Big story: a tough start in life

11 April 2019

A report by the Health and Social Care Select Committee finds that children in England are not being supported in their critical first 1000-day period. Journalist Juliette Astrup takes a look at the recommendations and the reactions.

A child’s first 1000 days are well understood as a critical period, where the foundations of future health and wellbeing are laid. It’s at the heart of health visiting and community nursery nursing. It was this understanding that was central to the Health and Social Care Committee’s inquiry into the first 1000 days of life, which reported in February (Health and Social Care Committee, 2019).

Bringing together evidence from 90 written submissions, an online forum on Mumsnet, three oral evidence sessions, focus groups and a visit to the Blackpool Better Start project, the inquiry sets out with clarity the importance of intervening early in childhood to improve people’s lives – their physical and mental health, their development and growth, and their life chances.

In short it found that ‘by intervening successfully in this period to give every child the best start in life the government can help make society fairer and more prosperous’.

Yet, vitally, it concluded that not enough was currently being done to make this happen, and that with cuts to children’s centres, health visiting and services to support parents, families had been left vulnerable. They want this to change and have set out how they would like this to happen.

What should services look like?

The committee identified three strategic goals to deliver improved outcomes for children and reduce inequalities: reducing infant mortality, reducing adverse childhood experiences and increasing school readiness.

The report begins with the six principles on which local services for children, parents and families should be founded: proportionate universalism, whereby services are available to all but targeted in proportion to the level of need; prevention and early intervention; community partnerships; a focus on meeting the needs of marginalised groups; greater integration and better multi-agency working; and evidence-based interventions.

The report advocates continuing the Healthy Child Programme, but it found it is ‘not adequately supporting the improvements in health and wellbeing and reductions in health inequalities which it aims to do’ and calls for it to be ‘revised, improved and given greater impetus’.

The recommendations are that the programme should begin before conception, extend beyond the age of two and a half years, and expand to become more family-focused, as well as provide greater continuity of care.

The report also recommends an additional mandatory health visitor check to be introduced at age three to three and a half to assess whether children are likely to be school ready. The report highlighted that Scotland, Wales and Northern Ireland all mandate a higher number of health visitor checks than England.

Focus on families

In addition, the committee wants the government to develop a targeted support programme for families that need it, building on the Flying Start programme in Wales and the Family Nurse Partnership in Scotland, Northern Ireland and parts of England.

Asha Day, vice-chair of the CPHVA Executive, says members will welcome the report and the six principles it outlines, which are ‘reflective of the core health visiting priorities’ and give even more weight to the importance of early years interventions in ‘reducing health inequalities, not just for infants, but for wider families and the communities at large’.

The report’s emphasis on family-focused health visiting, and its specification that visits should take place in the home is crucial she adds. ‘Children can’t be seen in isolation; they are part of families, part of communities. It’s not just about their emotional and physical health and wellbeing, but it must also encompass the wider social determinants of health, including their environment.

‘I’m also delighted to see that it says all families should have the same health visitor and midwife who actually follows the client journey, rather than compartmentalised pieces of care. ‘I’m also really pleased to see the emphasis on working collaboratively with partners including midwives, obstetricians, social care and the voluntary sector, which forms an integral part of the work health visitors continue to do, although we have seen so many funding cuts to statutory services.’

Asha concludes: ‘I’m sure our members will also welcome the report’s recommendations of the additional contact at age three to three and a half, although we would have liked to have seen an additional visit at three to four months recommended too, as this is a pivotal time in terms of maternal mental health assessment and infant attachment.’

Unite-CPHVA submitted evidence to the inquiry. Obi Amadi, lead professional officer, says: ‘We asked for eight mandatory visits – they have gone with six. The additional contact at age three is to be welcomed – any additional contact is to be welcomed – but we still think that a three to four month contact is really important. It’s about having that quality contact early on and eliminating things further down the line. Focused early interventions are priceless.

‘Following this, Public Health England is going to be refreshing and modernising the Healthy Child Programme, making it relevant and fit for the future, so what it sets out to do and the evidence base will be restated. For example, in many areas there is an excessive and at times inappropriate grade mix – for example, health visitors not doing the antenatal visit.’

Obi also welcomes the report’s emphasis on the role of the health visitor, adding: ‘The named key professional needs to be the health visitor, and the report identifies that.’

Nearly 1/3 of children in England are not ‘school ready’ by the time they are five, because they have not reached the necessary level of development

Leadership and Accountability

As part of her evidence to the inquiry, Obi pointed out the need for greater consistency rather than ‘political chopping and changing’, and the lack of a ministerial lead.

These concerns were clearly recognised, and the resulting report calls for a ‘long-term and coordinated response nationally and locally’ to improve the provision for families during this period. It states that the government should take the lead by producing a long-term, cross-government strategy for the first 1000 days of life, ‘setting demanding goals to reduce adverse childhood experiences, improve school readiness and reduce infant mortality and child poverty’.

And the report calls for the responsibility for oversight to sit with the minister for the Cabinet Office, with the support of a small, centralised delivery team.

It also sets out that each local authority area should develop, jointly with local NHS bodies, communities and the voluntary sector, a ‘clear and ambitious plan’ to improve support during the crucial first 1000 days, which sets out how each area will meet key national goals.

The government should also establish a transformation fund, in which multiple departments would pool resources to incentivise the transformation of local commissioning and provision of services.

Obi says: ‘We have lobbied around all these different issues and it finally seems as though someone is listening. Hopefully the committee has the ear of the health secretary and can actually make this happen. We are here and ready to work with them to support it.’

The cross-party group wants the government to pay for extra contact with health visitors beyond the age of 2 1/2

Extra funding

Members heard that 65% of families were not formally seeing a health visitor at all after their baby was aged six to eight weeks

The current pressure on services and lack of investment is also acknowledged by the committee. Evidence put before it revealed a substantial regional variation in service in terms of the percentage of completed health visitor assessments; members heard that 65% of families were not formally seeing a health visitor at all after their baby was aged six to eight weeks, and might instead be seeing other early years workers with less training, and that a ‘contact’ might mean only that families are receiving a letter, not a visit.

The report also notes the falling numbers of health visitors and the consensus from the evidence that there are currently too few health visitors, and many have too many families on their caseload. It makes clear that the government should publish a ‘holistic workforce plan for services covering the first 1000 days’, setting out how government and national bodies will support local areas to enhance the capacity and capability of staff.

The report also recognises the drop in public expenditure on children since 2010-11, the ‘tight financial climate’ local government operates in, and that spending on most public health services is down considerably since 2014-15. It also mentions the widespread closure of children’s centres, down by a third since 2010-11.

Leaders needed

‘Quite simply, I want this country to be the most supportive and caring place in the world that a child could be born into’

However, the message that investing in the early years is ‘the best investment any government can make and saves money in the long-term’ is unequivocal. The report says the government must use this year’s spending review to shift public expenditure towards intervening earlier rather than later, and provide a secure, long-term investment in prevention and early intervention during this critical period.

Dr Paul Williams MP, a practising GP and father who led the committee for this inquiry, says: ‘Quite simply, I want this country to be the most supportive and caring place in the world that a child could be born into.

‘There is a crisis in children’s mental health in this country. But all we are seeing are cuts to health visiting, children’s centre closures and increasing child poverty. Government must now show inspiring leadership to help children get the best possible start in life.

‘If our country is serious about prevention and reducing health inequalities then we must make massive investments and drive coordinated action right at the start of life.’

Unite-CPHVA would ideally like to see an extra contact with health visitors at 3-4 months

What next?

Whether the recommendations are implemented remains to be seen, but there are positive signs about the government’s intention in this area.

As the report highlights, the recently published Prevention is better than cure (Department of Health and Social Care, 2018) aspires to give every child the best start in life, to be supported by the work of the ministerial group on family support from conception to the age of two, established last year.

But Colenzo Jarrett-Thorpe, Unite national officer for health, sounds a note of caution. While he welcomes the sentiments and recommendations of the report, he says they are at risk of ‘withering on the vine’ without the necessary leadership and funding in place to deliver them. This is made all the more challenging because fragmentation following the Health and Social Care Act means that the ‘whole system is a labyrinth’.

He added: ‘We need to ensure that this is a first step. We want the fantastic recommendations of this report to become a reality, and we are going to be a voice to make sure that happens.

‘We need a new call to action for health visitors, community nursery nurses and school nurses, and the recognition that they are critical in delivering services for children, young people and families. We will talk to politicians in local authorities and at a national and local level, beginning with how we can undo the damage by putting back together the services piece by piece.’

Asha says: ‘How this gets implemented depends on how the spending review money is allocated and if it is hypothecated to these specific services – is it going to be shared funding or will it be put into public health?

‘We also have health visitors leaving, so it’s not just about the money – it’s about having enough highly trained and educated health visitors to deliver the service.’

She adds: ‘It is a fantastic report and it is welcomed. If the funding falls as it should and the strategy falls as the report outlines, the future of our children and communities will be looking a lot more positive than it has in some considerable time.’

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Department of Health and Social Care. (2018) Prevention is better than cure. See: (accessed 15 March 2019).
Health and Social Care Committee. (2019) Health and Social Care Committee: First 1000 days of life. Thirteenth Report of Session 2017–19. See: (accessed 15 March 2019).