Proportionate universalism in the foundation years

Sarah Cowley 29th January 2015

Inequalities in early childhood: proportionate universalism

•  “Giving every child the best start in life is crucial to reducing health inequalities across the life course. . . .

•  “(We need) to increase the proportion of overall expenditure allocated (to early years, and it) should be focused proportionately across the social gradient to ensure effective support to parents, starting in pregnancy and continuing through the transition of the child into primary school. . . . .”

Marmot (2010 p 23) Fair Society, Healthy Lives

Why ‘Foundation Years’? •  Strong, expanding evidence

showing the period from pregnancy to two years old sets the scene for later mental and physical health, social and economic well-being

•  Direct links to cognitive functioning, obesity, heart disease, mental health, health inequalities and more

•  Social gradient demonstrates need for universal service, delivered proportionately

•  Foundations of health: –  Stable, responsive

relationships –  Safe, supportive

environments –  Appropriate nutrition

www.developingchild.harvard.edu

Both. . and. .; not . either. . or. .

•  Universal and targeting •  Need for targeted services delivered from within

universal provision delivered to all •  Population assessment (commissioner) and

family/individual assessment (practitioner) •  Different intensities and types of provision according to

individual need •  Generalist health visiting and embedded specific,

evidence based interventions •  Take into account social gradient and prevention

paradox

Universality: for the social gradient and the prevention paradox1

Caution: figures (next) are for explanation only

•  Figures are old (2000-09) and approximate

•  Primary Care Trusts (PCTs) no longer exist

•  Index of Multiple Deprivation (IMD) data designed for small areas, whereas PCTs covered up to a million population

•  Family Disadvantage Indicators omit key markers, e.g. illicit drug use, domestic violence and abuse

1Rose’s strategy of preventive medicine

Family Disadvantage Indicators

•  No parent is in work •  Family lives in poor quality or

overcrowded housing •  No parent has qualifications •  Mother has mental health

problems •  At least one parent has

longstanding, limiting illness, disability or infirmity

•  Family has a low income below 60% of the median

•  Family cannot afford a number of food or clothing items.

•  NB: A rise in adverse outcomes for children becomes evident when their families experience only one or two of these seven indicators

•  Mapped to children in the Millenium Cohort Study and area to show spread across social gradient

Social Exclusion Task Force (2007) Reaching Out: Think Family. Analysis from ‘families at risk’ review

Children with no Family Disadvantage Indicators by area disadvantage (IMD 2009)

Social Exclusion Task Force (2007) Think Family: analysis from ‘families at risk’ review ’

Children with Family Disadvantage Indicators by area disadvantage (IMD 2009)

Social Exclusion Task Force (2007) Think Family: analysis from ‘families at risk’ review ’

Pre-school children: distribution across Primary Care Trusts (IMD 2009)

ONS 2009

Number of children affected in each group in each centile

65% of Children - 864,465

35% of Children

- 475,164

Obesity prevalence and deprivation National Child Measurement Programme 2013/14 – Year 6 children

11 Patterns and trends in child obesity (note – a similar patternis seen in Reception year)

Child  obesity:  BMI  ≥  95th  cen6le  of  the  UK90  growth  reference  

Local authorities in England

‘Prevention paradox’

•  “A large number of people at small risk may give rise to more cases of disease than a small number of people at high risk”

•  High risk groups make up a relatively small proportion of the population

•  Need to shift the curve of the gradient and distribution of need across the whole population to reduce overall prevalence

Khaw KT and Marmot M (2008) 2nd edition Rose’s Strategy of Preventive Medicine

Strengths: capacity and resources across population

Health visitor direct input: Universal provision, delivered proportionately

Health visitors do not work alone

Wider community

Neighbourhood

Family

Parent

Child

Bronfenbrenner’s (1986) concept of nested systems

Shifting focus of attention to need Situation, resources to meet need Simultaneous assessment, prevention, intervention

Wider community

Neighbourhood

Family

Parent

Child

Health visiting practice

•  Focus on situation and resources needed for prevention and promotion

•  Community and caregiver capacity1 •  Foundations of health1

Stable, responsive relationships

Safe, supportive environments

Appropriate nutrition

1www.developingchild.harvard.edu

Relational process; focused practice

Bidmead C (2013) http://www.kcl.ac.uk/nursing/research/nnru/publications/Reports/Appendices-12-02-13.pdf

Salutogenic (health creation) Person-centred Person-in-context

Updated Health Visitor Implementation Plan

Growing the workforce

Professional mobilisation

Service transformation

Oct 2015: Commissioning of HVs shifts to Local Government

DH: 4-5-6 model for health visiting

Acknowledgements

Empirical  study  Voice  of  service  

users  

AIMS

Literature  review  Narra6ve  synthesis  of  health  visi6ng  prac6ce  

Empirical  study    Recruitment  and  

reten6on  for  health  visi6ng        

This work was commissioned and supported by the Department of Health in England as part of the work of the Policy Research Programme. The views expressed are those of the authors and not necessarily those of the Department of Health.

For families - universality should mean: •  Universal ‘offer’ of:

–  Five mandated contacts: everyone gets this – Healthy Child Programme (HCP) –  Service on their own terms

•  ‘Service journey’ – Meet/get to know health visitor: trust relationship,

partnership working – ‘relational autonomy’ –  Services delivered to all – i.e., home visits (HCP) – Health visiting outside home – well baby clinics, groups

etc, in conjunction with others (e.g. Children’s Centres) •  ‘Open secret’ of safeguarding/child protection

Cowley et al (2014) http://dx.doi.org/10.1016/j.ijnurstu.2014.07.013

‘Universal Plus:’ simultaneous prevention and treatment •  Across six high priority

areas and more, e.g. – Specially trained health

visitors can simultaneously prevent Brugha et al 2010, detect and treat post-natal depression through ‘listening visits’ Morrell et al 2009

– Post-qualifying training being rolled out by Institute of Health Visiting (Perinatal Mental Health ‘Champions’)

Mental health •  Post-natal depression (PND)

•  Early identification and treatment with listening visits Morrell et al 2009

•  Prevention of PND Brugha et al 2010

•  More relaxed mothering Wiggins et al 2005, Barlow et al 2007, Christie et al 2011

•  Improved mother/infant interaction Davis et al 2005, Barlow et al 2007

•  Special needs: Reduced children’s ADHD symptoms and improved maternal well-being, by HV working in specialist team Sonuga-Barke et al 2001

Health visitor research programme

•  Literature - evidence of benefits, if sufficient staff, skills, knowledge

•  Health Visitors’ desire to make a difference for children and families

•  Parents’ desire to be ‘known’, listened to and ease of access

•  Shared desire for: •  Others to value their knowledge and

contribution •  Respectful, enabling relationships •  Flexible service (varied intensity +

type, e.g. home visits and centre-based) to match need

What is needed? Organisational support •  Conflicting demands •  Population needs (e.g., KPIs, targets) vs.

individual/family needs Sufficient time •  Staffing levels •  Equipment for job

Sufficient skills •  Education: – For qualification/pre-registration health visitor programme – Continuous professional development

Revenue costs

Funding 1999/2000 – 2001/02 £millions (actual)

2002/03 – 2004/05 £millions (actual)

2005/06 – 2007/08 £millions (actual)

2008/09 – 2010/11 £millions (estimated)

Sure Start Local Programmes

141 840 1074 838

Children’s Centres

0 13 656 2205

Health visitors 965 965 900 840 totals 1106 1818 2630 3883

Source: Audit Commission (2010) Giving Children a Healthy Start

Whole time equivalent (WTE)health visitors employed in England (1988) 1998-2014

10,680

10,020

10,070

10,050

10,046

10,190

9,912

9,999 10,137 9,809

9,376 9,056

8764 8519

8017 7941

8385

9550

10800

7,500

8,000

8,500

9,000

9,500

10,000

10,500

11,000

11,500

12,000

1988

1998

2000

2002

2004

2006

2008

2010

2012

2014

WTE health visitors

Oct$2014$=$11,102$$Incl.$550$non1ESR$$

Target$=$12,292$WTE$$(May$2015)$$$$

ESR = NHS electronic staff record Source: Information Centre for Health and Social Care

*

Sufficient time •  What is appropriate level of staffing?

–  Family Nurse Partnership caseload = 25 families –  Starting Well = 80-85 families (including skillmix) –  Typical HV caseload = 400+ families, up to 1000

•  Funding model Cowley 2007, Cowley and Bidmead 2009

– Recommends range according to levels of deprivation, between 100 and 400 children per health visitor, not accounting for skillmix (consensus papers)

•  Research about skillmix/teamwork Cowley et al 2013

–  Scarce, not linked to outcomes –  Issues about referral, delegation, specialisation

Skills and knowledge Health visitor programme: •  Open only to registered nurses or midwives •  45 programmed weeks •  50% theory, 50% practice, i.e. 22.5 weeks in each ‘More education needed for. . . .’ •  Community development/public health practices, multi-agency/multi-disciplinary

engagement, need for more knowledge about breast feeding and immunisation, better preparation to promote home safety and unintentional injury, more/better skills in dealing with post-natal depression and mental health, better understanding, knowledge and skills for obesity prevention, health visitors should be better equipped to deal with skillmix, including delegation, support to develop more skilful, culturally competent practice with seldom heard groups, including BME populations and those experiencing current major life problems such as insecure housing or seeking asylum, sensitivity and skills in enabling disclosure of e.g domestic violence, hidden needs, able to develop authoritative practice in complex needs, e.g. in child protection situations . . . . .

How to get sufficient skills?

•  Post-qualifying – continuing professional development

– Better preceptorship for new/recently qualified and updates for all

– Cascade training through Institute of Health Visiting: •  Perinatal mental health •  Infant mental health •  Domestic violence and

abuse •  Etc., etc

•  Pre-registration programme

– The current 45-week programme is over-full

– Longer/different approaches needed

– All options need to be on the table, including a wider entry gate and direct entry degree or Masters programmes

Health and Inequalities: focus on the Foundation Years

•  Known importance of •  Caregiver and Community

Capacities •  Foundations of Health •  Biology of Health

www.developingchild.harvard.edu

Emerging understandings: •  what is necessary (required) for child

development •  what is foundational: ie, other

elements will not work without it •  how to measure foundations and

requirements (assets/capacity) •  which outcomes are appropriate and

helpful to measure •  connections that exist between

problem-based (prevention) and capacity-building (promotion) approaches

•  how to delineate attribution

Policy recommendations

•  Marmot’s ‘second revolution for the early years’: increase overall expenditure, focused proportionately across gradient •  Build on health visiting

plan successes – don’t lose the benefits of 2011-15 in transfer to local government

•  Enabling sufficient health visiting time, skills, organisation = –  better outcomes (six

high impact areas) –  flexible/acceptable

service –  both population

health needs and individual families

Thank you! sarah.cowley@kcl.ac.uk

‘Why  Health  Visi6ng’  References  

Reports  on  NNRU  website:  hJp://www.kcl.ac.uk/nursing/research/nnru/publica6ons/index.aspx    Bidmead  C  (2013)  Health  Visitor  /  Parent  Rela6onships:  a  qualita6ve  analysis.    Appendix  1,  in  Cowley  S,  WhiJaker  K,  Grigulis  A,  Malone  M,  

DoneJo  S,  Wood  H,  Morrow  E  &  Maben  J  (2013b)  Appendices  for  Why  health  visi,ng?  A  review  of  the  literature  about  key  health  visitor  interven,ons,  processes  and  outcomes  for  children  and  families.  Na6onal  Nursing  Research  Unit,  King’s  College  London  

Cowley  S,  WhiJaker  K,  Grigulis  A,  Malone  M,  DoneJo  S,  Wood  H,  Morrow  E  &  Maben  J  (2013a)  Why  health  visi6ng?  A  review  of  the  literature  about  key  health  visitor  interven6ons,  processes  and  outcomes  for  children  and  families.  Na6onal  Nursing  Research  Unit,  King’s  College  London  

Cowley  S,  WhiJaker  K,  Grigulis  A,  Malone  M,  DoneJo  S,  Wood  H,  Morrow  E  &  Maben  J  (2013b)  Appendices  for  Why  health  visi6ng?  A  review  of  the  literature  about  key  health  visitor  interven6ons,  processes  and  outcomes  for  children  and  families.  Na6onal  Nursing  Research  Unit,  King’s  College  London  

DoneJo  S,  Malone  M,  Hughes,  Morrow  E,  Cowley  S,  J  Maben  J  (2013)  Health  visi6ng:  the  voice  of  service  users.    Learning  from  service  users  experiences  to  inform  the  development  of  UK  health  visi6ng  prac6ce  and  services.  Na6onal  Nursing  Research  Unit,  King’s  College  London  

WhiJaker  K,  ,  Grigulis  A,    Hughes  J,  Cowley  S,  Morrow  E,  Nicholson  C,  Malone  M  &  Maben  J  (2013)    Start  and  Stay:    the  recruitment  and  reten6on  of  health  visitors.  Na6onal  Nursing  Research  Unit,  King’s  College  London  

Policy+  37:  February  2013  -­‐    Can  health  visitors  make  the  difference  expected?  hJp://www.kcl.ac.uk/nursing/research/nnru/Policy/policyplus.aspx  

Published  papers  Cowley  S,  WhiJaker  K,  Malone  M,  DoneJo  S,  Grigulis  A  &  Maben  J  (2014)  Why  health  visi6ng?  Examining  the  poten6al  public  health  

benefits  from  health  visi6ng  prac6ce  within  a  universal  service:    a  narra6ve  review  of  the  literature.  Interna8onal  Journal  of  Nursing  Studies  (online/early  view)  hJp://authors.elsevier.com/sd/ar6cle/S0020748914001990  

DoneJo  S  &  Maben  J  (2014)  ‘These  places  are  like  a  godsend’:  a  qualita6ve  analysis  of  parents’  experiences  of  health  visi6ng  outside  the  home  and  of  children’s  centres  services  Health  Expecta8ons  (online/earlyview)  doi:  10.1111/hex.12226    

 http://www.kcl.ac.uk/nursing/research/nnru/publications/index.aspx

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