HC 1048-III Health CommitteeWritten evidence from Jean Gross, Communication Champion (PH 177)

1. Executive Summary

1.1 I welcome the Health Select Committee’s inquiry into the future of public health. I urge that the Committee support proposals to transfer responsibility for public health to local authorities. I further urge that the Committee emphasises the vital public health role of services which address children’s early development, following the Marmot recommendations that “giving every child the best start in life is crucial to reducing health inequalities across the life course. What happens during the early years has lifelong effects on many aspects of health and well-being—from obesity, heart disease and mental health, to educational achievement and economic status. To have an impact on health inequalities we need to address the social gradient in children’s access to positive early experiences”.

1.2 I ask that the committee recognises the centrality of positive early experiences that promote good social, emotional and language development to improved life chances and health outcomes, and notes the positive work that has been done in many areas of the country in this respect.

1.3 I suggest that public health work aimed at improving development and wellbeing outcomes for children is likely to be given a lower priority by health and wellbeing boards than issues relating to adults. Health and wellbeing boards should, therefore, be required to have a children’s sub-board.

1.4 I note that there is a risk that the proposed new health premium will incentivise cost-ineffective activities aimed at adults rather than longer-haul but more cost-effective activities aimed at children and young people. The formula developed for the health premium should therefore include experts in early childhood development and wellbeing.

1.5 I suggest that the outcomes framework for public health use children’s communication and language, physical and personal, social and emotional development levels at age two and five as key indicators of success, since these are factors which best predict later health outcomes as well as later educational achievement and employment opportunities.

1.6 I commend the Healthy Child Programme to the committee as a prime public health strategy, but note that when this was commissioned by Primary Care Trusts it was given a low priority and not fully implemented in an estimated 40% of local areas. I ask the committee to recommend that the health visitors who lead the programme for 0–5 year olds are in the long term commissioned by local authority public health directors, rather than by GP consortia.

1.7 I recommend that government and Public Health England include the vital public health role of speech and language therapists in the Healthy Child Programme, and in guidance on the use of public health funding under the proposed transfer of commissioning from Primary Care Trusts to local authorities.

2. About the Communication Champion

2.1 The post of Communication Champion, for children and young people aged 0–19 in England, was created by Government in response to the 2008 Bercow Report on services for children and young people with speech, language and communication needs. A key role for the Champion, who is appointed by but independent of Government, is to assist commissioners and providers to develop services that improve outcomes for children with poor communication skills, including through spreading good practice.

2.2 In this role I have now visited 93 of 152 local authority/Primary Care Trust pairings, to discuss local practice within the Healthy Child Programme, children’s community health services and local authority services for under fives and for older children with disabilities or who live in poverty.

3. Where is the best point to intervene in order to improve public health?

3.1 Effective interventions to improve adult health begin in early childhood. As the Marmot Review has shown, poor health in adulthood is strongly related to poverty and to factors in early childhood that affect development. Marmot found that “giving every child the best start in life is crucial to reducing health inequalities across the life course. What happens during the early years has lifelong effects on many aspects of health and well-being—from obesity, heart disease and mental health, to educational achievement and economic status. To have an impact on health inequalities we need to address the social gradient in children’s access to positive early experiences.” Marmot identified as a priority objective reducing inequalities in the early development of physical and emotional health, and cognitive, linguistic and social skills—and put giving every child the best start in life as the review’s highest priority recommendation.

4. Why are children’s speech, language and communication skills a public health issue?

4.1 Research evidence shows that of all areas of early childhood development, early language skills are particularly powerful predictors of later life chances. After controlling for a range of other factors that might have played a part (mother’s educational level, overcrowding, low birth weight, parent a poor reader, etc), children who had normal non-verbal skills but a poor vocabulary at age five are at age 34 one and a half times more likely to have mental health problems and more than twice as likely to be unemployed than children who had normally developing language at age five (Law et al., 2010)

4.2 As well as being an independent predictor of adult outcomes, language skills are a critical factor in social disadvantage and in the intergenerational cycles that perpetuate poverty. Poor language skills are the key reason why, by the age of 22 months, a more able child from a low income home will begin to be overtaken in their developmental levels by an initially less able child from a high-income home—and why by the age of five, the gap has widened still more.

4.3 Research in the USA found that on average a toddler from a family on welfare will hear around 600 words per hour, with a ratio of two prohibitions (“stop that”, “get down off there”) to one encouraging comment. A child from a professional family will hear over 2,000 words per hour, with a ratio of six encouraging comments to one negative (Hart and Risley, 2003).

4.4 Low income children lag their high income counterparts at school entry by sixteen months in vocabulary. The gap in language is very much larger than gaps in other cognitive skills (Waldfogel and Washbrook, 2010).

4.5 Vocabulary at age five has been found to be the best predictor (from a range of measures at age five and 10) of whether children who experienced social deprivation in childhood were able to “buck the trend” and escape poverty in later adult life (Blanden, 2006).

5. Examples of existing public health action and its impact

5.1 A number of Primary Care Trusts and local authorities have recognised the predictive power of early language and communication development and have taken action to tackle the issue, aligning the work of speech and language therapists with the Healthy Child Programme and SureStart Children’s Centres.

5.2 Stoke Speaks Out, for example, is a primary prevention initiative set up in 2004 to tackle the high incidence of speech and language difficulties in the city. It aims to support attachment, parenting and speech and language issues through training, support and advice.

5.3 The programme has developed a multi-agency training framework for all practitioners working in the city with children from birth to seven years, or their families. The training has five levels, ranging from awareness-raising to detailed theoretical levels, and was jointly written by the project team of speech and language therapists, a psychologist, a midwife, play workers, teachers and a bilingual worker. All levels have an expectation that the practitioner will create change in their working environment. In addition the initiative has developed resources for parents, including a model for toddler groups to follow which enhances language development, and a website offering practical information for parents to help with children's language development. “Talking walk-ins” provide drop in sessions at Children’s Centres where parents can get advice from speech and language therapists.

5.4 Outcomes have been impressive. In 2004 64% of three year olds in the city had significantly delayed language skills. Now, as a result of the initiative, that figure is down to 39%.

5.5 Nottinghamshire has developed a Language for Life strategy, stemming from a decade of speech and language therapy work in SureStart Local programmes. In the most disadvantaged areas the therapy service provides training for all Early Years practitioners, support for practitioners to run listening and narrative groups for children with language delay, and leaflets, posters and charts for parents, such as a Talking Tree height wall chart which includes speech and language milestones. The speech and language therapy Children’s Centre core offer includes support for harder to reach families with 0–3 year olds through a ‘Home Talk’ home visiting programme. The Healthy Child Programme two-year development check includes a parent-interview language screen, with a ‘traffic light’ alert system which triggers use of relevant advice leaflets or access to the Home Talk programme, which has lifted 60% of two year olds supported out of language delay, with the remaining 40% referred early for speech and language therapy.

5.6 In Derby there is a team of speech and language therapists, therapy assistants and Family Visitors, who work from Children’s Centres in one of Derby’s localities. All two year olds are assessed on their language and development by Health Visiting team nursery nurses, or Family Visitors. Where the screening shows language delay, children are signposted to parent/child interaction groups, or home visits by the speech and language therapist or Family Visitor, to carry out a 4–6 week programme with the family.

5.7 In Herefordshire, local teams have maintained a Healthy Child developmental check at nine months, two years and three years. All members of the Health Visiting team (Health Visitors and community nurses) receive at minimum a two day course on children’s speech, language and communication development delivered by speech and language therapists. The community nurses follow an in-depth ten-week course, so that they are able to contribute to the developmental checks and provide follow up support to families where the check indicates a need. All early years consultants receive the in-depth training so that they can provide advice and support to early years practitioners and signpost them to appropriate training. This means that where children are identified as having difficulties, the first line of support can be delivered in the early years setting the child attends. Highly trained speech and language therapy assistants model for early years practitioners how to run group interventions for children.

5.8 I ask that the committee note positive work of the type described here, and its contribution to improved life chances and health outcomes.

6. Current risks

6.1 Under current proposals for commissioning of children’s community health services, GP consortia will hold the budget for speech and language therapy services. It is unlikely that they will commission therapy services to provide the kind of universal prevention work described above. They would rightly see this as falling within the public health remit.

6.2 Currently, government’s public health proposals and consultation documents do not mention the importance of primary prevention work to tackle children’s poor communication skills, particularly in areas of high social deprivation. Nor do they mention the public health role of speech and language therapists.

6.3 For these reasons there is a high risk that no-one will commission therapy services to undertake this work , unless there is a strong steer from government that it should be part of the local authority’s public health spend.

6.4 Similar issues are likely to affect the promotion of resilience and good mental health in childhood, where again there is a risk that specialist CAMHs staff who play a key role at the universal level may no longer be commissioned to work in this area.

6.5 Another issue is that that public health work aimed at improving development and wellbeing outcomes for children is likely to be given a lower priority by health and wellbeing boards than issues relating to adults. Health and wellbeing boards should, therefore, be required to have a children’s sub-board.

6.6 There is also a risk that the proposed new health premium will incentivise cost-ineffective activities aimed at adults rather than longer-haul but more cost-effective activities aimed at children and young people. The formula developed for the health premium should therefore include experts in early childhood development and wellbeing.

6.7 I suggest that the outcomes framework for public health use children’s communication and language, physical and personal, social and emotional development levels at age two and five as key indicators of success, since these are factors which best predict later health outcomes as well as later educational achievement and employment opportunities.

7. Who should commission public health services?

7.1 My visits to local areas suggest that it is very difficult for NHS commissioners of services for children to think beyond obesity, immunisation and breastfeeding. The agenda they ought to share with local authorities—one of improving development and wellbeing outcomes for children, as highlighted by Marmot as being key to tackling health inequalities in adulthood—escapes them. For this reason I believe that public health services should commissioned by local authorities, whose accountabilities already lie in these child development and wellbeing outcomes.

7.2 As the examples above demonstrate, the Healthy Child Programme is potentially to a prime public health strategy. My visits to local areas to date, however, suggest that four out of ten Primary Care Trusts have not implemented the programme universally. It has often been given a low priority. Commissioning the Healthy Child Programme from 0–5 needs to sit with local authorities, as it does from 5–19. This is necessary in order to make cost-effective integrated arrangements to provide the universal Healthy Child Programme, and targeted support for families, including health visitors working in partnership with children’s centres and early years providers. I therefore ask the committee to recommend that the health visitors who lead the programme for 0–5 year olds are in the long term commissioned by local authority Public Health directors, rather than by GP consortia.

June 2011

Prepared 28th November 2011