3Local service delivery
Principles for local service delivery
23.We heard throughout the inquiry that the following 6 principles should be used to underpin local approaches to the first 1000 days: ‘proportionate universalism’; a focus on prevention and early intervention; co-design of services with the local community; engaging with and supporting marginalised communities; multi-agency working; and delivering evidence-based interventions.
Proportionate universalism
24.The Marmot Review described the concept of ‘proportionate universalism,’ an approach to reducing health inequalities with a balance of universal and targeted services, whereby those services are delivered in proportion to the level of need.51 If targeted services exist without universal services, it is only the most vulnerable children who are identified, often very late, and there is no foundation for identifying other, less vulnerable children and families. If universal services exist without targeted services, there is no recourse to provide an enhanced level of support where appropriate.52
25.The principle of proportionate universalism is supposed to guide the provision of the mix of universal and targeted provision that comprises the landscape of services covering the period from conception to age 2 in England.53 In practice, however, these services are neither delivered nor commissioned in accordance with this principle, as demonstrated by the inadequate and unbalanced implementation of existing services such as the Healthy Child Programme, and variations in targeted services available locally, both discussed later in this report.
Delivering prevention and early intervention
26.Public spending in the United Kingdom, as in most OECD countries, increases proportionately as children get older.54 A 2018 report by the Children’s Commissioner and the Institute for Fiscal Studies, which examined local authority spending on children’s services, noted that financial constraints and rising demands, such as child safeguarding referrals and an increase in the number of looked after children, have meant that councils have focused on ensuring they meet statutory obligations, potentially at the expense of directing resources to prevention and early intervention.55
27.In its inquiry on evidence-based early years intervention, the Science and Technology Committee called for a shift of expenditure towards earlier interventions, which they say may necessitate an initial increase in expenditure, but which is likely to lead to long-term savings.56 We agree with our colleagues on the Science and Technology Committee that the Government should incentivise and support local authorities to make long-term investment in the early years.
Delivering community partnership
28.We visited Blackpool, one of five areas sponsored by the Big Lottery Fund’s A Better Start Programme, in November 2018. As part of the programme, the Big Lottery Fund is putting £215 million over ten years into five socially disadvantaged areas in England. These areas are developing and testing new approaches to promoting early childhood development, prevention and early intervention. The following core principles apply to each of the five areas:
- putting people in the lead;
- being place-based and adapted to the local context; and
- working in partnership to ensure that services are delivered efficiently.
29.The A Better Start Partnership in Blackpool is delivering a truly place-based approach to the first 1000 days. This is built on a successful collaboration between local government, local NHS providers and commissioners, the private sector, the voluntary and community sector and the community itself. A Better Start in Blackpool is led by the NSPCC.57 Having the voluntary sector in the lead enables the partnership to reach areas outside the usual remit of statutory services, and facilitates communities’ involvement in all stages of design, implementation and evaluation of community-owned assets.
30.The A Better Start Partnerships have demonstrated the importance of an approach to service design that involves families and the wider community in improving existing evidence-based programmes. In Blackpool, A Better Start has invested £1 million into a transformation of the health visiting service, co-designed by parents and healthcare professionals. The result is an enhanced service with an increased number (from 5 to 8) of minimum contacts with a health visitor, alongside a revision of the content of the visits to more effectively support parental and infant mental health.58
31.As well as giving local people power over the design of services, the A Better Start areas put people in the lead by giving them opportunities to be involved in service delivery. For example, in Nottingham, another A Better Start area, parents and community members are employed as Family Mentors to provide peer support to pregnant women or families with young babies. All local families are offered access.59 In Cornwall, Home Start Kernow is supporting around 600 families over three years with peer volunteers who provide regular home-based emotional and practical support for families.60
Children’s centres
The Sure Start programme was launched in 1998, with the aim of providing local services tailored to the needs of children and parents. The programme was initially rolled out in the most disadvantaged areas, but from 2003 the Government began to develop universal access. Children’s centres were intended to be hubs in which families and preschool-age children could access integrated services, including education, childcare, parenting support, health visiting services and support for benefits and housing.61 The Government’s 2013 statutory guidance defines the core purpose of children’s centres as improving outcomes for young children and their families and reducing inequalities in development, school readiness, parenting skills, and child and family health and life chances.62 In April 2010 there were 3,632 Sure Start children’s centres in England. The Sutton Trust estimated (in April 2018) that over 1,000 centres might have closed since 2009.63
Delivering on the needs of marginalised populations
32.In 2016, the National Children’s Bureau published research on the experience of low-income families in accessing children’s services, finding that such families were less aware of services and felt less comfortable in using them, owing to a lack of support and information.64 Families reported having limited opportunities to feed back about their experiences of services, and rarely heard how their feedback had been acted on. They also reported it taking too long to receive additional support, especially for housing, mental health problems and family support.
33.The Early Intervention Foundation has drawn attention to difficulties for the most vulnerable families in accessing universal services. Those difficulties can be related to the availability or distance of services, transport or other costs, or perceived stigma. In its Guidebook,65 the EIF describes evaluations of the evidence of programmes that include a home visiting component that have been shown to improve outcomes for children and young people.
34.An example of an approach which delivers targeted services for marginalised populations is Flying Start, the Welsh Government’s flagship early years programme.66 Flying Start is aimed at families with children aged 0 to 4 living in disadvantaged areas of Wales. The targeted programme is based on income benefit data, which is used as a proxy for deprivation.67 In the geographical areas in which Flying Start is delivered, it is a universal service, to avoid stigmatisation.
Delivering an integrated, multi-agency approach
35.Families need access to a complex system of support in the first 1,000 days from primary care, health visiting, midwifery, mental health services, housing services, childcare, education, social services, and sometimes probation and prison services. The National Children’s Bureau described strategic and operational coordination between these multiple agencies as “a major challenge.”68 They reported that early years providers and local authorities describe difficulties in planning for children’s educational needs because of a lack of information sharing between agencies, and have stressed the need for strong multi-agency working to deliver joined-up services.69
36.An example of where multi-agency working seems to be performing well is the Big Lottery Fund’s five local A Better Start sites, each of which has a partnership board, bringing together community members and representatives of partner organisations.70 The boards ensure that organisational leaders work in partnership to ensure that the A Better Start plans become embedded, scalable and sustainable, and also consider jointly where the barriers to progress are.
37.Several witnesses suggested a possible approach to improving multi-agency working in England based on Northern Ireland’s Infant Mental Health Framework. The Framework represents a commitment by the Public Health Agency, Health and Social Care Board and Trusts, as well as academic, research, voluntary and community organisations across Northern Ireland, to improve interventions from the antenatal period through to children aged 3 years old.71 The Framework highlights three priority areas—promoting and disseminating evidence and research; informing workforce development; and informing service development—and reports having supported systemic change and a joined-up approach across these areas.72
38.As the Royal College of Midwives state, the National Maternity Review’s Better Births report recommended “bringing care together in community hubs: local centres that could be located in children’s centres, GP practices or midwifery units, where women can access elements of their care with different providers working together.”73 However, we have heard several times during the inquiry that while co-location of multiple agencies and a multidisciplinary team in children’s centres is a necessary part of the universal offer for children, it is not sufficient. Deidre Webb of the Public Health Agency in Northern Ireland told us that more important than co-location is effective communication between services,74 a point which we heard reiterated in focus groups with local authorities, who told us that attempts to move services into the same building as a way to improve co-ordination has not necessarily had this outcome.75 Two examples of good practice are Lambeth Early Action Partnership,76 which is doing work on co-ordination of services not just depending on being co-located but also about having time to set up protocols, with staff getting to know each other, and Barnardo’s, who provided an example of good coordination at a children’s centre in Leicester:
The centre employs a small team of family support workers and play workers who are co-located with a range of specialists including health visitors, midwives, early years support teachers, a speech and language therapist, a children centre teacher, a community food worker, a link to learning officer, and housing officer. Health visitors register new families with the children’s centre and all parents with new-born babies are visited by the health team. Where there are concerns, the family is referred to the family support team for follow-up visits or involvement in a targeted group. Midwives also refer families where there are concerns even before the baby is born. They have regular ‘cause for concern’ meetings with local GPs, health visitors, and the wider integrated team to review families in need of support.77
Delivering evidence-based interventions
39.As well as improving access to early childcare and education, there is a need to ensure that early years programmes are delivered on the basis of the best available evidence of effectiveness. In an analysis of 35 interventions by the Early Intervention Foundation, one of the What Works Centres,78 the EIF found that only 13 had undergone a rigorous evaluation, and of those 13, only four had evidence of improving a relevant outcome.79 The EIF describes difficulties both in demonstrating the effectiveness of individual programmes and, crucially, in demonstrating the extent to which programmes result in return on investment for commissioners, which they say might be a barrier to uptake. In evidence to the House of Commons Science and Technology Committee’s inquiry on evidence-based early-years intervention, the EIF highlighted the lack of reliable information about the extent to which local authorities are using evidence-based interventions, although there is currently a peer-to-peer programme operating across local government which is seeking to compare local authorities.80
40.Ailsa Swarbrick, Director of the Family Nurse Partnership National Unit, captured the difficulty of the evidence base in the first 1000 days, since in many cases there is no evidence, the evidence is of poor quality, or there is controversy in the evidence:
There should be investment in thinking about what is valuable evidence, and what different forms of evidence there might be in this space, given the need for thinking long term and given that we are dealing with very complex systems where it is not always easy to attribute direct cause and effect.81
Conclusion
41.These six principles should together drive local service delivery in the first 1000 days. An evidence-based, integrated, and inclusive approach, delivered universally and proportionate to need is, from the evidence we have heard, likely to be the most effective way to improve outcomes for children and to reduce inequalities between children. The five A Better Start areas in England are funded by £215 million over 10 years, meaning that each site has a fund of around £4 million per year to enable systems change in promoting early childhood development.82 Drawing on the successes of the transformation funding for the A Better Start areas, we recommend that the Government should establish a fund to incentivise the transformation of local commissioning and provision covering the first 1000 days in accordance with the objectives set by the Government’s national strategy (see ‘Vision’ section), and the six principles we have outlined in this chapter.
42.Each local authority area should develop, jointly with local NHS bodies, communities and the voluntary sector, a clear and ambitious plan for their area, which sets how they will improve support for local children, parents and families during the first 1000 days and how they intend to achieve national goals. The development and delivery of these local plans should be led by a nominated officer, accountable for progress. Local plans should include a comprehensive assessment of local provision, including targeted and specialist interventions provided locally, and describe how each area will adopt the core principles for local service delivery outlined in this chapter.
43.Adhering to these principles requires reforming the delivery of universal services, with a revised Healthy Child Programme, and investing in existing evidence-based targeted services. The following two sections—on the Healthy Child Programme and targeted services—discuss the practical implementation of these six principles in services in England.
The Healthy Child Programme (HCP)
44.In 2009, the Government launched the universal Healthy Child Programme (HCP), with the aim of improving outcomes and reducing inequalities through a combination of universal provision and targeted support.83 The HCP is central to the delivery of the universal offer of prevention and early intervention services for children and families in England. Following the reforms instituted by the Health and Social Care Act 2012, in October 2015 local authorities assumed full responsibility from NHS England for commissioning public health services for children up to the age of five, including the HCP.84
Current delivery of the HCP
45.We heard throughout the inquiry about variable implementation of both the statutory and non-statutory aspects of the HCP across the country. Legislation requires 5 health visitor family checks to be carried out on a mandatory basis.85 These reviews are an important engagement point with families. They allow trained professionals to assess child development, identify any potential problems and refer families for targeted support. There is substantial regional variation in terms of the percentage of completed health visitor assessments.86 The Institute for Health Visiting told us in oral evidence that 65% of families are not formally seeing a health visitor at all after their baby is aged six to eight weeks, and may instead be seeing other early years workers with less training in identifying relevant risks. We also heard that even if a “contact” is recorded as having been completed, owing to a lack of specificity in the definition of a “contact” it might be that families are only receiving a letter, not a visit.87
46.The other countries of the United Kingdom mandate a higher number of visits: in Wales there are 9 reviews; in Northern Ireland there are 7 (with a planned increase to 9); in Scotland there are 11. Scotland and Wales additionally specify which reviews are to be carried out by a qualified health visitor, rather than another team member.88
47.The Greater Manchester Eight Stage Assessment Pathway demonstrated the value of additional contacts beyond mandated health visitor assessments and set out how this could be delivered.89 The pathway, part of Greater Manchester’s Early Years Delivery Model, involves health visitors and outreach workers assessing children and families from pre-birth to age 5. Evidence-based interventions are then made available for children who are identified as requiring additional support to achieve age appropriate development and school readiness.90 However, without additional resourcing, further mandated assessments might stretch budgets to unsustainable levels and increase caseloads to a dangerous level. In 2011, the Government introduced a plan in England to increase the number of health visitors, but despite the focused investment, there was a failure to achieve the aimed increase; there has been overall only a 1.7% increase since May 2010.91 In April 2018 the Government announced plans to increase the number of midwives by 3,000, by 2021.92
48.The Institute of Health Visiting has recommended that local authorities work towards their health visitors having caseload size not exceeding 250 children per health visitor, or a maximum ratio of 1:100 in more deprived areas.93 In Wales, the HCP is delivered with a set ratio of one health visitor to 250 children; and in Flying Start areas, it is one health visitor to 110 children.94 While we have not seen strong evidence for a particular ratio, there has been consensus from the evidence we have heard during the inquiry that there are currently too few health visitors, and many have too many families on their caseload.
49.We agree with the Science and Technology Committee that the first priority should be for every child to receive all the five mandated visits, in a manner that does not compromise the quality of these visits. We also agree with the Science and Technology Committee that the Government should set a date for when this will be achieved. However, we also recommend as part of a refresh of the Healthy Child Programme that the Government set out proposals for increasing the number of routine visits.
50.We recommend that all checks should be carried out by a health visitor, and that a minimum number of contacts should include a home visit.
Revising and refreshing the HCP
51.We have heard throughout the inquiry that, notwithstanding its successes, the Healthy Child Programme is not adequately supporting the improvements in health and wellbeing and reductions in health inequalities which it aims to do.95 We have heard that improvements in public health outcomes for children would be best achieved by a refresh of the HCP in accordance with the six principles we discussed in the previous section. Therefore, 10 years on from its inception, we are calling for a revised Healthy Child Programme, with interventions that:
- are family focused;
- begin before conception;
- extend visits beyond 2 ½ years; and
- ensure continuity of care including improved links between health visiting, midwifery, obstetrics and primary care, and ensuring that women see the same midwife and same health visitor for each visit.
A family focus
52.While the child should remain at the centre of the Healthy Child Programme, we have heard throughout the inquiry that healthy attachment, and preventing or mitigating the impact of stressful or traumatic experiences in childhood—known collectively as adverse childhood experiences (ACEs)—depends on involving the whole family. All health professionals, and particularly health visitors, need to understand a child’s health and development in the context of their family environment.
53.The Fatherhood Institute conducted a survey of over 1800 fathers in Scotland, finding that fathers describe being excluded in the antenatal period, with potentially worrying consequences for the child of the family.96 The National Children’s Bureau is currently working with the Big Lottery Fund to pilot an informal parenting programme with young fathers in Lambeth, which is aiming to break barriers to improve the engagement and involvement of young fathers with service design and delivery.97
54.Action for Children told us that perinatal services have focused largely on mothers presenting with severe mental health problems, and less on the child and fathers or partners.98 A step towards resolving this has been made in the NHS long term plan, which has announced plans to offer assessments and signposting for support to the partners of women accessing specialist perinatal mental health services.99
55.We recommend that a revised Healthy Child Programme should be expanded to focus on the health of the whole family and examine how this affects the physical and mental health of the child, recognising that the physical health and mental health of a baby’s parents, and the strength of their relationships with each other and their child, are important influences on their child’s health.
Beginning before conception
56.We heard evidence about the vital importance of the preconception period and intrauterine environment, and the health of both parents at these times, to postnatal infant health.100 Pre-conception interventions can often be challenging to implement prior to a woman’s first pregnancy, because a large proportion of pregnancies are unplanned;101 but there are opportunities subsequently to intervene between pregnancies, if women or their partners are identified as requiring additional support. Relationships and sex education at school is an ideal time to have discussions with young people about healthy relationships and healthy pregnancies.102
57.We recommend that the revised Healthy Child Programme should include the provision of pre-conception support to parents who are planning a pregnancy, or to parents who could have benefited from more support prior to a previous pregnancy. This should begin at school, where there should be focused attention on healthy relationships, pregnancies, including advice about smoking, alcohol, substance misuse and parenting.
Extending beyond the first 1000 days
58.The Early Intervention Foundation raised concerns with us about a “cliff edge” when a child reaches the end of the early years, telling us that it is important to consider what happens after a child reaches the upper end of the age range of the Healthy Child Programme at age 5.103 The last mandated visit by a health visitor in the HCP is at 2–2½ years, at which time the health visitor reviews the child’s development.104 In Blackpool, an additional visit is carried out at 3–3½ years, to assess and support ‘school readiness.’105 In areas of high disadvantage around 50% of children do not reach a good level of development by age 5 in which they are deemed ready to start school (school readiness).106 Improving school readiness, according to PHE, is a ‘best buy’ for public health.107 Introducing additional checks delivered by health visitors after age 3 to assess school readiness, in order to identify children likely to need extra support, may help to identify children who may be off course for reaching this level of development.108
59.We recommend that an additional mandated visit at 3–3½ years should be included in the Healthy Child Programme, to ensure that potential problems that may inhibit the ability of children to be ready to start school are identified and addressed.
Continuity of care
60.Women who have midwife or health visitor they know and trust are more likely to report domestic violence, mental health issues, or a personal history of adverse childhood experiences.109 Presently, the multidisciplinary team often works in siloes, and there is inadequate communication between people, teams, and IT systems.
61.Research suggests that women who see the same midwifery team for each visit are less likely to have miscarriages and premature births, and continuity of care has been shown to be associated with reduced mortality.110 The Government announced in April 2018 its ambition for the majority of women to receive continuity of midwifery care (that is, care from the same midwives) throughout their pregnancy, labour and birth by 2021, starting with 20% of women being cared for with this model by March 2019.111
62.We recommend that a revised Healthy Child Programme, with an increased focus on continuity of care, should include the explicit objective that so far as possible a family will see the same midwife and the same health visitor, at each appointment or visit.
Targeted provision
63.The Healthy Child Programme is the core of universal service provision in the first 1000 days. For some families, targeted support in addition to that available through universal services is helpful. The EIF defines two levels of targeted interventions: targeted selective interventions - those offered to families on the basis of broad ‘demographic risks’ such as low income, and which may prevent problems from occurring in the first place - and targeted indicated interventions - which are offered to families who have already been identified as having a problem which requires more intensive support.112 As interventions move from universal to “targeted selective” to “targeted indicated”, they are more intensive, and are offered to fewer people.
64.Targeted and specialist services such as the Family Nurse Partnership and Parent Infant Partnership services provide extra support for families and children. The Parent Infant Partnership service offers specialist psychotherapeutic services, relationship support, and a joined-up pathway of care to ensure that families get the right support at the right time.113
65.The Family Nurse Partnership is an intensive, preventive, home-visiting programme delivered by specially trained nurses and midwives.114 It is a programme for vulnerable first-time young parents and their babies, which “seeks to support women to have a healthy pregnancy, to improve child health and development, and to improve parents’ economic self-sufficiency.” At its peak in 2016, the FNP was delivered in 132 local authorities in England, and is currently reportedly delivered in 77.115 In Scotland, the FNP is being rolled out widely to teenaged mothers, and there are plans to extend it to eligible women up to 24 years of age.116
66.A Government-commissioned trial on the FNP demonstrated no evidence of benefit for the trial’s defined primary outcomes (smoking cessation, birthweight, second pregnancies, and Accident & Emergency visits), but the choice of these outcomes, and therefore the interpretation of the trial’s findings, has been widely questioned.117 The FNP is exploring an initiative (ADAPT) to learn from the trial’s findings by incorporating evidence-based innovation, learning and iterative improvement.118 The Science and Technology Committee has suggested that rather than disinvesting in the FNP on the basis of the Government-commissioned study, commissioners should act on the conclusions reached by the FNP’s initiative in due course.119 Based on five randomised controlled trials, the Early Intervention Foundation describes the FNP as having evidence of a long-term positive impact on child outcomes.120
67.There is limited information about the extent to which local areas commission targeted and specialist pathways. The Maternal Mental Health Alliance publish data on provision and performance of services for families affected by perinatal mental illness in the UK.121 The MMHA told us that a postcode lottery exists, such that many parents cannot access services.122
68.In written evidence the Royal College of Psychiatrists said that adverse childhood experiences such as maltreatment, domestic violence, parental imprisonment and poor mental health contribute approximately equally to increasing the risk of ill health.123 They recommended that preventing adverse childhood experiences must be the core priority for interventions in first 1000 days, with targeted support for parents and children at risk of ACEs needing to be a key part of the approach.124
69.We recommend that the Government, working with local areas and the voluntary sector, develop a programme into which children and families who need targeted support can be referred, drawing on the experience of the Family Nurse Partnership in Scotland, Northern Ireland and in some parts of England, and of Flying Start in Wales. Children in need of such targeted support should be identified during pregnancy. We agree with our colleagues on the Science and Technology Committee that commissioners should continue to appraise the evidence base for the Family Nurse Partnership, as well as for other targeted interventions, and consider investment or disinvestment accordingly.
51 Professor Sir Michael Marmot, Fair Society, Healthy Lives. The Marmot Review, 2010
53 Annual Report of the Chief Medical Officer 2012. Our Children Deserve Better: Prevention Pays
54 Organisation for Economic Co-operation and Development, ‘Doing better for Families’, 27 April 2011
55 The Children’s Commissioners and Institute for Fiscal Studies, Public spending on Children in England, June 2018; Institute for Fiscal Studies, Living standards, poverty and inequality in the UK: 2017/18 to 2020/21, November 2017
56 Science and Technology Committee, Eleventh Report, 30 October 2018, HC 506, para 146
57 Blackpool Better Start website (Accessed 29 Jan 2019)
58 Blackpool Better Start Invests £1million into Transforming Health Visiting Service, Blackpool Better Start, 17 April 2018
61 Education Committee, Fifth Report, 11 December 2013, HC 364-I, para 37
62 Department for Education, Sure Start children’s centres statutory guidance, April 2013
63 Sutton Trust, Stop Start: Survival, decline or closure? Children’s centres in England, 2018, April 2018
64 National Children’s Bureau, ‘Young children’s and families’ experiences of services aimed at reducing the impact of low-income’, February 2015
65 Early Intervention Foundation Guidebook (Accessed 21 December 2018)
66 Welsh Government, ‘Flying Start’, 26th May 2017
67 National Assembly for Wales Children, Young People and Education Committee. Flying Start: Outreach, February 2018
71 Public Health Agency, Infant Mental Health Framework for Northern Ireland, April 2016
72 Public Health Agency, Infant Mental Health Framework for Northern Ireland, April 2016
73 Royal College of Midwives, Summary of the report of the National Maternity Review ‘Better Births: Improving outcomes of maternity services in England’
75 See Annex 3
78 UK Government, What Works Network, 28 June 2013 (Accessed 15 January 2019)
80 Science and Technology Committee, Eleventh Report, 30 October 2018, HC 506, table 1
82 The National Lottery Community Fund: A Better Start (Accessed 16 January 2019)
83 Department of Health, Healthy Child Programme: Pregnancy and the first five years of life, October 2009
85 Department of Health, Healthy Child Programme: Pregnancy and the first five years of life, October 2009
86 Public Health England, Health Visitor Service Delivery Metrics: 2017/18 Annual Data, October 2018
89 Greater Manchester: Early years new delivery model, 3 August 2015 (Accessed 14 January 2019)
90 Greater Manchester: Early years new delivery model, 3 August 2015 (Accessed 14 January 2019)
92 “Women to have dedicated midwives throughout pregnancy and birth”, 27 March 18 (Accessed 1 February 2019)
94 Flying Start, 26 May 2017 (Accessed 1 February 2019)
99 The NHS Long Term Plan, January 2019
102 UK Parliament, Relationships and Sex Education, 25 June 2018 (Accessed 2 February 2019)
104 Department of Health, Healthy Child Programme: Pregnancy and the first five years of life, October 2009
105 Blackpool Better Start, “Blackpool Better Start Invests £1million into Transforming Health Visiting Service”, 17 April 2018 (Accessed 14 January 2019)
110 “Women to have dedicated midwives throughout pregnancy and birth”, 27 March 2018 (Accessed 14 Jan 2019)
111 “Women to have dedicated midwives throughout pregnancy and birth”, 27 March 2018 (Accessed 14 Jan 2019)
112 Early Intervention Foundation: What is early intervention (Accessed 14 January 2019)
116 Progressing the Human Rights of Children in Scotland: A report 2015–2018, December 2018
117 Science and Technology Committee, Eleventh Report, 30 October 2018, HC 506, para 57
118 Family Nurse Partnership: ADAPT (Accessed 8 January 2019)
119 Science and Technology Committee, Eleventh Report, 30 October 2018, HC 506, para 59
120 Early Intervention Foundation Guidebook: Family Nurse Partnership, July 2016 (Accessed 13 January 2019)
Published: 26 February 2019