Evidence-based early years intervention Contents

3The current state of early intervention in England

33.The most significant policy areas for early intervention aimed at addressing childhood adversity and trauma—local authority children’s services, public health and education—are devolved issues.105 This Chapter examines the current state of early intervention in England, including specific national programmes.

Early intervention in England

Local and national policy

34.The responsibility for many of the most important policy areas for the delivery of early intervention falls to local authorities.106 This includes a variety of statutory duties relating to child safeguarding.107 Statutory guidance states that “early help is more effective in promoting the welfare of children than reacting later”, and instructs local authorities to have measures in place to:

Jackie Doyle-Price MP, Parliamentary Under-Secretary of State for Mental Health and Inequalities, explained that “fundamentally, we believe in a localised approach, because local leaders can respond best to their particular circumstances”.109 Martin Pratt, Chair of the Association of London Directors of Children’s Services, told us that “the move to earned autonomy for successful authorities is welcome”.110 Nevertheless, he asserted the importance of “clarity about national policy, in particular that it is evidence-informed and that it is being supported”.111 This chimes with what the Mental Health and Inequalities Minister outlined as the role she saw for national Government:

We want local leadership to take place against an overarching national policy framework in which we want to identify best practice and the measures that will tackle these issues.112

35.Nadhim Zahawi MP, Parliamentary Under-Secretary of State for Children and Families, assured us that “both the Prime Minister and the Secretary of State [for Education] are committed to making sure that we prioritise early intervention and the home learning environment”,113 and outlined a variety of initiatives targeting different aspects of early years education.114 Jackie Doyle-Price MP, the Minister for Mental Health and Inequalities, made similar points:

In the health context, we have tackled each component in turn […] We have separate workstreams. Perhaps there is an argument for bringing that thinking together in some way, but it probably reflects the fact that doing things in England is slightly more complex.115

Mark Davies, Director of Population Health at the Department of Health and Social Care, explained further that “the adverse childhood experiences research is quite new; we are still working out how to make best use of it”.116

36.We heard, however, from several witnesses that these distinct initiatives did not constitute a clear national policy for local authorities to follow. For example, the Association of Directors of Public Health told us that there “has been a confused public policy approach [to early intervention] with varying definitions across different policy areas related to different approaches and different age groups”, and that “early years intervention has, to some extent, got lost in this at the national and local policy level”.117 Dr Jeanelle de Gruchy, President of the Association, explained:

It would be very helpful to have a much more strategic, overarching approach to what we do in terms of early years and children […] What we are getting at is something about definition on prevention, early intervention and early help, but also something more pertinent, which is about the different Departments having a shared understanding of what we are trying to do and what the evidence is for that. If we had that national strategic direction, it would be a very helpful framework for what then comes down to local level, and for what we do and how we join it up locally.118

37.The importance of cross-Governmental co-ordination was made clear by Donna Molloy, Director of Policy and Practice at the Early Intervention Foundation:

A lot of the work we do is to try to give Government a more holistic view on the complexity of child development and some of the specific departmental agendas on issues such as child sexual exploitation, youth violence or knife crime. The best way to tackle some of those things are not very specific knife crime initiatives, or whatever it might be, but building investment in a common core of interventions that build children’s social and emotional competency, strengthen parent-child interactions and so on.119

Tom McBride, Director of Evidence at the Foundation, additionally told us that “there needs to be a bringing together of that agenda across those Departments to focus on early intervention and vulnerability in a much more coherent way”, such as through “an inter-ministerial group; it could involve a strategy on vulnerability and early intervention that starts to join up this disparate agenda”.120

38.These views corresponded with an apparent confusion of responsibilities in Government. Nadhim Zahawi MP, Parliamentary Under-Secretary of State for Children and Families, told us that “as the children’s Minister, I take the lead on [early] intervention” for children.121 However, Professor Viv Bennett, Chief Nurse at Public Health England, told us that “it was agreed that Public Health England would take the lead in bringing together the cross-Government and national [oversight of] local work on early years, including early intervention”, adding that one of its aims was to “reduce the plethora of separate policy initiatives” in this space.122 The Government does, however, seem to be aware of the problem. It has recently announced the formation of a cross-Government working group to review the support available to families from the period around childbirth to the age of two.123 One of the main aims of this group is to “make recommendations on how co-ordination across Departments can be improved”. Both the Children and Families Minister and Mental Health and Inequalities Minister additionally told us that collaboration between their Government departments “is getting better”.124

39.The national policy on childhood adversity and early intervention in England was contrasted with the situation in the devolved nations. In 2017, the Scottish Government stated that it would “embed a focus on preventing ACEs and supporting the resilience of children and adults in overcoming early life adversity across all areas of public service, including education, health, justice and social work”.125 The Welsh Government similarly listed ‘early years’, ‘social care’ and ‘mental health’ as three of the five priority areas in their national strategy to 2021, and emphasised that early intervention was an important element of tackling each of them.126 The public health authorities in Scotland and Wales have also made ACEs a priority and each established an ACEs ‘Hub’ to co-ordinate action on this front.127 We heard repeatedly that England would benefit from a similar policy focus.128 For example, Dr Marc Bush, Chief Policy Advisor at YoungMinds, told us:

Scotland and Wales are not perfect, but their national leadership on the issue and also their want for local ambition, to address it on a population and individual level, is the kind of ambition that we need to see coming through to England as well.129

Monitoring the provision of early intervention

40.In addition to providing national strategy and guidance, there is a role for Government to play in monitoring what local authorities are doing to fulfil their early help responsibilities and in holding them to account. However, the Early Intervention Foundation told us that “there is not any reliable information about the extent to which evidence-based interventions are used and taken up by local authorities and partners”.130 Mark Davies, Director of Population Health at the Department of Health and Social Care, accepted that this was a “fair challenge”, saying that although “the Early Intervention Foundation has given us good information about what works […] we have not looked systematically at how that is applied”.131 The Children’s Minister agreed that ultimately the Government did not have “enough evidence that, at local authority level, we are delivering value for money and the right interventions”.132

41.The Mental Health and Inequalities Minister told us that the Government saw Public Health England “as our method of trying to ensure that we are spreading good practice and holding local areas to account for the responsibilities that we are giving them”.133 However, Public Health England described their main roles to us as “supporting local authorities [in meeting] their responsibilities to commission the Healthy Child Programme locally” and in “providing data and evidence on alcohol and drug harm to support policy making and local commissioners and which will contribute to reducing Adverse Childhood Experience (ACE) risk factors for adults and children”.134 Mr Davies told us that Public Health England collated “very good data on outcomes”, but accepted that there was not a “consistent approach to collecting information [on the extent to which different local authorities use evidence-based interventions]”.135

42.Local authority children’s services are inspected by Ofsted, whose evaluation criteria have included the provision of early help since 2012.136 Most local authorities are inspected approximately every three years, although those that have been judged ‘inadequate’ are inspected more frequently. Local authorities additionally share an annual self-evaluation of the quality and impact of their social work with Ofsted. However, a 2015 ‘thematic inspection’ of early help, undertaken by Ofsted, reported that “the current approach to quality assuring and monitoring the effectiveness of early help is disparate, disjointed and significantly underdeveloped”:137

Local authorities and their partners were not fully evaluating the impact of their early help work. The majority of their audits focused too much on process and compliance and not enough on the quality of the service and the extent to which it helped improve children’s lives. Many partnerships had not yet developed systems to evaluate whether the right children were receiving early help at the right time.138

The current state of early intervention services

43.The localised approach to early intervention, combined with this lack of national guidance and oversight, appears to have led to variable practice and outcomes across the country.139 We heard anecdotal evidence of local authorities delivering interventions later than would be optimal, and providing programmes that were not based on the latest evidence. For example, the Early Intervention Foundation told us that through their work, they had encountered “lots of examples where we see a gap between what we know from robust, peer-reviewed literature and what happens in local services and systems”.140 Ofsted’s 2015 thematic inspection of early help found that “opportunities to intervene earlier were missed in over 40% of the cases” they had reviewed.141 Ofsted concluded that, despite local authorities and their partners placing increasing priority on early help, and children consequently “benefiting from better focused and co-ordinated support earlier […] the quality and effectiveness of early help services […] remains too variable both between areas and within the same services”.142 Dr Caroline White, Head of the Children and Parents Service in Manchester, told us that even where local authorities were trying to provide evidence-based early intervention, the programmes were often not delivered as originally designed.143 This risks hindering the effectiveness of those programmes, and undermining the apparent case for early intervention in general.

44.The Government did not dispute that there was significant variability between different local authorities’ approaches to early intervention, with both Ministers acknowledging variability.144 For example, the Children and Families Minister admitted that:

If you take two neighbouring local authorities with a very similar demographic and very similar funding, you may find that one has much better outcomes for children’s services than the other.145

45.Whilst there is evidence of good practice in some local authority areas in England, there is no clear, overarching national strategy from the UK Government targeting childhood adversity and early intervention as an effective approach to address it. Nor does there seem to be effective oversight mechanisms for the Government or others to monitor what local authorities are doing. This has led to a fragmented and highly variable approach to early intervention across England, with evidence of a significant gap between what the latest evidence suggests constitutes best practice and what is actually delivered by many authorities. Where local authorities are not providing early intervention based on the best available evidence, vulnerable children are being failed.

46.There is now a pressing need for a fundamental shift in the Government’s approach to early intervention targeting childhood adversity and trauma. The Government should match the ambition of the Scottish and Welsh Governments, and build on the example set by certain English councils, to make early intervention and childhood adversity a priority, and set out a clear, new national strategy by the end of this Parliamentary session to empower and encourage local authorities to deliver effective, sustainable, evidence-based early intervention.

47.The Government should ensure that it has better oversight of the provision of early intervention around the country, so that it can identify approaches that are working well, detect local authorities in need of support and hold local authorities to account. It should determine what information is needed to be able to assess the local provision of early intervention and set out a framework as part of the new national strategy that ensures that all local authorities will provide such information, with as little disruption to their working practice as possible.

48.Co-ordination between the different Government departments whose areas of responsibility relate to childhood adversity or problems associated with this could be improved. We welcome the formation of the new ministerial group working to improve family support for those with young children. This group should: make tackling childhood adversity a focus of its work; improve cross-Government co-ordination on this issue; and ensure that there is clear accountability for driving this agenda across all Government departments.

National Programmes

49.Despite there being no overarching national strategy on childhood adversity and early intervention in England, there are nevertheless a range of specific programmes targeting different aspects of early years development, children’s social care or childhood adversity and trauma. We discuss the most relevant of these below.

The Healthy Child Programme

50.The Healthy Child Programme comprises screening tests, immunisations, developmental reviews, and information and guidance to support parenting and healthy choices. It has two strands—one for pregnancy through to age 4,146 and one for children aged 5–18.147 The programme uses a ‘progressive universalism’ model, with all families receiving basic elements of the programme and additional services being provided to those with specific needs and risks. A key component of the 0–5 years strand is a series of health and development reviews for each family, conducted at set periods. A 2015 statutory instrument mandated local authorities to provide five ‘health visitor reviews’ to all families within their area, during set periods in a child’s development:

This duty was initially due to last until March 2017, but following a review by Public Health England,149 it was extended indefinitely.150 Public Health England told us that the Healthy Child Programme was the “foundation of public health services for children and families”,151 and the Programme guidelines stated that it was “a core programme for delivering national priorities and statutory responsibilities on local partnerships”.152 Public Health England’s 2016 review of the mandatory service reported that:

Local authority colleagues highlight the fact that safeguarding all children is a defined responsibility and without this service it is possible for children not to be seen by any professional until they start school or not at all if they are home educated.153

The Institute of Health Visiting similarly told us that “home visiting and needs assessment are key to the identification of ACEs in families that would not access other services and that cannot be targeted because they are (otherwise) unknown”.154

51.Despite the importance of the Healthy Child Programme reaching all children, the most recent data published by Public Health England showed that—other than for the neonatal check—only around 80% of children were receiving the visits required.155 Professor Viv Bennett, Chief Nurse at Public Health England, told us that Public Health England did not currently have the data necessary to be able to characterise those who did not receive the checks.156 Jackie Doyle-Price MP, Parliamentary Under-Secretary of State for Mental Health and Inequalities, told us that the Government was “quite clear” that all children should receive the mandated health visits, but that:

There is a judgment as to how far we should worry if they do not happen. The fact that areas such as Blackpool and Thurrock, which have higher deprivation than their neighbours, are achieving better, is a good indication that the resourcing is happening. But we should never be complacent.157

However, ACEs do not necessarily occur in deprived areas. Indeed, the Institute of Health Visiting noted that:

Proportionately [ACEs] occur to a greater extent in the section of society not normally classed as being vulnerable as, although more diluted, the number of children in this cohort is significantly larger than in the conspicuously vulnerable group.158

52.In addition to problems with the coverage of the mandated health visits, we heard concerns around the number of health visitors and their consequent ability to do their job to the quality required. The National Health Visiting Programme ran from 2011 to 2015 and aimed to increase the number of health visitors by 4,200.159 This was in response to falling numbers between 2004 and 2010, and an acknowledgment by the Department of Health and Social Care that “in too many areas, there are just not enough health visitors to offer all families the support they need”.160 The exact number of health visitors currently is unknown, as data is no longer collected centrally for all health visitors. However, NHS workforce data—which does not include health visitors commissioned by private providers—recorded 8,205 health visitors in February 2018, compared to a peak of 10,309 in October 2015 (a roughly 20% reduction) and 8,092 in May 2010 (prior to the national health visiting programme).161 Professor Bennett acknowledged that “the peak of health visitor numbers in this country was clearly at the end of the national health visiting programme”.162 Dr Jeanelle de Gruchy, President of the Association of Directors of Public Health, clarified that “recruitment and retention is such that we have vacancies and we struggle to fill them for a range of reasons” and added that “the focus that has been brought to bear [on the health visitor workforce] has been really helpful, but it is about sustaining that”.163

53.The decline in health visitor numbers appears to be stretching the workforce thin. The Institute of Health Visiting’s 2017 survey of English health visitors found that one in five health visitors had caseloads of over 500 children,164 compared to the maximum of 333 children targeted by the Department of Health and Social Care,165 and double the 250 children recommended by the Institute themselves.166 The survey also found that one in three English health visitors worried that their capacity was “so stretched that there may be a tragedy in their area at some point”.167 Professor Bennett stated that “if you reduce a workforce, it will have an impact on the level of service being delivered”, but explained that “the impact on the mandated elements of service is, anecdotally, less than the non-mandated elements”.168 In this context, the Institute of Health Visiting warned against prioritising 100% coverage of the mandated health visits without consideration of the impact on the quality of health visits that could be delivered.169 Jackie Doyle-Price MP, Parliamentary Under-Secretary of State for Mental Health and Inequalities, noted the “massive increase in investment” in health visitors between 2011 and 2015 and suggested that “shakeout” from that investment could have caused some drop in numbers.170 She nevertheless asserted that:

I am not complacent, because I really do view the health-visiting workforce as being absolutely crucial in getting intervention right between nought and five.171

The Minister did not, however, outline any strategy or action the Government was pursuing to increase or sustain the number of health visitors, or ensure that workloads were manageable.

54.The Healthy Child Programme is the only mechanism in place through which all children in England should receive early years practitioner support before the age of five. Its coverage is therefore critical for identifying ACEs and other child development issues early. The Government should review the current provision of the Healthy Child Programme across England and set out, as part of the new national strategy, a date for achieving complete coverage in the number of children who receive all five mandated health visits. Given existing workforce pressures, the Government must ensure that this required increase in coverage does not negatively impact the quality of health visits. It should consult the Institute of Health Visiting on how this can be managed, and be ready to recruit additional health visitors as required.

The Family Nurse Partnership

55.The Family Nurse Partnership (FNP) offers a schedule of structured home visits by registered nurses, from early pregnancy until the child reaches the age of two.172 It is commissioned by local authorities,173 and in those local authorities that offer it, FNP nurses can deliver the mandated elements of the Healthy Child Programme as part of their service.174 Enrolment and participation is voluntary, and open to women who are:

Ailsa Swarbrick, Director of the FNP National Unit, outlined the aims of the programme:

The aim is to improve the mother’s pregnancy outcomes, the child’s wellbeing, health and development as it grows to two and in the long term, and the mother’s own long-term health and wellbeing—for example, going back into employment.176

In 2017, FNP was offered in over 80 (of the 152) local authorities in England and worked with over 10,000 children.177 On average, families receive around ten visits per year—in 2016 the average incremental cost for a place on the FNP (above usual care) was estimated to be between £1,993 and £4,670 a year.178

56.The Department of Health and Social Care commissioned a major study of the impact of the Family Nurse Partnership, which was published in 2016.179 Using a randomised controlled trial of 1,430 women, the study found “no evidence of benefit from FNP for smoking cessation, birthweight, rates of second pregnancies, and emergency hospital visits for the child”, and concluded that:

Continued provision of the Family Nurse Partnership programme cannot be supported on the basis of the trial evidence found for its effectiveness in the UK setting. Subsequent changes to the intervention itself, to [the care that is] usually provided , or to the population targeted would justify re-examination. Similarly, any positive benefits observed through longer-term follow-up of the current trial cohort might shift the evidentiary balance in favour of the intervention and warrants continued evaluation of the trial cohort.180

The study did, however, report that “some secondary outcomes suggested small positive impacts of the FNP”. These included:

The negative conclusions of the study were in contrast to previous studies of partner programmes in other countries.181 Accounting for the difference in impact found in the USA and the UK, the authors of the British study noted that:

Unlike women in the US settings in which the intervention originated, teenage mothers in England can access many statutory supportive health and social services, including community based family doctors, midwives, and public-health nurses, and, in most trial sites, specialist teenage pregnancy midwives.182

They suggested that this level of care available to mothers who did not receive FNP support might have diluted any relative benefits of the programme.

57.Many commentators have cautioned against responding too decisively to the findings of the UK study.183 Jason Strelitz, Assistant Director of Public Health for the London Boroughs of Camden and Islington, has said that although the results of the study should form the basis for future discussion and scrutiny of the FNP, the primary outcomes measured by the study did not match the aims of the Family Nurse Partnership as much as the secondary outcomes (which recorded small positive outcomes). He also noted that the evaluation started not long after the Family Nurse Partnership programme had started, and therefore potentially before its delivery had been fully developed.184 Professor Melhuish similarly told us that there “was a fundamental mistake that was made at the Department of Health in choosing which outcomes were critical in the randomised control trial”.185 He noted that a similar study conducted in the Netherlands with different outcomes found “entirely positive results”. Based on the British and international evidence, the Early Intervention Foundation continues to list the FNP as one of three early intervention programmes with the strongest evidence of effectiveness.186 Ailsa Swarbrick, Director of the FNP National Unit, told us:

The trial was disappointing, obviously. FNP is a very complex programme […] It is therefore very difficult to measure it absolutely and to say, ‘This has passed’, or, ‘This has failed’. Your view of it depends very much on what outcomes you choose and the point in time at which you measure it.187

Ms Swarbrick added that the FNP National Unit had introduced a “significant and ambitious improvement programme” to learn from, and act upon, the study findings.188

58.Asked for the Government’s interpretation of the study’s findings and how widely it would like to see FNP used across England, the Parliamentary Under-Secretary of State for Mental Health and Inequalities told us that the Family Nurse Partnership was an “important aspect” of the Healthy Child Programme but that ultimately its use “comes down to local commissioning”.189

59.There appears to be significant concern within the early years community at the outcomes for assessment chosen by the then Department of Health for the major study it commissioned of the Family Nurse Partnership. We therefore do not encourage national or local Government to act upon the study’s overall recommendation to discontinue provision of the Family Nurse Partnership. Nevertheless, the study’s findings should be considered and where they can be used, to improve the impact of the Family Nurse Partnership programme such action should be pursued. We commend the Family Nurse Partnership National Unit for implementing its ‘ADAPT’ initiative to learn from the study’s findings, and we urge local commissioners and providers to act upon the conclusions reached by this initiative.

60.Although we commend the Government on its willingness to commission a significant study of the effectiveness of the Family Nurse Partnership, such studies are only of value if their findings are widely supported and acted upon. The provision of evidence-based early interventions will clearly benefit from studies that can provide a strong evidence base. If the Government commissions future major studies of significant early intervention programmes—which we would welcome—it must ensure that the outcomes it decides are to be assessed, and other elements of the design of such studies, are supported by the early years practitioner community. The Government must then act upon the evidence generated by those studies.

Sure Start children’s centres

61.The Sure Start programme started in 1998 and has evolved considerably since then.190 Sure Start children’s centres currently provide or co-ordinate a variety of early years services (such as education, childcare, health services, social services and information, advice and training), based around a broadly-defined ‘core purpose’ to improve child and family outcomes and reduce inequalities in child development, parenting, health and life chances.191 A national evaluation of Sure Start found in 2012 that Sure Start local programmes had beneficial effects on family functioning and maternal wellbeing, but not on child outcomes at age seven.192 Professor Edward Melhuish, who led the national evaluation study, told us that changing formats and funding over the life of the Sure Start programme had led to varied success, but said that “the children’s centre model can work, when it is done properly” and indicated that the model for effective centres was known.193 He endorsed the House of Commons Education Committee’s 2013 Report on Sure Start,194 which recommended a more detailed core purpose, better evaluation and more focused delivery to those most in need.195 Instead, he told us that the Report “has just been sitting on the shelf somewhere” and that the children’s centre approach “has been left to wither on the vine, by and large, by central Government”.196

62.After initially intending to target Sure Start children’s centres in the most disadvantaged communities,197 the then Government decided in 2004 that there should be one in every community in England.198 However, after a peak of 3,632 centres in 2009, the number of centres has since fallen.199 The Sutton Trust estimated that at least 14% of children’s centres closed between August 2009 and October 2017, with closures concentrated in certain areas but equally distributed between more and less-deprived communities.200 It also reported that the children’s centres that remained open offered fewer services and had shorter opening times. Martin Pratt, Chair of the Association of London Directors of Children’s Services, attributed these closures to limited available funding and told us that they should not be interpreted as “a loss of faith in the model but simply as the prioritisation of a shrinking resource”.201 The Sutton Trust similarly reported local authorities citing financial pressures as the principal driver of reduced services, just ahead of changing strategies and priorities.202 The Children’s Minister, Nadhim Zahawi MP, told us that he wanted to focus on outcomes rather than “obsess about bricks and mortar”,203 and suggested that some local authorities had achieved more by investing in direct outreach programmes instead of infrastructure.204 The Minister added that children’s centres would be reviewed as part of the Government’s social mobility action plan, to identify good practice.205

63.The Government first announced that it would review children’s centres in 2015, with a proposed consultation on the future of Sure Start children’s centres.206 The same year, it also suspended Ofsted’s regular inspections of children’s centres “on a short term basis” to await the results of the consultation;207 this suspension was reconfirmed this January (registered early years provision within children’s centres continues to be inspected as part of the Common Inspection Framework).208 The consultation on the future for Sure Start children’s centres has still not been launched. The Minister declined to give us a date for the launch of the consultation,209 and later suggested that it might not happen at all:

The [Early Years Social Mobility Peer Review Programme] will spread best practice and help councils looking to close the gap between disadvantaged children and their peers. This will inform the next steps in our strategy to close the development gap, including considering any future consultation on the role of children’s centres.210

Martin Pratt told us that London councils wanted to see the consultation happen “so that we can be clear about the position Sure Start centres have in national policy going forward”.211

64.The delay in launching a consultation on the future of Sure Start Centres is regrettable and has meant that Ofsted has not inspected children’s centres since 2015. Local authorities have been left unsure of the status of children’s centres in future policy. The Government should clarify its position on Sure Start centres. In response to this Report, it should specify if—and when—it intends to hold a consultation. If it intends to proceed with a consultation, this should be held within three months. The Government should also set out the focus and purpose of such a consultation. If a consultation is not going to be held, the Government must urgently reinstate Ofsted inspections of children’s centres and make clear its thinking on the role and value of children’s centres.

The children and young people’s mental health green paper

65.The Department of Health and Social Care and the Department for Education jointly published a green paper outlining the Government’s strategy for “transforming children and young people’s mental health provision” in December 2017.212 The paper acknowledged the “emerging evidence that Adverse Childhood Experiences in infancy may have negative impacts on future mental health and wellbeing outcomes”, and put forward a number of ways in which the Government intended to address this issue, such as:

However, the main focus of the green paper’s proposals related to delivering mental health support through schools and colleges. The Centre for Mental Health, a mental health charity, expressed its concern to us that “the green paper is limited in its focus on prevention and early intervention”.214 Dr Marc Bush, Chief Policy Adviser at YoungMinds, flagged similar “obvious gaps” in the paper:

One is around the early years, where there can be good-quality early intervention […] Does [the green paper] carry the level of ambition and make [childhood adversity and trauma] a national priority, with a public health priority and a commitment to co-ordinated commissioning across the board? No. Do we think that that should be there? Yes.215

Kate Stanley, Director of Strategy, Policy and Evidence at the NSPCC, told us that the green paper lacked ambition, describing it as “meek overall”.216

66.The House of Commons Education Committee and Health and Social Care Committee heard similar evidence during their joint inquiry into the Green Paper, and recommended that the Government should “place a greater emphasis on, and provide a strategy for, prevention, early intervention and dealing with some of the root causes of child mental health problems”.217 In its response to the Committees’ Report,218 the Government outlined a variety of measures it was taking to address prevention and early intervention but these still mostly relate to training for school teachers or pupils (including the establishment of Public Health England’s Special Interest Group, whose findings “will feed into the prevention work that is supported in schools”219). The Prevention Concordat on Mental Health that the Government also referred to provides no focus on childhood adversity.220 Respondents to the consultation launched by the Green Paper also recommended broadening its remit to include support during the early years, but in its response to the consultation the Government simply committed to “considering further analysis” in areas such as low-stress pregnancy, perinatal mental health and healthy childhood.221

67.Overall, Jackie Doyle-Price MP, Parliamentary Under-Secretary of State for Mental Health and Inequalities, acknowledged that:

If you look at the statistics, there is a good chance that, if there is a contributor to poor mental health, it will come in the first five years, within traumatic environments and so on. That is why I am very keen to see what else we can do in that nought-to-five space. You are right that it is not a big feature of the Green Paper, but the important thing about the Green Paper is that, finally, we have broken down the silo between our two Departments.222

68.We welcome Minister Doyle-Price’s ambition to do more in this area. However, there was a disappointing level of ambition and focus on pre-school aged children in the Government’s 2017 Green Paper on ‘transforming children and young people’s mental health provision’. As it develops its action on children and young people’s mental health, the Government should recognise the importance of child development and the impact of adversity in the early years, and ensure that it adopts ‘transformative’ ambitions and policies for pre-school aged children alongside its work targeting schools and colleges.

69.In keeping with the early intervention ethos, one strategy for improving mental health in schools is through ‘social and emotional learning’. This aims to promote children’s social and emotional competency from the outset, instead of seeking to identify emerging problems as soon as possible. The Education Endowment Foundation has said that “on average, social and emotional learning interventions have an identifiable and valuable impact on attitudes to learning and social relationships in school”, with evidence of positive impact in early years, primary and secondary school settings, and particular benefit for disadvantaged or low-attaining pupils.223 However, this approach was not an area of focus in the Government’s green paper. Indeed, the Centre for Mental Health told us:

It is also disappointing that the green paper dismisses Social and Emotional Learning programmes despite the strong evidence of their benefits. Classroom based programmes that seek to build resilience and wellbeing are among the few examples of universal mental health promotion programmes that have been shown to be cost-effective over time.224

70.Prevention of mental health problems can start before signs of low mental wellbeing start to appear, through promotion of healthy mental wellbeing to all children. The Government should set a policy for primary and secondary schools that seeks to promote wellbeing as well as improving the early identification of, and support for, emerging problems.

Other programmes

71.The Government administers other programmes and strategies that affect early years children or their families. The most prominent examples of these are outlined in Table 1, along with an assessment of how directly they address childhood adversity or trauma.

Table 1: Other early years programmes



Relation to childhood adversity and trauma

Children’s Social Care Innovation Programme

The Children’s Social Care Innovation programme aims to “support local efforts to transform services for the most vulnerable children by providing tailored funding and professional support to innovative projects”,225 and will see £200m invested into 98 projects by 2020.226 Alongside the Innovation Programme, there is a ‘Partners in Practice’ scheme that tasks leading local authorities with:

• continuing to demonstrate what works and drive innovation to build understanding of the conditions needed for excellent practice to flourish;

• driving sector-led improvement through peer support to authorities who need to improve; and

• supporting the Department for Education to shape and test policy on wider programmes and reforms.227

The final wave of the programme to 2020 is focusing on four policy areas “where there is a need to quickly develop and test new approaches”;228 all of these relate to children who have already received some form of statutory support and hence fall outside of our focus on early intervention to address childhood adversity and trauma.229

The Troubled Families Programme

The Troubled Families Programme has run since 2012, with a second phase starting in 2015. Under the programme, local authorities are asked to identify and support families with multiple problems (at least two of six defined problems, including domestic abuse, physical or mental health problems and having children in need),230 and can claim funding if the family achieves “significant and sustained progress” against all identified problems or if an adult in the family moves into continuous employment.231 The Children’s Minister told us that 40% of the 400,000 families involved in the programme have a child under the age of five, and that they present with “all sorts of different traumas and problems”.232 The Early Intervention Foundation described the programme as “an important vehicle for reaching vulnerable families who may be at risk of exposing children to adverse experiences”.233

The Government said in 2017 that it would use the next phase of the programme to “encourage a greater emphasis on tackling worklessness and issues associated with it”.234 Although it went on to say that “this will be done without diminishing the other vital work the programme does across the many other problems that families experience”,235 the Government’s latest report to Parliament on the programme re-iterated that it “will be encouraging local authorities to prioritise families experiencing worklessness”.236 The Kidstime Foundation and the Children’s Society told us that this new prioritisation “does not make it easy for the programme to adequately address ACEs and improve long term outcomes for future generations”.237

Social Mobility Plan

The Government announced a new strategy to improve social mobility in 2017, with £800m funding to “deliver equality of opportunity for every child, regardless of where they live”.238

The strategy set out ambitions for the four key life stages of people’s education, including “closing the ‘word gap’ in the early years”.239 It highlighted the importance of the early years in the development of “strong cognitive, social and emotional foundations on which future success is built”, and proposed a range of measures intended to improve early years literacy and communication.240

Despite the importance of the announced measures to improve early years education and reduce inequality, it is clear that the social mobility strategy is focused on educational attainment, and does not directly relate to early years adversity or trauma.

72.In addition to these programmes, all three and four-year-olds in England are currently able to receive 570 hours a year of Government-funded childcare or early years education, commonly taken as 15 hours per week for 38 weeks.241Parents who are in work and earning at least the National Minimum Wage for 16 hours a week qualify for 570 further hours per year.242 Some two-year-olds also qualify for 570 hours of childcare or early years education, these are typically children whose parents are receiving certain benefits.243 Professor Melhuish told us that the childcare offer for two-year-olds had achieved “positive results”,244 but that “the Government are missing a trick” in its deployment by not being more prescriptive of the childcare or education provided. He explained that:

The two-year-old offer is targeting the 40% most disadvantaged families in the country […] You have a ready-made audience for a range of strategies for improving children’s development. At the moment, all that [the Government] are doing is paying for this provision, regardless of what it is. There is no specification of what it should be, apart from the rules that Ofsted lays down.245

73.There are a variety of programmes beyond the Healthy Child Programme, the Family Nurse Partnership and the Sure Start initiative that reach children who are experiencing or have experienced adversity and trauma. However, none of these programmes specifically target these children and they do not prioritise preventing ACEs or mitigating their effect. This reinforces the need for the Government to develop a new national strategy specifically focusing on childhood adversity and trauma, and on evidence-based early intervention initiatives that can address these issues.

74.There is an opportunity for the Government to increase the provision of evidence-based early years programmes, without increased cost, by setting more prescriptive specifications on the content of childcare eligible for Government funding. The Government should work with researchers and practitioners to examine how new specifications on the free childcare it funds could increase the use of evidence-based programmes, and what the impact would be on the families affected. Such specifications could rapidly increase the number of families receiving evidence-based programmes and we call on the Government to review this by the end of this Parliamentary session, although local providers should be given a period of time to adjust to any new specifications.

105 ‘Early Intervention’, Briefing Paper 7647, House of Commons Library (2017)

106 Ministry of Housing, Communities and Local Government, ‘Review of local government statutory duties: summary of responses’, accessed 9 May 2018

107 For example, the Children Act 1989, section 17 and section 47, the Children Act 2004, sections 9, 10 and 11, the Childcare Act 2006, sections 1, 2, 3 and 4 and the Health and Social Care Act, section 12

109 Q384

110 Q244

111 Q289

112 Q378

113 Q381

114 For example, the Minister referred to funding for early language and literacy initiatives, the social mobility action plan and the Troubled Families Programme—Qq379 and 381–384

115 Q378

116 Q380

117 Association of Directors of Public Health (EYI0031)

118 Q311

119 Q207

120 Q206

121 Q386

122 Q309

124 Q385

126 Welsh Government, ‘Prosperity for All: The National Strategy’ (2017), p4

127Adverse Childhood Experiences’, NHS Health Scotland, and ‘Hub to tackle Adverse Childhood Experiences’, Welsh Government, both accessed 18 July 2018

128 Q88, Q98, Q185 and Association of Directors of Public Health (EYI0031)

129 Q88

130 Q175

131 Q388

132 Q389

133 Q384

134 Public Health England (EYI0033)

135 Q388

137 Ofsted, ‘Early Help: Whose Responsibility?’ (2015), p23

138 Ofsted, ‘Early Help: Whose Responsibility?’ (2015), p5

139 See, for example, The British Psychological Society (EYI0069), p11 and Qq176 and Q216

140 Q175

141 Ofsted, ‘Early Help: Whose Responsibility?’ (2015), p14

142 Ofsted, ‘Early Help: Whose Responsibility?’ (2015), pp28–29

143 Q226

144 Qq384, 390 and 412

145 Q412

147 Department of Health, ‘Healthy Child Programme: From 5–19 years old’ (2009)

148 The Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) and Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) (Amendment) Regulations 2015 (SI 2015/921)

150 The Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) (Amendment) Regulations 2017 (SI 2017/505)

151 Public Health England (EYI0033)

153 Public Health England, ‘Review of mandation for the universal health visiting service’ (2016), p32

154 Institute of Health Visiting (EYI0107)

156 Q319

157 Q438

158 Institute of Health Visiting (EYI0107)

159 Department of Health, ‘Health Visitor Implementation Plan 2011–15’ (2011)

160 Department of Health, ‘Health Visitor Implementation Plan 2011–15’ (2011), p8

162 Q332

163 Q332

168 Q332

169 The Institute of Health Visiting told us that “the translation of the mandation of the five reviews into key performance indicators as measures of service performance can have distorting effects that can subvert the intentions of the Healthy Child Programme” and that “to be effective health visitors need to know the families they look after, the current contact rather than outcome driven culture has rendered this impossible”—Institute of Health Visiting (EYI0107)

170 Q439

171 Q439

172 Department of Health, ‘The Family Nurse Partnership Programme’ (2012)

173 Q151

175 Department of Health, ‘The Family Nurse Partnership Programme’ (2012), p5

176 Q102

177 Q102; In two-tier local council systems, the county councils hold responsibility for public health which leads to the figure of 152 cited here—see ‘The new public health role of local authorities’, Department of Health and ‘Local government structure and elections’, Ministry of Housing, Communities & Local Government, both accessed 11 September 2018

181 These results came from studies in New York, Tennessee and Colorado, USA, and the Netherlands. Full details can be found in the Family Nurse Partnership entry in the Early Intervention Foundation Guidebook.

183 For example, see Qq109–110 and 205

184The FNP evaluation: Inconvenient truth or a bump in the road?’, Early Intervention Foundation, accessed 21 June 2018

185 Q109

186Early Intervention Foundation Guidebook’, Early Intervention Foundation, accessed 21 June 2018

187 Q115

188 Q103; see also Family Nurse Partnership National Unit, ‘FNP ADAPT Interim Report’ (2018)

189 Q440

190 ‘Sure Start (England)’, Briefing Paper 7257, House of Commons Library (2017)

191 Department for Education, ‘Sure Start children’s centres statutory guidance’ (2013), pp 6–7

193 Qq113–114

194 Q114

195 Education Committee, Fifth Report of Session 2013–2014, ‘Foundation Years: Sure Start children’s centres’, HC 364-I

196 Q114

197 HC Deb, 20 January 1999, cols 501–502W

198 This amounts to 3,500 Children’s Centres in total—HM Treasury, ‘Choice for parents, the best start for children: a ten year strategy for childcare’ (2004), para 5.10

201 Q284

203 Q458

204 Q384

205 Q459–462

206 Nursery World, ‘Exclusive: Gyimah launches children’s centre consultation’, accessed 4 June 2018

207 Letter from Sam Gyimah MP to Sir Michael Wilshaw, dated 25 September 2015, accessed 4 June 2018

208 PQ 124199 [on Children’s Centres: Inspections], 22 January 2018

209 Qq459–464

210 Department of Health and Social Care and Department for Education (EYI0109)

211 Q288

212 Department of Health and Department for Education, ‘Transforming Children and Young People’s Mental Health Provision: a Green Paper’ (2017)

213 Department of Health and Department for Education, ‘Transforming Children and Young People’s Mental Health Provision: a Green Paper’ (2017), paras 12, 97, 118 and 124

214 Centre for Mental Health (EYI0050)

215 Q90

216 Q90

217 Education Committee and Health and Social Care Committee, First Joint Report of Session 2017–19, ‘The Government’s Green Paper on mental health: failing a generation’, HC 642, paras 26 and 42–46

218 Department of Health and Social Care and Department for Education, ‘Government Response to the First Joint Report of the Education and Health and Social Care Committees of Session 2017–19’ (2018), pp 11–13

219 Department of Health and Social Care and Department for Education, ‘Government Response to the Consultation on Transforming Children and Young People’s Mental Health Provision: a Green Paper and Next Steps’ (2018), p35; the Mental Health Support Teams that will carry out this work will all be linked to groups of primary and secondary schools and to colleges

221 Department of Health and Social Care and Department for Education, ‘Government Response to the Consultation on Transforming Children and Young People’s Mental Health Provision: a Green Paper and Next Steps’ (2018), pp 14–15

222 Q452

223Social and emotional learning’, Education Endowment Foundation, accessed 30 August 2018

224 Centre for Mental Health (EYI0050)

226The Children’s Social Care Innovation Programme’, Spring Consortium, accessed 25 June 2018

227Partners in Practice’, Spring Consortium, accessed 25 June 2018

228The Children’s Social Care Innovation Programme’, Spring Consortium, accessed 25 June 2018

229 Department for Education briefs: ‘Staying Close’; ‘Testing the use of social investment to improve outcomes for care leavers’; ‘Alternative delivery models’; and ‘Targeted Support’, accessed 25 June 2018

230 Department for Communities and Local Government, ‘Financial’framework for the troubled families programme’ (2018), p18

231 Department for Communities and Local Government, ‘Financial’framework for the troubled families programme’ (2018), p24

232 Q379

233 Early Intervention Foundation, para 26; The Foundation cautioned that "much of the focus [of the Troubled Families Programme] to date has been on making the system work for complex families rather than expanding the availability of evidence-based provision", but suggested that "this may now be changing". ‘(EYI0061)’

234 Department for Work and Pensions, ‘Improving Lives: Helping Working Families authorities’ (2017), p49

235 Department for Work and Pensions, ‘Improving Lives: Helping Working Families authorities’ (2017), p49

236 Department for Communities and Local Government, ‘'Supporting disadvantaged families—Troubled Families Programme 2015–2020: progress so far' (2017), p24

237 Kidstime Foundation and the Children’s Society, ‘(EYI0082) para 32

238Plan to boost social mobility through education'’, Government Digital Service, accessed 18 July 2018

241Help paying for childcare’, Government Digital Service, accessed 26 June 2018

242 ‘The Government made clear that this extended entitlement to childcare for 3- and 4-year-olds is “primarily a work incentive” (HC Deb, 25 January 2016, col 58)

243 Help paying for childcare: Free education and childcare for 2-year-olds’, Government Digital Service, accessed 18 July 2018

244 Q141

245 Q145

Published: 14 November 2018