Before yesterday vaccination levels in parts of the country had fallen to less than 70 per cent. No fuelling of concerns was required; the problem is already raging out there. Many people are sufficiently worried to take the option of no vaccination. The most irresponsible thing would be for us to allow parents to go ahead without providing any vaccination cover for their children, but that is what is happening.

Measles is not a soft option, and I make one criticism in particular. We have not made enough of the danger of mumps and rubella and especially of measles, which is a killer and can cause serious brain damage. A few weeks ago, I met the 41-year-old son of a constituent. He caught measles as a baby and has been brain damaged to the extent that he has been unable to communicate ever since. The dangers need to be rather better communicated. Some people still seem to believe that measles is a soft option. It is not.

Ms Drown : The hon. Gentleman points out the dangers of measles. If the Opposition are to recommend single vaccines, what order and what intervals between them will he recommend? He also knows about the huge dangers of rubella and the damage that it can cause. Mumps is one of the biggest causes of viral meningitis, and we do not need to describe how awful that is. Have the Opposition thought through their policy? They do not seem to have done so.

Tim Loughton : The hon. Lady makes my case for me. However, she is happy with the status quo in which 30 per cent. of the children in some parts of the country—that is the equivalent of up to 150,000 children—will have no vaccination and no protection against the horrendous diseases and symptoms that she mentions. That is the reality of the situation to which we must respond. It would be highly irresponsible to do nothing.

Yvette Cooper : Will the hon. Gentleman give way?

Tim Loughton : I wish to make progress, as many hon. Members wish to speak.

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I gather that the chief medical officer remarked that single jabs are equivalent to Russian roulette. That is an irresponsible comment. People who have gone to the trouble to seek out—and pay for—individual jabs are now having doubts cast on the efficacy of that treatment. That fuels the public's concerns.

Nothing is more universally effective than the treble jab in one. The Conservative party has always said that, as have the Government. However, the public are not heeding our advice.

Mr. Lansley : My hon. Friend is right about what our party has been saying. Before yesterday, the official Opposition's policy was to support the Government's assurances about the efficacy of the MMR vaccine, and the undesirability of the alternatives to it. Before the last general election, we consistently stated that we held to that policy because it was important to try to retain public confidence in the MMR vaccine. However, a new ethical question has now arisen: when does the principle of defending the MMR vaccine begin to be outweighed by the need to provide alternative protection to children whose parents will not accept it? However, I will not express my opinion on that at present.

Tim Loughton : That is a fair point when the safety of the MMR vaccine becomes a hot issue, and the vaccination rate falls below 70 per cent. Unsurprisingly, measles outbreaks are now occurring, and they cause much grief.

Dr. Kumar rose—

Yvette Cooper rose—

Tim Loughton : I am reaching the conclusion of my speech, and I am tempted to finish it. The Minister spoke at length, and many other hon. Members wish to contribute.

I reiterate that we urge everyone—our constituents, and every parent who is considering what to do—to choose the MMR vaccination for their children. There is no dispute about that between the Government and the Conservative party.

Yvette Cooper : I am grateful to the hon. Gentleman for giving way, because he has generously allowed many interventions. However, I wish him to clarify one point. Is he saying that he rejects the advice of the chief medical officer, the British Medical Association, the royal colleges and the Faculty of Public Health Medicine? All of them have advised us that the introduction of separate jabs would reduce coverage—it would not increase it—and that it would increase the number of children who are exposed to deadly diseases.

Tim Loughton : It is clearly the case that, if the choice is between MMR and nothing, more people will be exposed if they do not choose the triple vaccination.

I have said all along that the triple vaccination is the best option; single jabs are not as effective. There are questions marks about the timings between them. There are also question marks about the licensing of

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vaccinations that come from France and other countries, the way that they are administered and the charges for administering them. The Government must address those questions.

Despite the Minister's reassurances, hundreds of parents are telephoning private clinics to get hold of the individual vaccinations. How much less effective they are than the triple vaccination is a matter for debate, but they are better than nothing. The Government are currently offering all or nothing, which is the worst policy of all.

I have spoken for long enough but, not surprisingly, my final comments on MMR have been the most topical and contentious and will continue to be so. In practice, there is a crisis of confidence among many hundreds of thousands of our constituents, and we must restore that confidence to ensure that vaccination coverage is as thorough as possible.

This is an important debate. We are dealing with many complicated issues and, when it comes to children, we need a comprehensive approach. As I said, the measure of the success of the Government's programme will not be the number of committees and the structures that they set up, or the number of tsars whom they appoint, but the health improvement outcomes that result from it.

We all agree, I am sure, that the health of our nation's children is one of the most important aspects, if not the most important aspect, of the national health service and health care in this country. I welcome the contribution that this debate can make to raising the profile of these matters.

4 pm

Ms Julia Drown (South Swindon): I welcome this debate and the action that the Government are taking on maternity and children's services, particularly the emphasis on inequalities. I know that my hon. Friend the Minister is committed to that.

I shall start by responding to the comments of the Opposition spokesperson, the hon. Member for East Worthing and Shoreham (Tim Loughton). The policy that the Opposition have dreamed up over the past week is outrageous and a serious matter, because of the potential implications—I need hardly say "potential"—for children.

The hon. Gentleman is right to say that a lack of confidence has been fuelled by irresponsible media stories, but the Opposition do not help by jumping on the bandwagon and trying to extract political advantage from it. That seems to be the only explanation for the Opposition's policy, because all the Front-Bench spokespersons, including the hon. Gentleman today, have clearly said that MMR is the best option. To suggest otherwise merely undermines confidence and fuels more unjustified speculation.

At a push, the Opposition could say that we may need to consider the issue if they talked about particular constituents who had read all the evidence, had received counselling and had come to particular decisions, but I would feel uncomfortable even with that. Having considered all the evidence, every major college, doctors, paediatricians, health visitors and all such bodies have clearly said that the best option is to stick with MMR.

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The Opposition should be backing the Government. This issue should not be a political football because the health of thousands of children is at risk, and the Opposition have not answered my question. They have not given us their recommended timetable for when children should have the measles vaccination and those for rubella and mumps. Without that timetable, we do not know which ones they think people should be exposed to first. The Opposition's policy is risky. I hope that they will review it and return to the position that they held a while ago, which was to do the sensible thing by using the evidence that clearly exists and backing the Government's advice on MMR. There seems to be no other option if we are to protect children.

Mr. Lansley : I am sorry to interrupt the hon. Lady, but we have discussed the issue and we must keep various subjects in balance. I am on record as supporting MMR and I would say the same today; I would not be ambiguous about that. However, the hon. Lady and the Government must consider at what point the undermining of the MMR vaccine and the take-up level raise the question whether it has become safer for children and ethical to offer the single vaccine—admittedly, establishing protocols is intensely difficult—as compared with leaving the population wholly unprotected.

Ms Drown : I appreciate the hon. Gentleman's point, but it would be insane to say that we had reached that point. Take-up of the vaccine is still huge. We need everyone to back the evidence that is clearly there to create a balance. We must try to get the media to step back coolly and rationally to consider that evidence. If the Opposition could help us to do that, rather than proceeding in the other direction, we could make some progress and see the uptake increase again rather than decrease.

Tim Loughton : When the official Opposition offered the full weight of our party on a bipartisan approach to supporting MMR before the public at large, why was that rejected out of hand by the Minister and her colleagues? Why does she think that happened? Was our approach not helpful?

Ms Drown : I am aware that my hon. Friend the Minister wants to intervene.

I have heard nothing to suggest that we would not welcome support from the Opposition on that basis. There might be a debate about exactly how and what.

Yvette Cooper : Is my hon. Friend aware that the Opposition offered a bipartisan approach about two years ago? They were invited to an all-party group meeting with the Liberal Democrat spokesperson and me. They never turned up and we have not heard from them since.

Ms Drown : I feel that I am beginning to chair this meeting.

Tim Loughton : The Minister knows that that is complete rubbish. This is not to be done through an all-party group. The shadow Secretary of State for Health went to see the Minister. Unqualified support was

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offered, but it was never taken up. For her so to misconstrue those events is shameless and shows that she and her Department have been using this issue as a political football, not the Conservative party.

Ms Drown : We are getting into silly bickering about who did what and who said what. The real people who can suffer as a result of this issue are children. This is not a matter for laughter. There may be a debate about which meeting and whether people liked the exact proposal that was coming from one area or another. If anyone is cross about that, that is not a reason to change policy on such an important issue. Instead, we should keep going and say that we need to have more of a campaign and to try again. This is where politicians' pride, pigheadedness and arrogance get in the way of what is best for children. The Government have been clear throughout: they have said what is in the best interests of children, and that is MMR. The Opposition need to rethink their policy because they are putting children's health at risk.

I shall take the wise suggestion of the hon. Member for South Cambridgeshire (Mr. Lansley) and move on to another important issue: maternity services. I start by paying tribute to all the staff in maternity services who do fantastic things throughout the country. I pay tribute also to all volunteers such as the National Childbirth Trust, the breast-feeding counsellors and the wider family networks that often have the greatest input into births and maternity services.

There are real issues of concern in maternity services, some not relating to Government policy. The Cumberledge report, which was produced under the last Conservative Government, showed a way forward for maternity services and was widely welcomed. Achieving some of those aims has been difficult and is not happening in so many places. A fundamental problem is that a medical model is applied to too many maternity services. Giving birth to a healthy baby, which should be a problem-free experience for most healthy women, in too many instances is turning into a major medical event. Medical events that are generally not justified by the evidence produce a worse experience for the mother and a cost to the NHS that far outweighs the cost of a less medicalised model. That is not to say that there are not many instances in which medical interventions are necessary, and generally the NHS is fantastic at dealing with those instances.

The most serious issue, raised by the hon. Member for East Worthing and Shoreham, is the rising rate of caesareans that are not justified by the evidence. There is a huge variation in caesarean rates across the country; although sometimes they are clinically necessary, there are questions about whether the NHS offers the best treatment in areas where caesareans are not clinically justified. Obstetricians tell me of their concerns that caesareans that are not medically needed are hard to justify, yet they are carried out. Having a caesarean in such circumstances increases a woman's risk of dying by at least three, if not four or six, times. It also increases the risk of urinary infections, infertility problems and inflammation of the womb. The incidence of respiratory distress in babies is four times greater in elective caesareans than in a vaginal birth. There are serious questions to be asked about the rising rate of these operations.

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Given that evidence, why does the Government-sponsored booklet that goes to all mums describe a caesarean section as "safe"? I appreciate that the Government want to give assurances to those women who have to have a caesarean because it is medically the best option, but it is major abdominal surgery and saying that it is safe, with few qualifications, may be a factor that encourages women to ask for a caesarean when it is not medically required.

Obstetricians in this country and abroad suggest that a caesarean should not even be offered as a choice when it is not medically indicated. The Committee for the Ethical Aspects of Human Reproduction and Women's Health, the international umbrella organisation of national obstetric organisations, states in a 1999 report that

yet it is happening in this country.

This is a matter of serious concern, where more government action could produce better health outcomes. We could learn a lesson from Canada, where they have had some success in tackling the matter by focusing on and celebrating hospitals with low caesarean rates. In this country, midwife-led services that have produced lower caesarean rates could show how best to make improvements.

Caesareans are the most serious form of intervention in childbirth, but there are also questions to be asked about other interventions. The real problem is having a doctor-led rather than a midwife-led service. There is good, scientific research that shows that when doctors, rather than midwives, attend low-risk hospital births, unnecessary interventions increase and women's satisfaction decreases. In New Zealand, the Netherlands and the Scandinavian countries, more than 80 per cent. of women see only midwives during pregnancy and birth, either in or out of hospital, and they have some of the lowest maternal and perinatal mortality rates in the world, which suggests that lowering intervention rates and having a more midwife-led service could help us.

The definitive study of the safety of midwife-attended birth, which was published in 1998, took account of all births in one year in the United States—more than 4 million births. It considered only singleton, vaginal births, removed social and medical risk factors and compared outcomes between midwife-led births and physician-attended births. Compared with physician-attended births, midwife-attended births had a 19 per cent. lower infant mortality rate, a 33 per cent. lower neonatal mortality rate, and a low birth-weight rate that was 31 per cent. lower. That is clear evidence of the need for midwives to be in the forefront of the service.

Birthing centres such as those in Edgware and Crowborough have great success in letting the midwife lead the service and have better health outcomes, lower caesarean rates, high breast-feeding rates and much higher satisfaction for the families involved. The other great spin-off is that the midwife's job is so much better and there is no problem with recruitment. Indeed, Edgware still has a waiting list of people wanting to work as midwives there. Once again, letting midwives lead the service brings further benefits.

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A midwife-led service should also allow more women to experience home births. I receive letters throughout the country from women pleading for home births, but facing health authorities that refuse to help by providing a midwife in support. The evidence clearly shows that home births are safe, if not safer than hospital births. The National Birthday Trust survey of 6,000 home births found that outcomes were just as good as from hospital births and that women's satisfaction levels were much higher. With fully trained midwives, a home birth should be a feasible option—particularly for low-risk women, but also for many others currently denied that choice. If we could lower the caesarean rate, finding the resources to ensure sufficient midwives to meet women's choices would not be such a problem.

I mentioned the letters that I receive from women wanting home births. I also received a letter that arrived last year when we were discussing regulations affecting the Central Council for Nursing, Midwifery and Health Visiting. Home births were debated then and the fine imposed on medically unqualified people attending home births was increased. The Government have not yet clarified the issue, however, because some women who had lost confidence in hospital births were going ahead with a home birth, irrespective of whether a midwife could be provided. Some were confident in the ability of the husband to attend the birth but, because they were worried about the fines, they intended to send their husbands out of their homes and give birth alone—a seriously dangerous prospect. Will the Government make it clear that the regulations were intended to fine not people trying to help with home births but people who impersonate midwives?

I have dealt with where and how women want to give birth and move on briefly to discuss the delivery of care. Much of the difference between a good and a bad birth experience lies in the manner in which the care is delivered. One-to-one midwifery care is clearly crucial and the greater the continuity of care, the greater likelihood of building trust between the health professional and the woman giving birth.

A recent study of 20 women who, along with professionals, permitted their births to be videoed showed some surprising results. Of the 20, 11 had to go through one shift change of professionals and three went through two changes. One woman saw 11 different health professionals during her birth experience, which makes it difficult to build up trust. The women were observed for 111 hours, during which midwives were out of the room for 30 hours. There was record keeping for 21 hours and sitting at the bedside for only 16 hours. Time clearly needs to be reallocated. Building midwives' confidence about spending time with the woman and viewing that—rather than record keeping—as a priority is important. We understand that litigation is a problem, but midwives must be encouraged to spend more time with their women. The research also examined how doulas added a positive element to the birth experience. I hope that the Government will reflect on how that might benefit the service.

The advantage of midwifery-led care could also mean better post-natal support. One of the first tasks after giving birth is to establish breast-feeding. Clear evidence shows that it benefits both mother and child. Yet, rates in many parts of the country are still extremely low. The key to increasing the number of women who breast-feed

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is to encourage consistency and advice, and for there to be a supportive attitude and training. The low level of breast-feeding training that is given to midwives and health visitors is shocking. I hope that the Government will deal with that problem.

I wish to read out a letter that I received last year about breast-feeding. It states:

That shows just how much we need to do to encourage women to ensure that they receive consistent advice and that training and breast-feeding counsellors are available. Efforts should be made to tackle the social stigma of breast-feeding. Some communities still reach for the bottle-formula milk, and there is far too much advertising by baby milk companies. We are not giving enough of a lead nationally. It is also an international issue; 1.5 million babies die because of breast-feeding rates. The more than we can do to encourage breast-feeding, the healthier will be the outcome.

The House could take a lead and allow visitors, staff and Members to breast-feed. All professional organisations back such a practice. It should be allowed. I hope that through you, Mr. Beard, we can encourage Mr. Speaker to reach a decision. Women are the best people to judge where and when to feed their babies. We have been arguing about the issue for years and it is important that the House takes a lead, both for national and international reasons.

There is only sparse training in respect of domestic violence in pregnancy. It is frightening. Maternity is a key area in which domestic violence happens. It is a trigger for women to report such instances. There are more domestic violence incidents when a woman is pregnant than outside pregnancy. In 1997 to 1999, a confidential inquiry into maternal deaths in the United Kingdom showed that only 12 per cent. of the women—45 of the 378 women—had reported incidents of domestic violence to health professionals yet, few, if any, were offered help to deal with it. None of those women was routinely asked about violence but, during pregnancy, women are more likely to die from domestic violence than from pre-eclampsia or gestational diabetes. We screen for those illnesses, but not for domestic violence. I hope that the Minister will consider such matters. Women must build up trust.

4.33 pm

Sitting suspended for a Division in the House.

4.38 pm

On resuming—

Ms Drown : I was talking about the need for women to build up trust and to report domestic violence. I am sure

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that more could be done to stop many women being battered. Unfortunately, too many women are killed by domestic violence during pregnancy. I stress the need for the Government to do more to support midwifery-led care. I hope that they will consider a more flexible transfer from midwives to health visitors in the post-natal period to maximise the chances of supportive relationships being created.

I hope also that the Government will consider ways in which to add to maternity care and to ensure that more woman are supported in their choice to give birth at home. More needs to be done to tackle the high caesarean rate and low breast-feeding rate. I congratulate the Government on the work that they have done so far and I am looking forward to the national service framework for maternity and children's services. I hope that as much as possible can be done in advance of that. The result will be a more satisfying job for both midwives and obstetricians, and recruitment and retention will be improved. The key test is whether there will be better experiences and health outcomes for both women and children. I am pleased to support the Government in their work.

4.40 pm

Sandra Gidley (Romsey): I welcome the debate. The subject is huge, and it was difficult to decide on what to concentrate in the time available. I thought that I would approach the issue chronologically, discussing the normal progression of pregnancy, then childbirth and then what to do with a child after he or she is born, and how to do the best for him or her. Those are certainly among the most difficult experiences that I have faced in my life.

I had my first baby nearly 20 years ago—that makes me feel terribly old. I vividly remember meeting my general practitioner and midwife. The awful truth suddenly dawned on me that those people, in whom I had great trust, were not going to be there when I needed them, at the birth. I asked my GP who was going to deliver the baby. He said, "If you're lucky, it'll be a midwife, and if you're unlucky, it'll be a doctor." I was horrified by that reply. To someone like me, who had not really researched pregnancy and to whom it was a bit of a shock, it seemed inconceivable that someone should be surrounded by strangers when most vulnerable and having a life-changing experience. That concept seemed fairly alien.

Thankfully, the position is better in some parts of the country. I later started to work with the National Childbirth Trust and began campaigning for better maternity services. I then learned about team midwifery, which has been mentioned, in which a group of midwives are responsible from early pregnancy through delivery until after the birth, when they can give the support that the hon. Member for South Swindon (Ms Drown) mentioned is so vital in breast-feeding. They are a reassuring presence throughout. Women are almost guaranteed that, at that daunting time when they are about to give birth, one of those midwives will be available.

Sadly, although there has been a general increase in such arrangements, some trusts have stopped providing the service due to midwife shortages. We have heard some of the figures. I looked at the 2001 figures, and

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there is no huge shortage of midwives in Scotland, Wales or the north-west. However, shortages are a huge issue in London and the south-east. There is an overall vacancy rate of at least 10 per cent., rising to 16.5 per cent. in London hospitals. Many of the posts—up to 10 per cent. in London—are vacant for more than three months. Much has already been said about the cost of living, and I endorse those comments, because it is vital that we keep a good midwifery service in London and the rest of the country.

I hope that the Minister will enlighten us on what is being done to retain and attract midwives and to ensure that there are enough of them to cope with demand. I cannot over-emphasise how important a midwife is in ensuring that a women is happy with her birth experience. I do not think that the shortage is getting worse, although I have not been able to compare figures for different years. However, we urgently need to address the issue.

I wish to consider the choice issues surrounding the birth. Rates of home births vary widely, and in many areas they are actively discouraged. The choice is better than it was 20 years ago. There are many more midwife-led units, and there is greater acceptance from obstetricians that midwives are professionals in their own right, and are capable of performing the role that they are trained to do, and I welcome that. Whatever the birth method, my overriding concern is that women should retain some say in the process. The issue is one of how, not just where, women give birth.

I have some worries about the concept of a national service framework. It has been widely welcomed, but I hope that the Minister can reassure me on several points. I shall highlight foetal monitoring, which is one aspect of childbirth, to illustrate my point.

Many women would be happy with a low-key approach of being monitored only by a midwife with a stethoscope during labour. The midwife could detect any problems, especially if her skills were up to date, and there is no evidence to suggest that that is a poor way of approaching the matter. Many women do not want to be continually strapped to a machine; they do not even want to be strapped to a machine for a quarter of an hour every few hours, because that is restrictive and uncomfortable. Of course, if a midwife is worried, she may say to a woman, "I'm a little worried about the baby's heartbeat, so we'd like to put you on a monitor." Most women would accept that because they want a healthy baby and they trust their midwife.

A fundamental difference with maternity services that is often forgotten is that they deal with not an illness but what I prefer to think of as a modified state of health. However, obstetricians, especially, think that they are addressing a medical situation. If an obstetrician insists on electronic monitoring at regular intervals, it is likely that the odd unusual trace will be produced. Some suggest that that can lead to more interventions. The hon. Member for South Swindon highlighted the problems that might be caused by such interventions.

If the NSF states that electronic monitoring is a good thing, which it might, because obstetricians believe that, that would become the norm despite the lack of clear evidence to support it. I want reassurance that women

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who want a natural birth may have that. If women want a high-tech birth that involves all the drugs in the world, maybe that should be available. Electronic monitoring is an example of trying to apply a procedure that is used in many medical models to a process that is not totally medical. I could highlight other similar aspects, but time is short.

One-to-one care during labour is a concept that is often bandied about as the holy grail. I saw figures—I could not believe them—showing that more than 95 per cent. of women enjoy one-to-one care during labour. Will the Minister tell us the official definition of one-to-one care? My local midwifery unit believes that one-to-one care means that a midwife stays with a woman throughout her labour, rather than going off to fill in records. In a busy maternity unit, midwives sometimes must dash between two women and pray that the women do not deliver at the same time. Does the Minister agree that a woman should be able to have a midwife present throughout her labour if that is her wish? Many people who are involved in maternity services would welcome a precise definition of one-to-one care.

We cannot leave the discussion about the delivery room without commenting on the alarming increase in rates of caesarean sections. A report by the World Health Organisation says that the rate should be 10 to 15 per cent. However, the United Kingdom's national rate is 21.3 per cent. Department of Health figures show that the average cost of a normal delivery is £700, but the average cost of a caesarean section is £1,700. That represents a significant difference. Every 1 per cent. rise in the rate costs the NHS an additional £5 million, which could be spent on employing more midwives or attracting midwives to areas with many vacancies. We must examine closely the reasons for the rate's steady increase. It is alarming, and a proportion of women undergo an unnecessary caesarean section.

I was alarmed to learn from the World Health Organisation's report that Afro-Caribbean women have a caesarean section rate of 31.3 per cent. What is being done to investigate the reason behind that huge difference? Is the reason cultural? Is it due to something simple, such as that different races have differently shaped pelvises? I doubt that that is the reason—indeed, I am unsure whether there is more than one pelvis shape. Perhaps communication in hospitals is the problem. We must ensure that everyone receives the optimum service. In general, I am opposed to setting targets, but it would be interesting if we could follow what happens with regard to this matter.

After their baby is born, most parents start to think about breast-feeding. The hon. Member for South Swindon has highlighted many of the key issues with regard to that, and the Minister has acknowledged that lack of breast-feeding is linked to poor health outcomes. We all know the benefits of breast-feeding, so I will not repeat them.

However, there are significant class and age differences that should give rise to great concern. We have heard that there are increasing numbers of young mothers, because of the rise in teenage pregnancy, and that they are far less likely than a mother in her 20s to breast-feed—or if they do, they are less likely to continue breast-feeding.

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The differences in breast-feeding rates between the social classes are particularly alarming. Ninety per cent. of new mothers in social class 1 start breast-feeding, compared with 50 per cent. of new mothers in social class 5. Two weeks later, the rates fall to 83 and 36 per cent. respectively. Only slightly more than a third of babies who are born into the most deprived families are breast-fed at two weeks. Four months later, the rates fall to 56 and 13 per cent.

Children from poor and disadvantaged families have a tough start in life. We should tackle the resistance of their mothers to breast-feeding. I am unsure whether they do not breast-feed because they are resistant to it, or because they lack the education to be aware of its benefits. However, we must target those women, because if we manage to increase the proportion of them who breast-feed, that will have lifelong knock-on benefits for their babies.

Breast-feeding rates have not changed much in the past few years. Scotland has a breast-feeding strategy, and England would benefit from the introduction of a similar initiative. Does the Minister plan to do that?

Things are being done well in pockets of the country. My local hospital employs someone specifically to help mothers to breast-feed. She is not a midwife; she started training as a breast-feeding counsellor for the National Childbirth Trust. She helps mothers to start to breast-feed, and when they leave hospital, she gives them her telephone number so that she can continue to support them. That is a good system, but it is not the norm. It should be extended to other hospitals.

I agree with the hon. Member for South Swindon that we must tackle discrimination with regard to breast-feeding, although I am unsure what a Public Health Minister can do to address that. There are still attitudes in society that lead to people frowning on women who wish to breast-feed in public places, such as a restaurant—indeed, some hon. Members might wonder why a mother would wish to do that.

It might beggar belief, but I have breast-fed without anyone really noticing in a variety of public places, such as the top of a mountain, a bus queue, aboard a boat, and in a restaurant. It can be done discreetly. It is not necessary for a big scene to be made of it. Many women will not want to breast-feed in public, because it makes them feel uncomfortable. As the hon. Member for South Swindon said, the mother concerned is the best person to make a decision about where to breast-feed.

After a new mother leaves hospital and takes her baby home, midwife cover is provided for a few days. If the team midwifery approach is adopted, the situation is much easier for the mother. If she has a problem, she can talk about it more easily with the midwives, because she will have built up a relationship with them. We live in a society in which we all want to do well and to feel that we are a success, and we do not like to admit that we have problems.

When I took my baby home from hospital, I suddenly realised that my husband and I had sole responsibility for this little bundle, and I freely admit that that was the most frightening experience of my life. The early stage of motherhood is a very vulnerable time, and new mothers need all the help and support that they can get—not just half an hour a day, if that, from a pressed midwife, and subsequently from an overstretched health visitor.

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I want to discuss health visiting, because we may be missing a few tricks. Since becoming a Member of Parliament, I have become painfully aware that some families repeat patterns from when they grew up. It sounds terrible, but some people do not really know—they have a rough idea—how to be parents. We all live in little boxes, families are often spread further apart, and role models are sometimes not available.

If health visitors worked with groups of women as friends to build up a network and educate in a low-level way, not saying, "Oh, I'm going to give you a talk on healthy diets today," many positive messages could be sent. For example, in the case of feeding and diet, we hear a lot about food poverty, but we also see people on benefits buying food that is not the most appropriate. Not everyone knows, and not everyone is taught at school, how to eat a healthy diet. We might believe that it is blindingly obvious, but it is not to everyone. The same applies to the benefits of exercise.

Some people do not even know how to play with their children. I laughed when I first heard about a friend who was involved in teaching parents how to play with their children, but for some people that is necessary, because they were never played with as children and have no role model. We need to do something positive for such people. Such families often hit the social services buffers. The family may in the past have resisted working with social services, resulting in a huge reaction against society and the Big Brother approach. We need to be more creative in tackling such problems early on.

I want briefly to touch on vaccination. I welcome the chance to make clear a matter that my intervention did not. If the hon. Member for East Worthing and Shoreham (Tim Loughton) had been listening to me, rather than wondering how he could indulge his penchant for attacking the Liberal Democrats, he would have realised that we were not saying anything terribly different.

As I said earlier, I agree that there is no statistical evidence that the MMR vaccine causes a problem, and I stand by that. However, I have recently been investigating autism—a huge subject—more closely, having become involved with a group of parents in my constituency, none of whom blames the MMR vaccine. Reading around the subject, I have become aware of what many people say about when the condition developed. I fully accept the argument advanced by the hon. Member for South Swindon that symptoms sometimes become apparent at the same time. People put two and two together and make not four but 22. They link events because of the chronology. However, when reading evidence or testimonies in which people say that their child went into reverse, questions arise. The incidence is minute and does not show up statistically. I wanted to establish whether it was acknowledged that such children should be closely examined. I believe that I had the answer from the Minister when she said that the fundamental problem is that we need more information about the causes of autism.

The Conservatives' recent announcement about the three single vaccines was highly irresponsible. There is no evidence that the three vaccines are as safe as MMR, and there is some evidence of risk. A theory that is not

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widely espoused is that giving three vaccinations presents three challenges to the immune system and may increase the probability of an adverse event.

The media have been irresponsible and it would be helpful if they could get the positive health messages across and spell out the benefits of immunisation rather than highlighting a story for a week and then leaving people high and dry. Child health problems also centre on poor housing conditions and poverty. While I welcome the good sure start programme, there needs to be more joined-up thinking on such issues. Joint working often offers particular problems. Getting health, social services and housing together is a nightmare, but getting them to agree which service will pay for something is an even worse nightmare. It would be helpful if we could have pools of money and schemes such as sure start that people can access rather than fighting and guarding their individual budgets closely.

The subject is wide ranging, but the fact that many of us have chosen to highlight the same issues means that particular attention should be paid to them. I look forward to hearing the Minister's response.

5 pm

Dr. Ashok Kumar (Middlesbrough, South and Cleveland, East): First, I congratulate you, Mr. Beard, on your appointment to the Chairman's panel. It is the first time that such an encounter with you has taken place and I am privileged to speak in the debate. My hon. Friend the Member for South Swindon (Ms Drown) and the hon. Member for Romsey (Sandra Gidley) focused strongly on maternity. I have little knowledge of the subject, but their speeches were highly illuminating. I learned more about maternity this afternoon than I have done during most of my adult life.

I want to focus on child health, on which a large part of the Minister's speech concentrated. The hon. Member for Romsey referred to the value of nutrition in children's health. I want to link that aspect with the Government's wider programme and how they have been trying to tackle poverty. I shall also refer to issues that perhaps the Minister can take up. Being healthy does not necessarily mean the mere absence of sickness, which is, all too often, the measure of health in our society.

Everyone will agree that children have a need to be nurtured and healthy, not only when they are newly born, or learning to walk, talk, spell or ride their first bicycle, but throughout their formative years. The future of human society depends on children being able to achieve their optimum physical growth and psychological development. The phrase "healthy mind, healthy body" comes to mind. I want to encourage the adoption of positive values for children to help them grow up as healthy young people and, eventually, to be fit adults. I am not alone in such thinking. Never before have we had so much knowledge to assist families and society as a whole in their desire to raise children so that they can exploit their own potential.

In the past several decades, the relationship between health, physical growth, psychological development and parental care have become clearer. The Government have made an immense effort to tackle poverty. There

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are many explanations for poor child health. The Minister mentioned a few, but most experts agree that environmental factors such as poverty are the most damaging. Poverty is complex, multi-dimensional and manifests itself in many ways, such as lack of access to good-quality housing, poor health, high levels of unemployment, low rates of pay, high crime rates and poor educational performance. Given that children's experiences are fundamentally influenced by their family circumstances, it is essential that such problems be tackled as a high priority, especially where those experiences will lay the foundation for later life.

Each aspect of poverty is linked, and poverty breeds further poverty. Unemployment can lead to crime, and living in poor, overcrowded housing can result in poor health and have a detrimental effect on a child's education. One reason why I am proud to be a member of the Labour party and a Labour Member of Parliament is that the Labour party and Government have made the greatest progress on this issue. Indeed, they have tackled it head on.

Under Labour, child benefit has increased significantly since 1997, and the introduction of a children's tax credit that would provide a family with about £1,000 extra was announced. The Government have taken 1.2 million out of poverty, and that is to their great credit. Other measures have helped to tackle poverty: the national minimum wage, the working families tax credit and the legislation that gives workers paid holiday rights, which arose from the "Fairness at Work" White Paper. All those are powerful anti-poverty measures.

We are heading in the right direction but, as I have said, there are areas of concern, and I shall say a few words on food and poverty. Diet-related diseases, which are defined as health problems due to the composition of the diet, are a major factor in premature death and disability. Coronary heart disease, high blood pressure, stroke, diabetes and cancer—I could go on—are all directly linked to diet. We would like to think that we have a good record, but in fact it is a very poor record, certainly when compared with the record of other affluent countries.

My hon. Friend the Minister quoted many figures; I shall quote one or two. British women are five times more likely to die from coronary heart disease than their French counterparts, and 300 per cent. more British men die from coronary heart disease than our Gallic neighbours. The low fruit and vegetable consumption in the United Kingdom is highlighted as a causal factor in many illnesses. For some, that is a matter of choice, but children often have little choice in what they consume. They rely on their parents or local education authority to provide a balanced and healthy diet.

A recent article about food, but not as we know it, in my local evening newspaper highlighted the issue. In a survey, schoolchildren confused sweetcorn with potatoes, peas with beans and even melons with celery. That shows the confusion between different healthy foods.

Food poverty relates to the ability to afford, or to have regular access to, a range of foods from which to select a healthy and varied diet. The food justice campaign has been aimed at eradicating food poverty. It claims that an average of 5,000 people in every parliamentary constituency may be malnourished. That

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is a very large figure, but it is that campaign's estimate. An estimated four in every 10 people admitted to hospital are malnourished in some way.

Last December, the Child Poverty Action Group produced a report that stressed the importance of healthy eating to a child's development and general health. Entitled "Poverty Bites", it claimed that 2 million children lived in families who could not afford to eat healthily. The report backs up research conducted by the Joseph Rowntree Foundation two or three years ago, which found that the number of people in the UK without access to a healthy diet topped 4 million. The Minister mentioned the Acheson report of 1998, which highlighted the problems of food poverty and access to healthy food. While the social exclusion unit has recognised the problem, it has been left to my hon. Friend the Member for Nottingham, South (Mr. Simpson) to take the issue forward in his ten-minute Bill, Food Poverty (Eradication).

What needs to be done? Consumers need more information to make real choices. They need to know where their food comes from, how it was produced and whether it has any nutritional value. That is particularly true of children's food, and the Government have a powerful role to involve schools in promoting a balanced diet and healthy eating. Nearly a third of pupils in Middlesbrough are eligible for free school meals. Often, school is the only place where a poorer student can get a decent balanced meal. It is not enough to offer a baked potato and some limp lettuce alongside the usual chips and burgers and expect children to go for the healthy option. Local educational authorities and councils must work together to assess the extent and nature of food poverty in their area. They can identify the needs of local children and set them on the road to a reasonably healthy future.

The Government and the Minister have highlighted many things. We have made an excellent start. I want to thank the Government for that. Tackling child poverty gives hope to many of the children in my constituency. Great credit is due to the Government. Tackling child poverty and the wider issues of health and fitness must remain fundamental objectives if we are to achieve our social objective. It is a moral issue and it is an economic necessity. I am glad that we are having this debate. It has been a responsible and mature debate, although it was polarised on the vaccination issue for a moment or two. I have tried to bring the spirit of Westminster Hall debates back to it.

Several hon. Members rose—

Mr. Nigel Beard (in the Chair): Order. There are just under 50 minutes left of this debate and four hon. Members wish to speak. If they can keep their remarks within 10 minutes, everyone will have a chance before the Minister replies to the debate.

5.13 pm

Mrs. Marion Roe (Broxbourne): I am delighted that we are having this debate this afternoon on child health and maternity. As the Minister may know, child health is an issue in which I have taken a special interest over many years. I have initiated a number of Adjournment debates in this Chamber on that important subject.

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I was chairman of the Select Committee on Health for five years during which time we undertook a lengthy inquiry into children's health and produced a number of reports and recommendations. As a result of my involvement in those reports and my continuing quest to pursue Ministers with my concerns relating to children, I am now the chairman of a child health group which comprises representatives from many different organisations involved in child care, including the Royal College of Nursing and the Royal College of Paediatrics and Child Health.

I listened carefully to the Minister's speech. I welcome many of the initiatives that the Government are promoting. However, while I acknowledge that the Government have a desire to improve child health, certain shortcomings and problems in the delivery of services need to be addressed. Many recommendations of the Health Select Committee's reports were focused on children in hospital. The Minister should know that surveys by the Royal College of Nursing paediatric nurse managers forum highlight the fact that children continue to be admitted to adult wards—as mentioned by my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton). The increase in ambulatory and day care service provision has exacerbated the problem, as many units do not employ sufficient numbers of appropriately trained children's doctors and nurses.

Recent research in the UK shows that health care provision for adolescents remains inadequate. A study of teenagers in hospital demonstrated that only one in 10 stayed in a specific adolescent ward. I remind Members that adolescents who have to stay in adult wards often feel lonely, isolated, embarrassed and patronised. A survey of 18 hospitals in Wales showed that 7 per cent. of child patients admitted for in-patient care in 1998-99 went into adult wards, and 19 per cent. were treated as day patients in adult wards. The majority of the in-patient children were aged between 11 and 18, while day patients included children from the whole range of nought to 18. Almost half the children cared for in adult wards were day patients.

Action for Sick Children (Scotland) surveyed all the wards admitting children to Scottish hospitals in 2000. It found that 101 wards in 44 hospitals admitted patients aged between nought and 18. About 57 per cent. of the wards admitting children were designed as children's wards, while 43 per cent. were designated as mixed adult and children's wards. About 30 per cent. of those 44 mixed wards were medical, general and surgical; 23 per cent. ophthalmology and ENT; and the remainder split among 13 other specialties.

Will the Minister tell us what action is being taken to end the nursing of children on adult wards and ensure that specially trained staff care for all children? Children constitute a third of all attendees at accident and emergency departments, but the vast majority are not seen in an environment conducive to their needs or by staff appropriately trained and skilled in the care of children.

I welcome the Government's recent investment in accident and emergency services, often awarding funding to schemes intended to improve facilities for children and young people. The Minister will know, however, that a recent Audit Commission study showed that many dedicated children's areas cannot be used

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because funding for appropriate staff is unavailable. Will the Minister make it clear how funding for such capital schemes is awarded, whether the cost implications for appropriate staffing are considered, and whether such schemes are monitored on the basis of outcomes?

Three other major concerns of the medical profession should be put to the Minister. Child health services are becoming unsustainable under working hours directives and clinical governance requirements. Does the Minister intend to make best use of nurses' talents by encouraging their extended role, which will mean significant investment in training, salaries and proper career pathways?

Commissioning tertiary specialist paediatric services is another problem. What arrangements will the Minister put in place, given that primary care trusts are unlikely to have the understanding or ability to promote those services? It is suspected that preference is likely to be given to adult services.

Unbalanced provision is another issue. Too many patients are going into intensive care neonatal services, which is generating disquiet. Clear direction is needed from the Department of Health regarding managed clinical networks to provide neonatal intensive care and special care for sick babies. What action are the Government are taking on that?

All sick children should be cared for in their own homes as far as possible. Children's community nursing teams, such as the Diana nurses in England and Wales, provide essential care and support in the home for children—and their families—who are disabled, chronically sick or terminally ill. However, fewer than one in 10 sick children has access to a 24-hour community service. With the establishment of primary care trusts, many children's community nursing services are becoming fragmented across adult-orientated organisations, which lack insight into the needs of sick children and their families. It is essential that changes to children's services should be instigated to meet the needs of children and their families rather than adults or organisational convenience.

For some time it has caused serious concern to those with an interest in child health that the majority of medicines used to treat children have not been researched for paediatric use. When such drugs are used on children, they are being used outside their licence, and adverse reactions cannot be recorded and monitored in the usual way. Each prescription is a small informal experiment. That state of affairs is surely unacceptable.

The Americans legislated in 1997 to provide incentives for investment in paediatric research, and with great effect. Within three years, 58 paediatric studies had taken place, and last year the United States Food and Drug Administration reported:

In Europe, more than a year has passed since the Council of Ministers resolved to do something similar, but we are still waiting for a European Commission consultation that is supposed to be imminent. At the

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usual stately pace of Brussels, it could be several years before any real progress is made. I should like to know what the Minister is doing to give the matter the priority that it deserves so that children can be treated more safely sooner rather than later.

It is right that the remit of the Children's Commissioner for Wales was extended to include all services for children in all settings. I welcome plans for the creation of similar posts in Northern Ireland and Scotland. The appointment of Professor Aynsley-Green as national director for children's health care services is a positive step. However, his role focuses on health services, whereas it is the breadth of the remit of the Children's Commissioner, which crosses all Departments, that makes the position so important to children. Do the Government plan to have a Children's Commissioner in each country of the United Kingdom, to act as a powerful advocate for all children?

I turn to an issue with which I have been involved for many years. In 1985 my private Member's Bill on the prohibition of female circumcision in the UK became law. My quest to place the Bill on the statute book was intended not only to make people aware of the practice but to obtain Government funds to set up an education programme among the immigrant communities in which the abuse is prevalent.

I have raised the issue at many international conferences organised by the Inter-Parliamentary Union and have sought the assistance of international parliamentarians in stamping out the unacceptable genital mutilation of young girls. I am pleased to have recently been invited to participate in a three-member panel set up by the IPU to focus on the issue and devise ways in which we can assist in prohibiting female genital mutilation in all the countries in which it is practised.

The panel will be meeting in Marrakesh in March to take the taskforce forward. It would be a great help to my international parliamentary colleagues and me if the Minister could outline the actions that the Government are taking, first, to ensure that the education program for immigrant communities continues, and secondly, to identify, through social workers and the medical profession, when the abuse occurs. Also, can the Minister explain what action is being taken to prevent children from being sent abroad for this illegal procedure to take place, and whether, if girls are subjected to female genital mutilation in other countries, prosecutions can be brought under UK law on their return? It is estimated that as many as 15,000 girls may be at risk of female genital mutilation in the UK.

Child health must never be allowed to slip off the Government's priority agenda. I hope that my comments this afternoon will assist in focusing the Minister's mind on important issues relating to the subject, and I look forward to hearing her response to all the points that I have raised.

5.25 pm

Mr. Gareth R. Thomas (Harrow, West): I, too, congratulate you, Mr. Beard, on your elevation to the Chairman's Panel. I have long thought that the House did not give sufficient recognition to outer London constituencies such as ours. I am delighted by your appointment, which is, I hope, a small but significant step towards that recognition.

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I pay tribute to the hon. Member for Broxbourne (Mrs. Roe). I cannot hope to compete with her expertise and knowledge of, and record on, the subject. I do not have any children, and, indeed, I hope to avoid personal experience of maternity services for a little while longer. My reason for attending the debate is entirely parochial. I wish to discuss the quality of the maternity services unit at Northwick Park hospital, which serves my constituents.

Before I address that, I reinforce the point that I made during an earlier intervention to my hon. Friend the Minister about the need for more funding and support packages for carers of those with autism and Asperger's syndrome, which is a form of autism. I say that because I have supported a constituent and friend, the excellent Raj Ray, through difficult pressures during a dispute with his local authority about accommodation, which related to his son. I pay tribute to the excellent Harrow carers centre, and the Harrow branch of the National Autistic Society. They are two bright spots in Harrow, providing services for the carers of people with autism and Asperger's syndrome.

I urge the Minister to pass back the request for a review of the revenue allocation process that applies to grants for children's services that are given to local authorities. In Harrow, the number of children who are taken into care has increased greatly, and the pressure on our adoption services has also grown. The present funding formula does not recognise those additional pressures.

I shall comment on the maternity services of North West London Hospitals NHS trust and, particularly, Northwick Park hospital. When I was first elected in 1997, there was considerable worry in my constituency about the quality of service that Northwick Park hospital offered. It had an appalling reputation. Operations were cancelled regularly, waiting lists were rising, the fabric of the hospital was often dreadful and the accident and emergency unit was under huge pressure. There seemed to be a financial crisis every year that usually kicked off in December and lasted until the end of March. The sense of secrecy that pervaded many discussions with the chief executive and the hospital board caused great frustration to many of my constituents. Indeed, the only planned capital investment during the previous six years was in the private ward.

Things have improved, but real challenges remain. There is a great need for investment in maternity care services at Northwick Park hospital. There was a sensible merger with the Central Middlesex hospital, and a benefit of that has been to widen the pool of expertise of the clinicians and midwives who are involved with maternity services. The merger delivered a new leadership team for Northwick Park hospital that has experience of running units and has succeeded in attracting investment for maternity services. Accident and emergency facilities have received a long overdue £2.2 million investment, and a new 21-bed unit opened in January that will help to ensure that there is sufficient bed capacity this winter to allow planned operations to continue.

However, additional Government resources are necessary to improve the fabric of the building and the environment for maternity services at Northwick Park hospital. Some would say that we should look to the

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budget of Brent and Harrow health authority. Although the 9.5 per cent. increase in that budget for the next financial year is extremely welcome and an excellent start, it is simply not enough to fund the investment in maternity services that is necessary.

The hon. Member for East Worthing and Shoreham (Tim Loughton) alluded to the extra investment for maternity services that the Government announced in October. Some would say that that should have funded the expansion and refurbishment of maternity services at Northwick Park hospital. The money that we secured—about £535,000—was extremely welcome and has been well used. It has provided vital medical equipment for monitoring and anaesthetics in the laboratory wards and the obstetrics theatres, and other basic equipment that was lacking. Nevertheless, the substantial investment necessary to improve the quality of maternity services at the main hospital serving my constituents has not yet been provided.

The circumstances surrounding maternity stand in stark relief to those surrounding adult intensive care at Northwick Park hospital, which received an investment of more than £1 million in January last year. Similar investment is necessary in neonatal intensive care facilities at Northwick Park hospital as part of a wider modernisation of maternity services and provision. I assure the Minister that investment in Northwick Park hospital is extremely worth while. The investment in adult intensive therapy unit services resulted in a substantial reduction in the number of transfers of patients in intensive care from Northwick Park hospital to other hospitals—down from more than 106 transfers before that investment to just a small handful now. That throws into stark relief the issues surrounding maternity services.

I warn my hon. Friend the Minister that I have raised the issue before in questions to Health Ministers, and I intend to continue to press the need for investment in the maternity unit until such time as she signs off the necessary investment. The fabric of the maternity services building is a massive problem for the mums, the families who visit and staff, who try to provide a service in a challenging environment. I even went to the trouble of persuading my right hon. Friend the Secretary of State to visit the maternity services unit, and he was impressed by the need for investment. It would cost about £12 million—a small sum in the general scheme of things—and would help tackle issues surrounding the recruitment and retention of midwives in north-west London.

My hon. Friend the Minister will be delighted to hear that a bid has been submitted to the London regional office of the national health service. I experience violent mood swings about the performance of that office. Sometimes I believe that it does an excellent job, especially in listening so sensitively to the need for investment in adult intensive care provision. I was delighted that the then chief executive of that office, Nigel Crisp, was duly elevated.

I am deeply unconvinced by the performance of the London regional office when it comes to defending the Mount Vernon cancer unit from the predators in the eastern regional office. I hope that it will get its act together on that. It has been sympathetic in the past about Northwick Park and I hope that it will be deeply sympathetic about that hospital.

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There is a real issue about the quality of neonatal intensive care. It is currently graded a level 3 intensive care facility. If investment can be delivered by the Minister and the London regional office, it will be the fourth or fifth largest unit in London, handling some 5,000 births a year. It is inevitable that a percentage of those births will need neonatal intensive care. Surely there is a sensible case for investing in neonatal intensive care facilities where they are needed most, rather than just locating them close to teaching hospitals in central London.

Finally, the Minister touched on recruitment and retention of midwives. I welcome the news that she is in discussions with the Royal College of Nursing about that. We have a particular concern about recruitment in London and the need for residential accommodation. Northwick park hospital is looking at the issue. I urge her to be munificent, perhaps not now, but certainly within the next few weeks and to grant or to encourage her officials to grant the business case that has been submitted for investment in maternity services at Northwick Park.

5.36 pm

Mr. David Amess (Southend, West): I pay tribute to midwives and in particular the Royal College of Midwives, which is celebrating its centenary. We had a function in the House only last week. The Amess family has much to thank midwives for, and I am especially grateful to Eve and Ladze. There is perhaps no more intimate experience than to be present at the birth of a child. It is a unique experience and a joyful one when there is a successful outcome. When it does not go the way that one would like, it is obviously traumatic. I certainly have much to thank those midwives for.

Having been there from the start of the births of all my five children, I think that I would know what to do if a message were to go up on the annunciator screen to say that someone needed assistance in delivering a baby. It would not just be boiling water and using towels. I am sure that no one would want me to assist, but I have an insight into what goes on. I would not swap places with my wife and other ladies for all the tea in China. I keep many animals and my fish and birds seem to produce their babies so much more easily. I pay tribute to them all.

In a speech to the annual conference of the Royal College of Midwives last year, the Secretary of State said:

Can the Minister tell us whether that is happening? He continued:

It would be useful if the Minister could tell us what sort of progress is being made in that regard. As she knows, the royal college is concerned that there should

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be an additional 5,000 midwives nationally to provide the levels of care required by women. It believes that women should have one-to-one care from their midwife: they should be cared for by the same midwife throughout the term of their childbirth continuum.

This year, the level of midwife vacancies has decreased only slightly, resulting in the situation being described as "very serious" instead of "critical". A recent Royal College of Midwives survey of issues affecting midwives shows that midwives are as concerned about the standards of care that they can give women as they are about the low levels of pay. Indeed, those low pay levels are perceived by midwives as reflecting the value placed on them by the health service. Has the Minister any ideas about how to address that problem?

I shall describe a number of the ideas that came into my mind as the Minister was speaking. She mentioned smoking. My wife was a chain-smoker who could not have cared less about smoking being antisocial until she became pregnant, and she has never touched a cigarette since. Indeed, she is now probably the worst sort of reformed smoker. I am not advocating that ladies should become pregnant to give up smoking; I am simply saying what happened in my wife's case.

I do not want to start a row about immunisation, but it is not good enough to talk about people jumping on the bandwagon. The Government know only too well—I am not looking to apportion blame here—that it is a difficult situation. Even if every Member of Parliament with children said that their children had had the MMR jab—my three youngest have had it; the two oldest, who are 17 and 16, had single jabs—that would not restore confidence. The Government face a considerable problem.

The Minister said that there was no evidence or proof in relation to the dangers of mobile phones. I do not accept that. Mobile phones damage children's health in a real way, and the entire country is obsessed with using them. Parents—I am guilty of this—give children mobile phones because they think that they can use them if they are ever under threat, but the situation has become ridiculous. Children over-use mobile phones; they come home from school texting one another. The situation is completely out of control.

Putting aside the threat of radiation, I agree with my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton) about speech therapists. Before hon. Members start smiling, let me explain that from the age of five, I had to go to a speech therapist for three years. I was extremely grateful for the help that that wonderful lady gave me. There is no magic solution to the problem, but there is a huge shortage of speech therapists.

I also agree with my hon. Friend's point about mental health. That is a huge problem, as I know the Minister recognises. I am talking about the number of children who, for whatever reason, seem to be depressed and to have eating disorders. Some commit suicide. I do not have an easy answer, but that area certainly needs to be addressed.

The Minister knows that I was not best pleased when Southend hospital was given a one-star rating, and we could argue about the six points that were used to give it that rating. It is an excellent hospital, particularly with

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regard to the treatment of children and the maternity service. The Harbour unit, for instance, provides care in the children's ward at the hospital for up to four highly dependent and chronically disabled children. The unit was opened two or three years ago and has enabled the hospital to repatriate patients who had been cared for in London and elsewhere in specialist units.

I am fortunate enough to be the patron of a project called "Building Blocks", whereby some children's services will be linked with Kingsdown school for children with special needs. That is a good example of the local authority and the hospital working closely together. We have the wonderful Neptune children's unit and an excellent special care baby unit, and many other good things are happening in the hospital. I am sure that the Minister will not have time to reply to many, if any, of the points that I have made, but perhaps she will drop me a line on that.

5.44 pm

Mr. Andrew Lansley (South Cambridgeshire): So much to say, so little time—I will be brief. Of the many points that could be made, I shall pick out only two. The first relates to maternity services, and I acknowledge my indebtedness to the Rosie maternity hospital, which is part of the Addenbrooks NHS trust, in my constituency. None of my children was born at the Rosie, as we lived elsewhere then, but it does a terrific job, with some 4,500 deliveries a year. Only 3,000 are from the Cambridge area, with others travelling up to 50 miles to attend the hospital. That shows the importance of enabling choice, and the changing childbirth system does precisely that.

When I discussed issues with staff at the Rosie maternity hospital, I found that the service was under intense pressure. The return-to-practice initiative of the past year had not delivered what it should because midwives felt that they did not want to return to a practice in which they felt stressed by excessive work-load. The Rosie understood that problem during the past two years and the response, as at Addenbrooks, was to be highly proactive in work force planning and introducing a sense of work-life balance and career development for the staff in the trust. Awards were won on that basis.

One important insight is that it is not just about offering work-life balance for midwives with family responsibilities, because the net result was other full-time staff bitterly complaining that they were working round the needs of those staff, and thus working late, at weekends and to accommodate emergency pressures. The burdens of mentoring other staff all fell on those who did not have access to family-friendly policies. The right balance had to be found and work-life balance had to apply to everyone, not only those with family responsibilities.

Evidence-based management of care is crucial. The Rosie found that it was not always easy to remove hierarchies and previous patterns of care. By responding not only to the obstetrician's view of the appropriate level of care and intervention but to midwife's ideas, it was possible to reduce the pressure on beds. Mothers attending the Rosie for an extended period created some of the worst work load pressures.

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Offering substantial education and development to staff is also important. I visited Papworth hospital last week and spoke about extending the role of education and development for non-medical staff in the NHS. An issue that arose was the difficulty, through the process of transferring commissioning to primary care trusts, of making education and development in acute hospital services a sufficient priority. Funding negotiations between the primary care trust and the acute service focus greatly on the delivery of specific outputs to the PCT's priorities, yet education and development of staff is crucial for a trust to develop as a business. In the past two years, it has delivered a great deal to the Rosie hospital.

I move on to children's acute hospital services. I spoke in the debate on the Bristol Royal infirmary inquiry report and was surprised that more was not said about the timetable and the Government's intentions on the reconfiguration of children's services.We must consider, almost from scratch, how to structure children's hospital services. The current primary, secondary and tertiary organisation is not necessarily the best structure, with regard to outcomes for children and child-centred care. Roles and relationships must be re-examined, as the Kennedy inquiry suggested, because a hospital such as Addenbrook's might not currently fit the criteria for a tertiary children's hospital, but it might be the sort of place where one would want to position a hub, in a hub-and-spoke model for children's hospital services.

5.50 pm

Yvette Cooper : I congratulate you, Mr. Beard, on your elevation to the Chairman's Panel, and on your chairmanship of the debate.

I will address as many as possible of the points that have been made, and I will write to hon. Members if I fail to cover the subject that they raised.

Many hon. Members raised points about maternity, such as the importance of women-centred care, and of providing choice. The hon. Member for Romsey (Sandra Gidley) expressed concern that the national service framework might be too rigid, and that it might provide too many national standards. On the contrary, the purpose of the NSF is to increase the choices that are available to women. However, it also has the task of ensuring that those choices satisfy recognised national standards, so that women throughout the country can have confidence in the quality of the care that they receive.

Several hon. Members raised issues about the number of midwives. I agree that the national health service needs to recruit more of them. My hon. Friend the Member for Harrow, West (Mr. Thomas), and other hon. Members, asked about midwife recruitment in London and the south-east. During the past year, there has been an increase in the number of midwives in those regions, and there has also been an increase throughout the country, which has more than 18,000 whole-time equivalent midwives, compared with 17,660 in the previous year.

The number of midwives—both whole-time equivalent, and the head-count figure—is rising, but we must ensure that that trend continues. To achieve that, we have increased the number of midwives in training by 20 per cent. since 1997.

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Recruitment and retention must also be improved. A more attractive recruitment package has been introduced that includes free refresher training, a grant of £1,500 to midwives, help with child care, free travel and eligibility for housing packages. We are working with the Royal College of Midwives to improve recruitment and retention.

As 60 per cent. of returners work part time, the hon. Member for South Cambridgeshire (Mr. Lansley) is correct that we must ensure that working pressures are not too great for midwives who return to the profession, and that there is the right kind of flexibility to support midwives in their family lives—and that should not apply only to midwives who have children.

With regard to our endeavour to improve recruitment and retention, the improving working lives package that is operating throughout the country is making an important contribution, but we need to make further progress.

My hon. Friend the Member for South Swindon (Ms Drown) made important points about the need to improve maternity services, and I wish to highlight the issue of domestic violence. She is right that domestic violence sometimes starts, or increases, during pregnancy. With regard to identifying domestic violence, there are examples of excellent practice throughout the country, and important work has been done in partnership with the Royal College of Midwives to help midwives to identify and support women who are suffering from it. However, a consultant raised an interesting problem when she told me that her practice was experiencing tensions between the principle of involving fathers at every stage of pregnancy—to which she is committed—and finding opportunities to address domestic violence with the women on their own. This is not a simple issue, but good practice exists, and better ways to disseminate it throughout the NHS must be found.

Issues were raised about breast-feeding, and the importance of post-natal care. Again, shining examples of good practice can be cited. On Friday, I visited a general practice in my constituency where the staff have doubled the breast-feeding rate of their patients in five years. They emphasised that that had been achieved not by telling women what to do, but by giving them the information to make their own choices, and by giving them support when problems arose.

My hon. Friend the Member for Harrow, West made a strong case about maternity services at Northwick Park hospital. I cannot give him a detailed answer about the hospital, but he knows that we are providing additional investment for maternity services and increased investment for neonatal intensive care. We must go further, but I heard the points that he made.

My hon. Friend the Member for Middlesbrough, South and Cleveland, East (Dr. Kumar) made important points about food poverty and the importance of access to a healthy diet during childhood. He is right that that is critical for preventing coronary heart disease in later life. It is true that there are deep inequalities in that area because a person with a low-income background is three times more likely to suffer coronary heart disease than a person with a high-income

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background. We are making progress with the five-a-day community programmes, but I agree that more could be done.

The hon. Member for Broxbourne (Mrs. Roe) raised important points about the problems that are faced by children in adult services. There is a general problem that acute services have historically been designed around adults, and children have been slotted in later on. Young people are in a difficult position. That problem is due to the way in which the NHS developed, and many such points were made in the Kennedy report to which the hon. Member for South Cambridgeshire referred. We have brought forward the national service framework's acute module for children in order to address the points more rapidly. The NSF will report this year, and I want hon. Members who are interested to contribute points as part of the consultation on the national service framework. If hon. Members wish to pursue that, I shall arrange it.

I shall take a few minutes to address issues that surround the MMR vaccination. Throughout the debate of this week, I have tried to keep politics out of the issue because it is too important for that. Children's health is at stake. I did not raise political differences during my opening speech, and I have tried to refrain from a political discussion. Medical experts are lined up together, and I hope that political parties can also line up together. We had disputes about who said what and when two years ago, and hon. Members said that they tried to establish a bipartisan approach. Letters and minutes of meetings are on record about the subject. However, all that is too trivial in comparison to what is happening at the moment.

The Opposition have called for separate jabs to be available. Let me make it clear that medical advice indicates that the introduction of separate jabs on the NHS would push coverage down compared with the current process. There are several reasons for that. First, the vaccination process would require six jabs rather than two, which increases the chance that people would not complete the course. Secondly, there would have to be gaps between jabs and, indeed, Dr. Wakefield has recommended that there should be a year's gap between immunisations. If separate jabs are used, parents are effectively asked to choose the jab that their children should not receive and, therefore, the disease to which their children should be exposed at that time. That is not a real choice.

The controversy is having an impact on confidence. Evidence from Japan and the 1970s shows that confidence is wrecked completely when government shift policy in response to worries. That is why Japan had serious measles outbreaks during the 1970s, and it is why coverage of whooping cough also fell during the 1970s. That led to children going to hospital, and children dying.

Why do parents want separate jabs? There is no evidence to show that separate jabs are associated with a lower risk than the MMR vaccination. Indeed, the position is quite the reverse, and even Dr. Wakefield's research suggests that. People want single jabs because people such as Opposition Members keep calling for them. They can qualify their remarks as much as they like, but they know the way in which their remarks are interpreted. They were interpreted in that way before the election.

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I have a quote from Conservative party central office from before the past election. It states:

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The Conservative party was calling for single jabs then. The public interpreted that, and that is what they expect. They know that Opposition politicians are calling for single jabs, and that undermines confidence in the MMR vaccination.

Question put and agreed to.

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