In recent years research has shown that a child’s experience in the womb and in early life has a strong influence on their health, development and well being throughout life During the rapid development of the brain in the first years of life the neural pathways, synaptic connections and bio-chemical responses are significantly influenced by a child’s environment and experience. The quality of early care giving and the infant-parent relationship has a major influence on the child’s outcomes equal, if not greater, than socio-economic circumstances. Deficient early years parenting experiences have been linked to a range of adverse later life outcomes including anxiety and depression, poor learning and cognitive development, increased risk of abuse and neglect, poor behavioural outcomes, criminality and anti-social behaviour. Early parenting experiences are especially critical in the development of the child’s emotional regulatory system and a large proportion of adult mental health problems are thought to have their origins in early childhood The high level of malleability in the brain during this period means this is also the time when it is most open to influence and change so intervening early and ensuring positive experiences and preventing negative experiences provides the greatest opportunity for improving children’s outcomes and, in turn, adult outcomes.
Shirley - the title in green and the ‘to prevent early…..” should be on slide, then babies and 723,165 opportunities appear on next click – please can you tweak animation to make it work.
Factors at child’s age 9 months and child’s subsequent outcomes at age 5. What factors will you target to either prevent or mitigate for pregnant women and families with new babies?
Where is the local need in the most immediate timescale? How will you expect your commissioned health visiting services (likely to be the only truly universal service for children under 5 in the mid-term future) to be deployed to get better outcomes?
Aim is to keep families moving towards the Communities Offer and return families up stream after a ‘resilience dip’ has meant they needed support from Universal Plus and Universal Partnership Plus offers.
Cost to support with FNP = £3000 per year so £6000/child. Recovered by age 4. So each team of FNP can support at least 110 families. Even if only one antenatal stay, one children’s A&E admission, and 1 week without additional family support at home was avoided for every family supported with FNP at least £3000 spend is avoided. If attendance is more than this then potential for avoiding spend and making a saving. So initially where to spend the same money and what additional value. For example additional value through mothers more confident and use GPs less, mothers more likely to return to education, more likely to be employed etc etc.
An overview of how the new system works. (Still a bit simplified – e.g. doesn’t show NICE or Information Centre) Animated: DH allocates £ and sets objectives for NHS CB. No longer any NHS HQ in DH NHS CB allocates to GP consortia Who commission services from a range of providers Who are regulated on a consistent basis (no longer some of them managed by SHAs): by CQC as now for quality and by Monitor as economic regulator (3 functions: 1 promote competition, 2 regulate prices, 3 ensure continuity of essential services) Meanwhile LAs have new role shaping NHS commissioning LAs also feed into new public health service, with their role taken from PCTs of promoting local population health improvement. And Public Health England itself is now part of DH, with a separate, ring-fenced budget. More details published in Healthy Lives, Healthy People White Paper Then adult social care: no change to structure (the debate is about financing – Dilnot commission) Finally, HealthWatch, nationally and locally So DH does strategic coordination at national level; LAs at local level.
Provides a visual picture of the health pathway from preconception to 5 years.
Introduce NCVO Early Action Task Force Obviously there are a number of challenges: Making the economic case work Infrastrcuture in place to have it happen This is the story of involving the VCS through the process
Micro – 5% state funding; larger 1/3 Concentration because: Empathetic development of organisations (kids first) Early action / prevention is obvious Also: 22,677 culture and recreation 13,552 religious
Most obvious – as illustrated by last slide Value of services are: Local – responsive local governance User led Flexible / need driven Trusted Specialist R&D Fuelled by grants Form follows funding – what is good about it and research ON PAGE THAT FLOATS IN PbR examples: financial incentive as opposed to public incentive
Expected drop of 1.246 billion over spending review (cuts only – not loss through competition)
Although very little is state funded 13.9 billion 2009 from 8.6 billion 2001 Total sector income is 36.7 billion
Second areas of relevance – social and financial economy Very existence: proof of need and resource Further column of funding to support social services and interventions (eg social investment and state funding) Where we have been poor though is in measuring the value of these more fluid things: what does this mean for communities? Support and investment is required to prove the case
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Crucial voice in commissioning LVAC anecdote: stories to action. ‘story of place’: that’s what the VCS is. And this story of cause and effect is exactly what early intervention seeks to trace and address. How are organisations involved?
Originally published as Arnstein, Sherry R. "A Ladder of Citizen Participation," JAIP, Vol. 35, No. 4, July 1969, pp. 216-224
What you end up with: -multi layered and integrated partnership -parallel to govt and economic structures; formal and informal
3 points: Commissioning is about partnership: which requires communication and engagement throughout the process Needs assessment: causal and integrated Maximise social capital by integration, development and SV Bill; and through procurement that reflects and enable preventative services to work
Revised slideshow afternoon session for e circulation june 13th
Primary Prevention – cheaper than cure,better outcomes for childrenAfternoon session June 13th 2012 Supported by
The Health perspective Dr Ann Hoskins, Interim Regional Director of Public Health/Director of Children, Young People & Maternity Supported by
C4EO/ WAVE Trust conference 13th June 2012Dr Ann Hoskins, Interim Regional Director of Public Health / Director Children, Young People and Maternity Services Healthier Horizons
Giving Every Child the Best Start in Life is Crucial to Reducing Health Inequalities Across the Life Course• Ensure high quality maternity services, parenting programmes, childcare and early years education to meet need across the social gradient• Ensuring that parents have access to support during pregnancy is particularly important• An integrated policy framework is needed for early child development to include policies relating to the prenatal period and infancy, leading to the planning and commissioning of maternity, infant and early years family support services as part of a wider multi-agency approach to commissioning children and family services
The Scientific Base1. A child’s early experience has a long lasting impact on the neurological architecture of their brain and their emotional and cognitive development2. Pregnancy and birth a key time for change – parents have an instinctive drive to protect their young and want their child to be healthy and happy and do well in life3. Evidence that effective preventive interventions in early life can produce significant cost savings and benefits in health, social care, educational achievement, economic productivity and responsible citizenship4. There is scientific consensus that origins of adult disease are often found in pregnancy and infancy 5
The Task of Commissioning for PreventionTo prevent early adversities becoming biologically embedded 723,165 new opportunities available each year in the UK
Factors That Can Hamper Positive Development During Pregnancy• Low birth weight in particular is associated with poorer long-term health and educational outcomes• Smoking can cause a range of serious health problems, including lower birth weight, pre-term birth placental complications and perinatal mortality. In addition smoking during pregnancy has been associated with poor child behaviour at age 5.• Drug use in pregnancy can increase the risk of low birth weight, premature delivery, perinatal mortality, cot death and impairment to the unborn child’s development.• Drinking alcohol during pregnancy is associated with increased risk of miscarriage, risk of Fetal Alcohol Syndrome whose features include: growth deficiency for height and weight, a distinct pattern of facial features and physical characteristics and central nervous system dysfunction.• Maternal depression during pregnancy may affect brain development in the foetus, reduce foetal growth and poses risks of premature labour. Antenatal depression has also been linked to altered immune functioning in the baby after birth. Antenatal anxiety at 32 weeks’ gestation has been linked to behavioural and emotional problems in the child at age 4
Using maternal factors to consider likely outcomes at 5 years old •Data already collected in maternity units •Predictive for outcomes at population level •Informs commissioners decision making for early years resources/ services Predictive Maps available for, Behaviour, Learning and Development , Health outcomes www.chimat.org.uk
Find Out About the Early Years Needs in Your AreaChild Health Learning, Development and Behaviourhttp://www.chimat.org.uk/prof http://www.education.gov.uk/iles researchandstatistics/datasets/ a00198391/dfe-early-years- foundation-stage-profile- results-in-england-201011 Navigate to Figures at Local Authority Level
Getting the Best Prevention from theResources you have for early years• Plan strategically at a population level; intervene proportionately at an individual level. E.g. Family Nurse Partnership• Health Visiting Service offers for families; universal children’s service• Promoting a ‘resilience developing’ asset based style to underpin all interactions
Where Should Support for Foundation Years Come From?• Co-ordinated by health visitors: lead a system for solutions, not services• Children’s Centres – PbR pilots• Building from & on citizens capacity• Third sector and charities
What do parents What is HV contribution? want? A community that supports children and families Needs Predicted Services that Assessed give our baby/child Expressed healthy start. Best advice on a being a parent To know our health visitor and how to Health Visitor contact themTo have the right A quick response if wepeople to help over a have a problem and tolonger term when be given expert advice Responsethings are really and support by the Providedifficult right person DelegateTo know those people Referand that they will worktogether July 2012with us. 25 and 15
Health Visiting Services – Offers for Families
FNP Short Term Impact on OutcomesPregnancy & Birth ↓smoking in pregnancy ↓ pregnancy related complications ↑ uptake of antenatal care ↑breastfeeding initiation ↑birth weights in very young teens ↑improved diet & nutrition in pregnancyInfancy ↓A&E visits –all reasons & for injuries and ingestions (indicator of abuse(0-2 years ) and neglect) ↓ hospital admissions for injuries and ingestions ↓language delay ↓punitive parenting ↓subsequent pregnancies and births ↓welfare use ↑ more sensitive care giving ↑ father involvement in parenting ↑better home learning environment ↑employment ↑emotional development
FNP Medium /Long Term Impact On OutcomesMedium term ↓ severe behaviour problems(2-9 years) ↓ future pregnancies & births (greater duration between births) ↓ welfare use ↓involvement with criminal justice system (mother) ↑ employment and participation in education (mother) ↑ sustained relationship with child’s father/partner (mother) ↑ language development ↑ school readiness ↑ school achievement scores (reading and maths) ↑ home learning environments ↑ stimulating parentingLonger term ↓ child abuse and neglect(Age 15+) ↓ Less criminal and anti-social behaviour (child)
Can it Be Justified in Current Economic Climate?• US economic modelling- $1 spend prevents $5 spend. Cost recovery by age 4.• UK – because of licensing, get same outcomes as US; economic analysis will be part of RCT scope• Babies born to teenage parents at higher likelihood of – £2,500/week to keep a child in residential care – £400/week to support a child in need at home – Up £300,000 /year for a child with additional support needs – £1000 /unscheduled ante-natal admission for investigation with overnight stay for under 18 – £15,000/year public service cumulative costs for a child with ’troubled behaviour’
The New Commissioning Landscape Department of Health NHS Public Health England NHS Monitor CQC Commissioning (economic (quality) Board regulator) HealthWatch(Local health Clinical Commissioningimprovement Providers Groups in LAs) Local authorities (via health & Local wellbeing boards) HealthWatch
The universal prevention and early intervention pathway from pre-pregnancy to 5 Pre-pregnancy information and services (e.g. stop smoking clinics) to improve women’s health Woman discovers she is pregnant and chooses which maternity service to book with via the GP or directly with the midwife Conception GP Team Midwife Online resources, books, leaflets and websites Promoting parents’ self-efficacy & helping them to care well for their child. Linking to other community resources and services including SSCCs. Facilitating community groups & community action
How Third Sectororganisations can help to “make it happen”Fiona Sheil, Public Service Delivery Officer, NCVO Supported by
How Third Sector organisationscan help to “make it happen” 13th June 2012 Fiona Sheil @fionapsdn firstname.lastname@example.org Public Services Team National Council for Voluntary Organisations
Prevention and early intervention – aCroydon perspectiveJon Rouse, CEO, Croydon Council Supported by
Prevention and early intervention – aCroydon perspectiveJon RouseChief Executive
Croydon Borough of contrastsLow wageeconomy withincreasingunemploymentDiverse population Major transport hub40% minority ethnic Good education system Population growth – baby boom
A philosophy – integrated teams around thecitizen to manage complex requirements ● Adult Learning Disabilities ● Adult Mental Health ● Family Justice Centre ● Turnaround Centre ● Youth Homelessness ● Integrated Offender Management ● Family Resilience Team
Croydon’s Journey from Total Place toprevention and early intervention• Customer-led transformation• Evidence based approach• A whole system approach to early help• Continued focus on early ‘early intervention’• Working out the metrics
The Escalating costs of intervention Child looked after in secure accommodation – £134,000 Child looked after in per year placement costs children’s home – £125,000 per year placement costs Cost Multi-dimensional Treatment Foster Care – £68,000 per year Costs increase as for total package of support children get older. Increasing related Child looked after in foster costs such care – £25,000 per yearyi mf / di hc r ept s o C healthcare and the placement costs criminal justice system make it Family Intervention Projects – clear joined up £8-20,000 per family per year working is a core part of cost effectiveness l a l Multi-Systemic Therapy – £7-10,000 per year Parenting programme (e.g. Incredible Years – £900-1,000 per family Family Nurse Partnerships – £3000 per family a yearInformation services –Around £34 via telephone helplineAround £2 via digital services PEIP – £1,200 - 3,000 per parent Children’s Centres - around £600 per user Schools - £5,400 per pupil Severity of assessed need
After Total Place - progressChildren’s Centres - based on collaborations – engaged parents and communities in redesign- hub of their community- universal through to targeted support- early helpFamily Space - website in place and network of children’s centresFamily Advocates & Peer to peer support - ‘Family Navigators’ and commissioned services
After Total Place Geographically based Family Engagement Partnerships with early years practitioners equipped to spot early signs of needs, know how to engage parents quickly in high quality services including early identification and peer2peer supportStruggling with Preparation for Parenthood• children and parents experience system from conception onwards which supports & develops parenting capabilities• pre-natal care holistic preparation for parenthood; emotional needs of parents supported
Continuing to develop preventative andearly intervention service in Croydon• Use a whole system approach and build our evidence base• Use the ‘wedge’ to help us plan interventions• Reduce high cost families so that we can reinvest in preventative services• Continue to work with health colleagues• Develop our metrics across the whole programme of interventions
Mapping Change for Croydon EIFS: Driving better long-term outcomes for children and families Target service level outcomes (Identified atEYS objectives/drivers of change Broader immediate outcomes Long-term outcomes for children & families practitioner workshop) Greater family Sense of control and autonomy over decisions Increased likelihood of parent resilience and Improved social networks & sense of community keeping / finding a job autonomy Stable housing and reduced homelessness Improved emotional Increased likelihood of financial resilience security for the family Stronger home learning environments Reduction in number of children on Child Protection Register/ looked Higher learning achievement among parents after children Improved child Improved educational behaviour at home and achievement Improved learning outcomes among children Reduced likelihood of children school becoming NEET Secure attachment between parent and child Improved long-term and Reduced risk of child intergenerational health including Less abuse/ family violence protection issues reduced risk of mental ill-health Improved parent-child relationship Improved parenting skills Reduced likelihood of drug misuse among parents, children/young Optimise health of children and mothers adults Improvements in child Reduced anti-social and maternal health Having somewhere to play/ be active behaviour/ community Reduced contact of parents with violence criminal justice system Integration of family skills/experience into services Reduced likelihood of children More responsive and entering the criminal justice system Staff awareness of child well-being consistent services Early identification of needs Greater take-up of universal services Well coordinated, consistent services
Early Help & Staged Intervention Support at Stage 1 Support at Stage 2 CRISS; Family Space & Family Practitioner Engagement websites Support at Stage 3 Partnerships Family Peer2peer Resilience Family Navigator Service Parenting Programmes Troubled Family Find me Early Navigators UNIVERSAL LOW/VULNERABLE COMPLEX ACUTEChildren & Young People requiring Children & Young People with low Children, Young People & Children, Young People & personalised universal level additional needs requiring Families with high level needs. Families with complex services single agency support or an additional needs requiring integrated response using a These children/young people specialist/statutory integrated common assessment. include ‘Children in Need’ response; includes child (Section 17) who require protection (Section 47) and integrated, targeted support children whose needs / safety cannot be managed in the community
Croydon – working across the wedge, whole system approach Cost Severity of need R Pb lies mi d Fa ble rou e–T vic Ser ce lien esi bR ly R –P mi es Fa vic ser re ent ’s c ren ild Universal Services Ch s ilie fam all for lp He rly Ea
Reducing High Cost Spend through Croydon’sFamily Resilience Service Av. savings Net saving per year Caseload Caseload Net per family per No. per family savings costs saving yearPhase1 - 60 60 £48.5k £2.91m £840k £2.07m £34.5kWholePilot231 231 £48.5k £11.2m £3.23m £7.9m £34.5k
Capturing net value – a complicatedbusiness• Costs to society include the benefits foregone from not using the resources for some other use• Large differences in the methodologies adopted by studies (few UK studies) aiming to evaluate the economic impact of early years interventions• Difficult to compare results across interventions• BUT emerging UK studies do provide indications that early years interventions generate benefits in the long term that outweigh the costs
Where we need to go next?• Children and parents to experience system from conception onwards which supports and develops parenting capabilities• Pre-natal care holistic preparation for parenthood; emotional needs of parents strongly supported• Maternity services within hospitals transformed and characterised by holistic preparation for parenthood• Continue to build our early intervention approach - evidence based and builds the resilience and autonomy of parents to ensure young children thrive and develop