Evidence-based early years intervention Contents

5A new national strategy

108.In Chapter 3, we recommended that the Government should draw up a new national strategy for evidence-based early intervention aimed at addressing childhood adversity and trauma. Drawing upon the evidence we have heard for what makes early intervention successful, and the challenges local authorities faces in delivering effective early intervention, we outline here what such a national strategy should include. The overall aim of the national strategy should be to ensure that the provision of early years intervention is available everywhere as required and that all interventions are evidence-based.

109.During the course of our inquiry, we encountered examples of successful early intervention services and ongoing efforts to develop ‘trauma-informed’ services across local communities (see Box 1). The new national strategy should aim to learn from these efforts and replicate these and other initiatives, where local success can be demonstrated.

Box 1: Model examples of early intervention services

The Children and Parents Service, Manchester

The Children and Parents Service (CAPS) in Manchester has been identified by the National Institute for Health and Care Excellence as a service that has achieved success in recognising and managing antisocial behaviour and conduct disorders in children and young people.337 CAPS is a jointly commissioned, multi-agency, early intervention service for pre-school children and their families.338 The service identifies early social and emotional problems in pre-school children, provides thorough psychological assessment for them and then offers intervention as appropriate. Families can be initially referred to the CAPS service from multi-agency staff across the early years workforce; CAPS psychologists provide one day training to frontline staff to improve communication across the workforce and establish referral pathways as well as to develop a consistent approach to parent support strategies across the workforce. CAPS also conducts outreach work to raise awareness and engage with local families. Referred families are assessed using the Eyberg Child Behaviour Inventory, the Beck Depression Inventory and the Abidin Parenting Stress Index as standardised and validated outcome tools to measure child behaviour problems, parental depression and parental stress respectively, as well as the ‘Index of Need’ tool to identify families at risk of developing any of these problems.339 Where families meet the thresholds for intervention, CAPS uses the ‘Incredible Years’ Parent Programmes,340 a series of evidence-based interventions which focus on:

  • strengthening parenting competencies to improve the parent-child relationship;
  • promoting children’s academic, emotional and social skills; and
  • reducing conduct problems.

CAPS additionally provides ‘wrap-around’ support to help families complete the courses, such as the provision of childcare or interpreting services, and aims to offer seamless access to other services from which families would benefit.

Between September 2017 and August 2018, CAPS delivered 75 Incredible Years parent courses to approximately 989 parents of 0–4 year olds. The impact of these interventions, as determined by the proportions of families in the clinical ranges for each of the outcome measures before and after the intervention, are shown in Table 2 below.

Table 2: Impact of CAPS intervention on clinical conditions and risk factors

Pre-intervention (%)

Post-intervention (%)

Proportion of families at risk of neglect or abuse*

86

56

Proportion of parents with clinical depression

68

19

Proportion of parents with clinical stress

72

12

Proportion of children with clinical behaviour problems

69

32

* Some risk factors are stable (for example having a parent with a learning disability or giving birth to twins) and so cannot be influenced by an intervention

Source: Children and Parents Service Early Intervention, Manchester

High parent retention rates are achieved by the programme, with around 81% completing it. As well as reducing the prevalence of clinical conditions and the proportion of families at risk of developing clinical problems, the programme was found to also help parents engage in work or education. Three months after completing the course, 24% of parents were back in work, 21% were attending college and 10% were doing voluntary work.

A Better Start Blackpool

During the course of our inquiry, we visited Better Start Blackpool, a multi-agency initiative aiming to develop ‘trauma-informed’ early years services across Blackpool. This involved outreach and training programmes for all professionals in the early years workforce, as well as across the wider community, to raise awareness and understanding of child development and the impact of trauma. Specific interventions were also being delivered, focusing on improving social and emotional development, communication and language, and diet and nutrition for children from conception through to the age of three. Examples of these interventions included:

  • dedicated mental wellbeing support for pregnant women with a history of child abuse and maltreatment;
  • dietary and nutrition advice for overweight mothers during pregnancy;
  • initiatives to encourage fathers to read to their children; and
  • refurbishment of parks combined with ‘park ranger’-led activities to create community garden spaces for use by local families with young children.

A Centre for Early Child Development was established to help co-ordinate the programme and deliver full-system transformation to ensure that families accessing different services encounter a consistent and seamless experience. Better Start Blackpool is a ten-year programme funded by the Big Lottery Fund.

HeadStart Kernow, Cornwall

We also visited Cornwall Council and Tretherras School in Newquay to learn more about the HeadStart Kernow programme, a Big Lottery Fund-supported initiative focusing specifically on adverse childhood experiences. HeadStart Kernow aims to improve the mental resilience of 10 to 16-year olds by giving every local young person access to an ‘emotionally available adult’. The programme provided training for school staff to equip them with conversational and relational tools for directly supporting children with specific mental health problems resulting from childhood adversity. Training was also provided to primary school staff and relevant members of the local medical, police and voluntary sector workforce. Funding had been made available for schools to develop action plans aimed at supporting emotional wellbeing and resilience. A HeadStart Young People’s Board had been set up to allow young people to contribute to the direction of the programme, and research projects focusing on online behaviour and the development of digital resources were also being supported.

Essex County Council Children’s Services

In March 2018, Essex County Council was selected as one of eight local authorities to develop and share good practice in children’s social care as part of the Department for Education’s Partners in Practice Programme.341 The council has reduced its number of children in care from 1,615 in 2010 to 1,055 in 2018, while reducing spending on children’s social care from £148m to £118m. It achieved this through a plan of:

  • developing quality assurance methods (such as team diagnostics, internal inspections and case audit systems);
  • investing in quality training—informed by academics—in strengths-based approaches to relationship practice, for practitioners and managers; and
  • avoiding prescriptive management to instead allow innovative services designed around vulnerable children.

Essex County Council has identified early intervention as a key strand of this success, with initiatives such as a voluntary, family-oriented support service and an intervention service that identifies young people aged 8–17 on the edge of care who have suffered a breakdown in family relationships or who are at risk of custody.

Essex County Council’s Cabinet Member for Children and Families chaired the Local Government Association’s national Children’s Social Care Taskforce, which published a report in 2017 outlining key issues and solutions for children services.342 Of the seven recommendations it made:

  • one called for “stronger investment in early help”;
  • one advocated an evidence-based approach to determining ‘what works’ for children’s services; and
  • one argued that local authorities should monitor outcomes and be held accountable for them, to ensure continuous improvement.

Better use of data

110.The importance of data collection and analysis for assessing the effectiveness of early intervention initiatives and for identifying families who would benefit from early intervention was outlined in paragraphs 83 to 88 of this Report. Challenges to collecting and using data were also identified, including the time it takes frontline practitioners to collect data, obstacles to sharing data between different organisations and practitioners focusing on aspects of their service other than data collection or analysis. The variation in local practice and lack of consistent national measures were also highlighted.

111.Tom McBride, Director of Evidence at the Early Intervention Foundation, acknowledged that it would be unfeasible for local authorities to run high-quality randomised controlled trials to evaluate the impact of their services, but argued that they should nevertheless be collecting and using routine administration data to monitor their impact.343 Matt Buttery, CEO of Triple P UK, told us that this was starting to happen in conjunction with the delivery of the Triple P programme in the USA.344 Martin Pratt told us that local authorities needed measures to be identified that would provide the information needed to be able to assess interventions while being simple to collect and easy to analyse.345

112.The Greater Manchester Combined Authority described the current measure of social and emotional development used at age two—the Ages and Stages Questionnaire (usually referred to as ‘ASQ-3’)346—as “the best evidenced measure to assess the progression of child development from two months to five years”, and advocated extending its use to cover this full period.347 Dr Shirley Woods-Gallagher, Special Advisor on School Readiness for the Greater Manchester Combined Authority, told us that, in combination with measures following Key Stage 1:

[Using ASQ-3 throughout the early years] would enable us to track child development from the age of two months all the way through to the age of 16, using a tracking system, with digitised means of doing that, for the best understanding of domains of child development, potential gap areas and things that we need to do and uplift on.348

Professor Bennett told us that Public Health England was “absolutely committed to using ASQ at two”, and noted that “some areas are already using the ASQ for various other developmental programmes”, but said that she did “not have the evidence to say whether it would be beneficial to make that almost mandatory across the country”.349 She indicated that such evidence could be gathered, but that it would be “quite a big piece of work” that would need to be commissioned by Public Health England or the Department of Health and Social Care.350

113.Social and emotional development is not the only characteristic affected by childhood trauma and adversity, and Dr Woods-Gallagher cautioned that ASQ-3 did not necessarily “give the whole picture”, adding that the Greater Manchester Combined Authority was looking at the “broader information” it also needed to collect.351 Professor Melhuish suggested language development and self-regulation as two attributes that depended upon mother-child attachment and which were critical for future life prospects.352 Dr Caroline White told us that the Children and Parents Service in Manchester used measures of behavioural problems, emotional difficulties and mental health problems in parents as key indicators to assess the success of interventions.353 The Social and Public Health Sciences Unit at the University of Glasgow advocated “inclusion of ACEs measures in routine child health surveillance”.354 Whichever indicators are chosen, Dr White cautioned against the temptation to use free measures instead of the ‘gold standard’ measures used in research, which she said was common but could impact the significance of the data collected.355 We also heard that self-reported measures (where families are asked to assess impacts themselves) should be avoided.356 Better Start Bradford additionally stressed the importance of choosing measures that could be used with families whose first language was not English.357

114.Despite the obstacles that exist, Kate Stanley, Director of Strategy, Policy and Evidence at the NSPCC, indicated that data-sharing could be achieved. She explained that the NSPCC had recently set up a data-sharing agreement between themselves, the council, the NHS Foundation Trust and the police in Blackpool.358 Dr Caroline White similarly told us that her service was now collecting and analysing data from a variety of agencies, but emphasised the importance of stipulating data collection requirements in multi-agency contracts and of appointing a dedicated information analyst, to achieve this.359

115.The Government’s new strategy for adversity-targeted early intervention should include plans to improve the use of data for assessing early intervention and identifying families who could benefit from early intervention, at local and national level. The strategy should promote the value of data collection and analysis by drawing on case studies of local authorities or their partners using data to improve outcomes. It should also set out the general principles of good practice with data collection and analysis, such as collecting baseline data in preparation of assessing a new intervention and avoiding the use of self-reported measures.

116.The new strategy should set out what local authorities should measure to assess their early intervention initiatives or to identify families who could benefit from receiving early intervention support, and give examples of specific data that would capture this. These measures should be identified in consultation with child development experts and local authorities themselves, and cover aspects such as social, emotional and language development from birth through to the start of school. Consideration should be given to the burden of collecting the data and the compatibility of its collection with existing practice. In identifying these measures, the Government should ensure that it seeks opportunities for local authorities to make use of data that they or their partners already collect.

117.The new strategy should also address challenges in data-sharing between different organisations working with young children. It should include guidance to local authorities and their partners on data protection legislation and provide examples of best practice in data sharing, focusing specifically on childhood development, trauma and related early interventions. The Government should additionally consider what infrastructure and licences could facilitate efficient, interoperable data processing by local authorities and assess the cost-benefit of providing funding towards this.

118.Collection of the most important data at a national level would provide central Government with information on the national state of childhood adversity and early intervention, and drive local authorities to ensure the necessary data is collected. Children are not currently assessed with a national measure of child development until the Ages and Stages Questionnaire at age two to two-and-a-half. In addition to ensuring full coverage of the health visits mandated by the Healthy Child Programme, the Government must ensure that the data collected during such visits is reported nationally. It should consult the Institute of Health Visiting and child development experts to determine if the Healthy Child Programme should include assessments of social and emotional development prior to the fifth mandated visit, and if so provide the resources necessary to allow for this.

119.The new adversity-targeted early intervention strategy should also set out measurable objectives for progress on data collection, such as the proportion of local authorities supplying full data from the Healthy Child Programme mandated visits, or the proportion of local authorities identified by Ofsted as delivering sufficiently data-driven early intervention. If data collection and analysis does not consequently improve within two years of the strategy’s implementation, the Government should consider introducing statutory requirements for the reporting of data that can be used to monitor the delivery and impact of early intervention.

Training and assessing the early years workforce

120.Paragraphs 93 to 104 of this Report identified the need for increased awareness, across the early years workforce, of the importance of early years experiences in child development. The need for an improved ability to engage with scientific evidence and data was also flagged, in particular for those in leadership positions.

121.The obvious route to improved awareness and knowledge is through training. Dr Shirley Woods-Gallagher, Special Advisor on School Readiness for the Greater Manchester Combined Authority, flagged that a “twin-track approach” was needed to train those coming into the early years workforce, via pre-qualification training, as well as the existing workforce, through continuing professional development.360 Martin Pratt told us that “there is a strong argument for having a national approach” to training, with “multidisciplinary training, so that different aspects of different professional disciplines are contributing”.361

122.The Government’s new national strategy for adversity-targeted early interventions must include steps to increase the knowledge that professionals across the early years workforce have of: the impact of childhood adversity or trauma and what can be done to remedy this; how to identify those families that could benefit from early intervention; how to access and use relevant, up-to-date scientific evidence; how to make best use of data in offering and delivering early intervention services, and in understanding and evaluating the effectiveness of those services; and child development and the importance of early years experiences. The strategy should identify and define the ‘early intervention workforce’, comprising the full range of professions that engage with young children or their families and that could either: help to identify those who would benefit from early intervention; or would play a role in delivering early intervention services. The Government should then review the pre-qualification training and continuing professional development offered to the different professions in the early intervention workforce and ensure that each covers the different elements outlined above, at a level appropriate to the profession in question.

123.Dr Caroline White, Head of the Children and Parents Service in Manchester, told us that ongoing support was required in addition to training schemes:

In commissioning a particular programme, there can be an expectation that it will just happen by training a workforce. It is so much more complex than that. For example, a workforce might be trained in an evidence-based programme, but people are just left to deliver it, rather than having the high-quality supervision and consultation that is required with most evidence-based programmes to get the outcomes.362

OXPIP, a voluntary sector parent-infant psychotherapy service, similarly advocated “specialist clinical supervision for statutory staff engaged in [early years service provision]”.363 The 2017 evaluation report of the Children’s Social Care Innovation Programme also reported that “strengthening supervision was part of many of the more successful projects” involved in the programme.364 Dr White cautioned that people across the whole workforce often confused line management for proper supervision covering case consultation and theoretical supervision of their practice, one reason why such supervision was still “hugely missing across the workforce”.365

124.One approach to promoting the use of evidence in commissioning and managing early years practice has been to appoint ‘champions’ within a service, with a responsibility to advocate this. Dr White made clear that for this to work, the champions must have the necessary influence and budget required to achieve change.366

125.Many evidence-based interventions require ongoing, accredited supervision from specialist supervisors with expertise in that particular model. As part of a new national strategy for adversity-targeted early intervention, the Government must make clear that in commissioning evidence-based programmes, local authorities should ensure that there is sufficient accredited, ongoing, specialist supervision from qualified supervisors in that programme for the workforce, throughout the delivery of the programme. Local commissioners should aim to support the development of their own accredited supervisors, to enable cost-savings and deliver an experienced and expert workforce, leading to greater sustainability.

The Apprenticeship Levy

126.Acknowledging the restricted budgets available for training, Dr Woods-Gallagher highlighted the resources made available by the Apprenticeship Levy,367 noting that they could be used for continuing professional development as well as initial training.368 Although the Greater Manchester Combined Authority was still exploring existing early years apprenticeship standards to determine their compatibility with the skills that the Authority wanted for its workforce,369 Dr Woods-Gallagher told us that a similar initiative was already underway for health and social care adult degrees:

We have lots of staff who might have come into practice and are really good family support workers, homelessness workers or home care workers. You almost reach a roadblock at the level 2 or level 3 qualification and have to jump the Rubicon to graduate a qualification on the other side and to accelerate your career through social mobility. That is the mechanism we want to create.370

Dr Woods-Gallagher additionally noted that with organisations being able to transfer 10% of their annual apprenticeship funds to external organisations,371 the funding opportunity of the Apprenticeship Levy was growing.372 Engaging with philanthropists was raised as another avenue for funding to supplement the Apprenticeship Levy.373

127.The Apprenticeship Levy offers an important potential source of new funding for training of the early years workforce. The new adversity-targeted national strategy should promote the opportunity presented by the Apprenticeship Levy as a source of funding for training early years practitioners. The Government should monitor the number of local authorities that make use of the Levy in this way, evaluate the impact where authorities have used it, and provide guidance to assist other local authorities in using the Levy funding if it proves to be successful.

Implementation science

128.A variety of initiatives, such as the Children and Young People’s Improving Access to Psychological Therapies programme and the Children and Adolescent Mental Health Services Outcomes Research Consortium, have previously aimed to improve the provision of early intervention in England through some of the measures advocated in this Report—an increased focus on early intervention, a commitment to use evidence-based interventions, the development of a trauma-informed workforce and better data collection and use of that data—without achieving as much as some hoped.374 Newcastle University highlighted that the practical considerations of transforming early intervention services were as important as identifying the changes to be made:

The relatively new discipline of ‘implementation science’ clearly demonstrates that to change behaviour we need to do more than simply communicate the evidence. Rather people’s capabilities, motivations and opportunities to change must also be addressed. This field is a rapidly developing one and plans to promote evidence-based policy and practice need to take these additional implementation steps seriously.375

Dr Caroline White, Head of the Children and Parents Service in Manchester, similarly told us that “there are things that we know make implementation successful, and we are not applying that knowledge as effectively as we could be”,376 and outlined some of the main components comprising implementation science:

It is things like being programme-driven rather than practitioner-driven; collecting good data […] and being able to report on that data and interpret it for people so that it is meaningful and not just number-crunching; it is about understanding policy, practice and need.377

129.Many of the main components of implementation science—the collection and analysis of data to enable rigorous evaluation of the programmes being delivered, ongoing specialist supervision and consultation for practitioners, leadership and long-term planning—have already been discussed in this Report. The additional consideration of ‘programme-driven’ service transformation was identified by multiple contributors to our inquiry,378 who usually referred to this as a need for ‘model fidelity’—close adherence of an intervention’s real-world delivery to its initial design. The Sheffield’s Children & Young People’s Public Health Team told us that fidelity extended to properly accredited training and supervision.379 This focus on fidelity was also reported by Graham Allen in his 2011 report to Government:

More or less every expert I talked to during the preparation of my review reminded me of the penalties of failure to implement these evidence-based early intervention programmes with fidelity to the design of their originators. This typically results in the loss of all their potential impact, economic gains as well as child well-being. The UK has a poor track record in fidelity of implementation.380

130.Professor Leon Feinstein, Director of Evidence at the Children’s Commissioner’s Office, has, however, warned that successful intervention is not guaranteed simply through rigorous application of a proven programme:

The recently emerging field of implementation science has emphasised the difficulty […] that for human services interventions in part ‘the practitioner is the intervention’. In practice, the child and family are also part of the intervention. This makes each local implementation subject to complex, individual level heterogeneity. The role of science and evidence in this approach is much more to support the quality of practice than to develop rigorous evaluations of gold standard products that can then be easily ‘rolled out’.381

George Hosking, CEO of the WAVE Trust, suggested that plans to deliver early intervention should consider implementation, effectiveness and appropriateness equally.382 The Early Intervention Foundation similarly told us that evidence-based interventions “are only likely to deliver results if delivered carefully according to the programme requirements and if effort is made to ensure they are integrated with wider local service arrangements”.383

131.Related to the need to tailor intervention delivery to the local setting without compromising on following interventions faithfully, we heard of the importance of local authorities being given sufficient time to plan and develop early intervention strategies, as well as detect the results achieved.384 For example, Dr Shirley Woods-Gallagher, Special Advisor on School Readiness for the Greater Manchester Combined Authority, illustrated the level of planning that had been undertaken prior to delivering training in routine enquiry (see the footnote for a definition):385

Over the last four months, we have taken great time and care, with two officers from my former team going out to spend detailed time with frontline police officers, health visitors, midwives, schools and so forth, saying, ‘If you were to do a routine enquiry in your day-to-day practice, what would that look like? What do your existing questions look like? What would the uplift be to include some extra questions? What are the systems that you record them on, and how could we do that?’ It is only now, at this stage, that we are considering what the actual training package would be like, because we have taken all that time to work out the implementation science, noting that it will be slightly different for one or another workforce, thinking, ‘this is how we will record the data, this is how we will supervise it at place level’.386

However, noting that “early intervention pays off in the long term”, the Children and Parents Service in Manchester warned us that “most policy makers, strategic leads and managers want results quickly”.387 This ties in with the short-term funding cycles described in paragraph 80 of this Report.

132.Implementation science is a developing field that can inform the delivery of service transformation programmes, to increase the chance of successful implementation and sustainability. In addition to the focus on data-driven practice and the delivery of relevant training and ongoing expert supervision, the new national strategy for adversity-targeted early intervention should encompass the latest evidence from implementation science, incorporating elements such as a commitment to model fidelity and the adoption of realistic timeframes for service redesign and deadlines for results. The Government should consult academics and practitioners to achieve this, and ensure that lessons from services that have successfully implemented evidence-based early intervention with positive outcomes are also taken into account.

Support for local authorities

133.As the What Works Centre for early intervention, the Early Intervention Foundation has a remit to:

Throughout the course of our inquiry, we have heard that the Foundation was performing an important role and had successfully established itself as an authoritative voice in this field.389 For example, Martin Pratt told us that when he surveyed Directors of Children’s Services across London:

There was a pretty universal view that the Early Intervention Foundation was a good source of [evidence regarding early intervention], that it was accessible and it was able to mobilise that information quickly into service design.390

Ailsa Swarbrick, Director of the Family Nurse Partnership National Unit (whose programme has been highly-rated by the Early Intervention Foundation), told us that:

It is helpful to have a well-respected organisation doing a thorough piece of work into what is available to advise commissioners, while being aware of the limits because some programmes are younger and have not been so well evaluated.391

134.Donna Molloy, Director of Policy and Practice at the Early Intervention Foundation, noted that “any assessment of our record in the five years since we have been going has to be made in the context of our current funding arrangements”:

We are one of the smallest of the What Works Centres. Our current turnover is £1.5 million a year and we are an organisation of 20 people, which is quite small in contrast to organisations such as the Education Endowment Foundation with a £100 million endowment, or even the newly created What Works Centre for children’s social care funded with £3 million a year.392

Indeed, Ms Molloy told us that:

One of our asks of this Committee is to put us on a sustainable and more secure financial footing so we are not wasting time in frequent funding negotiations with Government Departments that take a lot of energy and capacity in such a small organisation.393

Professor Melhuish, of the University of Oxford, independently recommended to us that the Early Intervention Foundation “be made permanent”.394 Donna Molloy added that there was scope for the Foundation to do much more if it had a bigger team,395 highlighting opportunities such as:

135.The comparison between the Early Intervention Foundation and the Education Endowment Foundation, a different What Works Centre focusing on education, was made several times during our inquiry.399 Tom McBride, Director of Evidence at the Early Intervention Foundation, told us:

If you look at the model that the Education Endowment Foundation was set up with—a £100 million endowment—it has been able to fund and co-ordinate a lot of high-quality evaluation of school-based interventions and programmes to build the evidence in that space. The funding is not there in the early intervention and prevention space currently to have that centralised model that would allow us to build the evidence base and tackle the gaps in our knowledge.400

Professor Feinstein, Director of Evidence at the Children’s Commissioner’s Office, also noted the Early Intervention Foundation’s funding constraints and described them as “a weakness in the system”.401 Nadhim Zahawi MP, Parliamentary Under-Secretary of State for Children and Families, highlighted the success of the Education Endowment Foundation, and told us that he wanted to see the Early Intervention Foundation “deliver similar things”:402

Where I would like us to get to with local authorities using data for early intervention is where we have got to now with schools, using evidence from the Education Endowment Foundation on what really works in a school setting […] If I could come here and tell you that we are at a place where local authorities are using [the Early Intervention Foundation] evidence resource to deliver widespread decision making on early intervention, we would have won, and we would have done something really good, but I do not think we are there yet.403

Michelle Dyson, Director of Early Years at the Department for Education, acknowledged, however, that “funding for the Education Endowment Foundation is huge by comparison with that for the Early Intervention Foundation”.404

136.The Government has allocated £10m for the establishment of a new What Works Centre for Children’s Social Care,405 which is due to be fully operational by 2020.406 The Department for Education’s 2016 ‘vision for excellent children’s social care’ outlined the remit for the new centre:

[It] will have a sharp focus on improving outcomes for our most vulnerable children and their families. It will identify best practice in supporting children suffering from, or at risk of, abuse and/or neglect from targeted early support all of the way through to permanence. By looking at both effective interventions and practice systems we expect that the Centre will be able to build a truly comprehensive picture of what excellence looks like.407

Although this is clearly related to adverse childhood experiences, Ms Dyson made clear that the new centre would “focus from the point of referral into the social care system” and therefore not share the same remit as the Early Intervention Foundation for early-stage intervention.408

137.Donna Molloy told us that “the questions local authorities and partners ask when they talk to us about getting help with evaluations are very common”, and said that “it is very inefficient for individual local authorities to be grappling with these evaluation challenges separately”:409

People up and down the country are grappling with how to show whether their early intervention system is delivering anything that might ultimately reduce pressure on their children’s social care system and so on. People want to evaluate their integrated systems rather than very narrow services or interventions. There is certainly a very strong case for central support and capacity to work with local authorities in combination on some of this.410

Indeed, one of Ms Molloy’s main recommendations for improving the use of evidence-based programmes was for increased central support for local authorities:

Funding and technical expertise should be available to those in local authorities and their partner agencies who are seeking to test the impact of some of the things they are doing locally [Government Departments] used to make available technical expertise to local areas to evaluate certain things. That does not seem to happen as much now and is much needed in terms of this agenda.411

Dr Jo Casebourne, Chief Executive of the Early Intervention Foundation, told us that:

Much more needs to be done to properly support the early intervention agenda, and that as an organisation we are not currently resourced to do all of what is needed […] with more secure and sustainable funding, the Early Intervention Foundation could do much more.412

138.As the What Works Centre established to review the evidence relating to early intervention and to help disseminate the latest findings to relevant stakeholders, the Early Intervention Foundation has a key role to play in improving the provision of evidence-based early intervention in England, and should be a key partner to Government in developing and implementing the new national strategy. As part of the forthcoming Spending Review, the Government should review funding for the Early Intervention Foundation with a view to increasing and extending it, to ensure that the Foundation has greater long-term security, and so that it can meet the Children’s Minister’s aims of achieving for local authorities what the Education Endowment Foundation has achieved in schools.

139.In working to deliver on the new adversity-targeted early intervention strategy, local authorities would benefit from the support of a central specialist team with experience in effectively and sustainably implementing early intervention programmes, to help with planning and delivering evidence-based early intervention and to overcome the various challenges we have identified. An expanded Early Intervention Foundation would be well-placed to host such a team, and the Government should invest in the Foundation to achieve this aim.

Early Intervention Places

140.One of the key recommendations from the 2011 Allen review of early intervention was for the establishment of ‘Early Intervention Places’.413 These were envisaged as pioneering local authorities that would trial new approaches to early intervention:

[The proposed Early Intervention Places] have strong political commitment [to early intervention], a good track record of innovation, an understanding of the need to improve the evidence […] and the willingness to share results of their work, whether successful or not.414

These Early Intervention Places were intended to “become focal points for the other 127 local authorities in the UK”.415 This proposal resembled a Canadian initiative recommended to us by Associate Professor David McDaid:

Looking to Canada, there is something called the innovation fund, developed by Public Health Canada, which provides funding for testing and, if the testing works, for rolling out a bit more, and then a third level of funding for implementation. The Committee might want to look at that model.416

Unlike the Allen Review’s recommendation for the establishment of the Early Intervention Foundation, the recommendation for Early Intervention Places was never taken up by the Government.

141.We have heard strong arguments for the improved provision of evidence-based early intervention targeting childhood adversity and trauma in England. Nevertheless, we recognise that open research questions remain and further lessons about the real-world delivery of early intervention can be learnt. The new national strategy should be targeted at, and acted upon by, all local authorities. In addition to this, the Early Intervention Foundation should identify local authorities willing to become ‘Early Intervention Places’, which would receive particular support from the central, specialist team we have recommended. Together with the central team, these local authorities would utilise implementation science to build sustainable implementations of evidence-based programmes, simultaneously generating new knowledge that can be rolled out to other local authorities at a pace consistent with the development of sustainable service transformation.

Funding

142.As outlined in paragraphs 76 to 82 of this Report, the spending on early intervention in England appears to be declining. Highlighting what they perceived to be a missed opportunity, the Royal College of Paediatrics and Child Health raised concern that this recent shift in funding away from early, and towards late, intervention was “in direct contradiction to the evidence on effectiveness and cost-effectiveness”.417

143.Martin Pratt, Chair of the Association of London Directors of Children’s Services, advocated adopting an approach that would lead to “an overall movement or shift in the centre of gravity in public investment towards prevention and early intervention”, and stressed that this would have to be done in a co-ordinated way, rather than through individual programmes.418 As an example of what such an approach could achieve, he told us that the proportion of children in care in Camden had reduced from 53 to 42 per 10,000 children in four years, which he attributed to a deliberate and co-ordinated shift in overall spending towards early intervention.419

144.The 2011 Allen Review acknowledged constraints in public funding and set out the opportunity for private investment in the sector.420 The Early Intervention Foundation reviewed the case for social impact bonds in particular and noted their potential to cover the upfront costs of early intervention without diverting funding from other areas, but cautioned that the timescales and magnitude of the cost-savings typical of early intervention may not appeal to private investors.421 Dr Woods-Gallagher, Special Advisor on School Readiness for the Greater Manchester Combined Authority, additionally told us that social impact bonds “can be complex to set up”, and argued that local authorities should seek to invest in, and gain from, proven programmes themselves.422 Professor Feinstein, Director of Evidence at the Children’s Commissioner’s Office, added that it might not be clear who would benefit directly from the cost-savings of early intervention, and argued that given the “collective economic benefit” of early intervention, the responsibility for investment in early intervention lay principally with the Government.423 The Allen Review similarly concluded that even with private sector involvement, the Government should still manage “99% of the expenditure in the field”.424

Using technology to reduce costs

145.One particular avenue that was raised as a potential route to delivering early intervention programmes at low cost was through greater use of digital technology. Matt Buttery, Chief Executive of Triple P UK, told us that digital service delivery “provides the ability to take parenting to scale and, in a low-cost, effective way, to reach into parts of the community that face-to-face interventions do not always reach”.425 During our inquiry, we heard from EasyPeasy, a digital service that sends game ideas, tips, and advice to parents through short video clips. This service had been the subject of a randomised controlled trial, which reported “statistically significant differences between intervention and control groups on two of the seven measures” that were assessed (parents’ self-efficacy regarding discipline and boundaries, and parent-reported child cognitive self-regulation).426 Professor Melhuish, of the University of Oxford, told us:

It is very early days to identify the relevant value of the digital approach versus a more traditional one, but my experience so far leads me to think that there is a lot more scope for taking advantage of digital technology. Private agencies are doing this and there is very little Government involvement in it. I think some Government involvement could be very beneficial.427

146.In adopting a new national adversity-targeted early intervention strategy, the Government should see effective early intervention as an opportunity to make long-term cost efficiencies—as well as improve people’s lives—rather than a demand on resources. The Government should correspondingly make the necessary funding available where elements of the new strategy will require funding from central Government. The new strategy should also seek to drive a general shift in the focus of current expenditure on ‘late interventions’, required where problems have escalated, to earlier intervention. Although this may require an initial increase in expenditure, there is good reason to expect this to lead to long-term savings across diverse sectors. The new strategy should seek to identify ways in which the cost of early intervention can be brought down without compromising its effectiveness, for example by reviewing the evidence for digital early intervention services, as well as considering how local authorities can be incentivised—rather than penalised—for making long-term investments. Where local authorities cannot invest in early intervention initiatives that are expected to deliver long-term cost-benefits, the Government should be ready to provide additional funding to ensure the opportunity to improve lives and save public money is not missed.


337Manchester CAPS: A Sustainable Implementation of Incredible Years’, National Institute for Health and Care Excellence, accessed 24 October 2018

338 More information about CAPS and lessons learned from its development and implementation can be found in Julia Faulconbridge, Katie Hunt and Amanda Laffan, ‘Improving the Psychological Wellbeing of Children and Young People: Effective Prevention and Early Intervention Across Health, Education and Social Care’ (London, 2018), Ch. 3

339 Eyberg Child Behaviour Inventory’, Psychological Assessment Resources; ‘Beck’s Depression Inventory’, Boston Medical Center; ‘Parenting Stress Index’, American Psychological Association; Kevin Browne, Jo Douglas, Catherine Hamilton-Giachritsis and Jean Hegarty, ‘Community Health Approach to the Assessment of Infants and their Parents: The CARE Programme’ (New Jersey, 2006), Ch. 3

340The Incredible Years Parents, Teachers and Children Training Series’, The Incredible Years, Inc., accessed 5 October 2018

341Minister announces £17 million to improve children’s services’, Department for Education, accessed 28 October 2018

343 Q195

344 Q106

345 Q262

346 ASQ-3 comprises a series of 21 questionnaires, covering ages 0 to 5½ years, which parents use to test their child’s abilities, for evaluation by early education or healthcare professionals (Welcome to ASQ’, Paul H. Brookes Publishing Co., accessed 27 July 2018). Public Health England currently recommend its use during the 2–2½ year health visit; in 2016–17, 89% of 2–2½ years health visitor reviews used ASQ-3 (Public Health England, ‘Health Visitor Service Delivery Metrics 2016/17 annual data’ (2017)).

347 Greater Manchester Combined Authority (EYI0047)

348 Q258

349 Q362

350 Q364

351 Q258

352 Q128

353 Q249

354 MRC/CSO Social and Public Health Sciences Unit (EYI0021), para 1.4

355 Qq250–252

356 For example, see Sue Gerrard (EYI0025) and Q126

357 Better Start Bradford (EYI0113)

358 Q84

359 Qq250–255

360 Q268

361 Q268

362 Q223

363 OXPIP (EYI0068), para 2

364 Department for Education, ‘Children’s Social Care Innovation: Programme Final evaluation report’ (2017), pp59–60

365 Q273

366 Q264

367 Q268

368 Qq230–231 and 295–296

369 Qq269–270

370 Q231

371Transferring unused apprenticeship funds to other employers’, Education and Skills Funding Agency, accessed 22 August 2018

372 Q229

373 Q246

375 Newcastle University (EYI0007)

376 Q215

377 Q285

378 For example, see Children and Parents Service (EYI0004), Centre for Evidence Based Early Intervention (EYI0029), Centre for Mental Health (EYI0050), Roots of Empathy (EYI0077) and Professor Peter Fonagy (EYI0097)

379 Sheffield’s Children & Young People’s Public Health Team (EYI0064), para 3.11

380 Graham Allen, ‘Early Intervention: The Next Steps’ (2011), para 73

381 Feinstein et al., ‘On Estimating the Fiscal Benefits of Early Intervention’, National Institute Economic Review, vol 240 (2017)

382 Q183

383 Early Intervention Foundation (EYI0061), para 23

384 For example, the Foundation Years Trust told us that “given the time that it can take to embed a programme within a community and to start to see an impact, there should be a long-term commitment to testing and evaluating what works”—Foundation Years Trust (EYI0060)

385 Routine enquiry entails asking all people who access certain services, such as medical appointments, if they have experienced ACEs and if so if it has affected them (see paragraph 30 of this Report)

386 Q237

387 Children and Parents Service (CAPS) Early Intervention (EYI0004)

388 Cabinet Office, ‘What Works? Evidence for decision makers’ (2014)

389 For example, see Q89, Q158, Q159, Q372, Q421

390 Q294

391 Q158

392 Q208

393 Q208; In supplementary evidence, the Early Intervention Foundation told us that as of 4 May 2018, the Foundation had still not been able to sign a grant agreement with the Department for Education for the 2018–19 period and were hence running on its charity reserves—Early Intervention Foundation (EYI0111)

394 Q168

395 Q208

396 Q197

397 Q195

398 Q199

399 For example, see Qq 89,195,208,421 and 448–451

400 Q195

401 Q89

402 Q451

403 Q421

404 Q448

405 Q417

406Setting up the Centre’, What Works Centre for Children’s Social Care, accessed 24 July 2018

408 Q442

409 Q195

410 Q195

411 Q210

412 Early Intervention Foundation (EYI0111)

413 Graham Allen, ‘Early Intervention: The Next Steps’ (2011)

414 Graham Allen, ‘Early Intervention: The Next Steps’ (2011), p95

415 Graham Allen, ‘Early Intervention: The Next Steps’ (2011), p95

416 Q93

417 Royal College of Paediatrics and Child Health (EYI0054), para 5.2

418 Q218

419 Qq218–221

421 Early Intervention Foundation, ‘Introduction to Social Impact Bonds and Early Intervention’ (2014)

422 Q245

423 Q79

425 Q105

427 Q167




14 November 2018