1                   Introduction

1.1.1         Public Health Wales welcomes the focus being given to the First 1000 Days through this series of Consultations and the opportunity to provide evidence for consideration by the Committee.

1.1.2         The Early Years is a priority area for Public Health Wales acknowledging the growing body of international evidence that investment in action in the early years of a child’s life brings life-long benefits[1]. The First 1000 Days Programme led by Public Health Wales on behalf of CymruWellWales is a response to this prioritisation. The programme is taking a whole system approach to improving outcomes and reducing inequalities in the period from conception to a child’s second birthday.

1.1.3         The origins of many of the inequalities we see in physical and mental health lie in early childhood and before birth.  The early years – from pre-birth to seven years of age – is a critical part of childhood when children grow, develop, play and learn. Children’s experiences in this time are a key factor in determining future health and well-being. There are proven long lasting and positive effects from early years programmes. Central among these important influencing factors is the potential to reduce or prevent exposure to adverse childhood experiences in the early years and to take steps to reduce the lifelong impact of childhood trauma when it does occur.

1.1.4         The core Flying Start offer to families living in eligible areas provides services that are evidenced to support improved outcomes in the early years including access to; free ‘quality’ part time childcare for all eligible 2 to 3 year olds; enhanced health visiting contact; parenting support programmes and support for early language development and play[2]. Public Health Wales considers the provision of these types of services to be key in reducing inequalities and improving outcomes for children in the first 1000 days and beyond. The impact of such services is however likely to be greatest where provision is based on individual/family rather than geographically measures of need.

1.1.5         We have responded to each of the areas highlighted within the consultation below, outlining the current position in Wales; evidence where it is available on the effectiveness of current programmes and where appropriate making suggestions for future improvement.

1.2             The outreach element of Flying Start requiring Local Authorities to identify children living outside defined Flying Start areas who would benefit from Flying Start services.

1.2.1         There is strong evidence that giving every child the best start in life is key to reducing inequalities. The most effective approach to achieving this is through the provision of universal services which can be supplemented by higher intensity support as individual’s and families’ needs or vulnerability increases[3].

1.2.2         In Wales midwifery and health visiting services represent the universal service in pregnancy and the early years. Flying Start currently provides targeted support in some of the most disadvantaged geographical areas of Wales and represents the more intensive support offer funded by Welsh Government to families living in these areas. 

1.2.3         The First 1000 Days Programme works through a collaborative model in localities across Wales, as defined by the boundaries of Public Services Boards. Together we are engaging the local workforce across a wide range of services and settings in the public and voluntary sectors, and this process begins with a System Engagement Event. There have been four held to date and a summary of the early themes coming from these events has been produced for the First 1000 Days Programme Board.

1.2.4         A key theme identified by areas working with the First 1000 Days Collaborative is that services should be proportionate to the needs of families irrespective of geography. There are currently significant differences in the level and range of services available to families between Flying Start and non-Flying Start areas, even though the level of need might be the same. There is a common feeling across First 1000 Days Collaborative areas that a more widely available enhanced service, particularly for midwifery and health visiting, would improve childhood outcomes. There is also consistent feedback that the way in which funding is organised and administered is a barrier to innovation and service development.

1.2.5         One argument often made for the geographical basis of Flying Start is the fact that making services available to everyone in a defined geographical area reduces the risk of families feeling stigmatised, as no one family is singled out for special support. There are a range of approaches that can be taken to reducing the risk of stigma, including embedding tiers of enhanced provision within universal services. In the first 1000 days the universal service is the NHS through its midwifery and health visiting services.  While we would not advocate that all action needs to be delivered by health professionals, they are uniquely placed to identify need for additional support and to co-ordinate enhanced care. 

1.2.6         There may be value in considering a mixed model for the future provision of Flying Start with some elements retaining a geographical focus, but others becoming more focussed on individual need. We would propose that Flying Start and similar programmes would have a greater impact at population level if the additional NHS services funded through these programmes were flexible enough to provide more intensive preventative interventions to all families where a defined level of need has been identified regardless of where they live. However Health Boards are challenged to resource the minimum universal contacts and assessments set out in the Healthy Child Wales Programme within existing resources.  Enabling Health Visitors and Midwives to make additional visits (enhanced universal provision) can often result in early intervention and prevent problems developing, but requires investment. 

1.3             The extent to which sufficient Flying Start funding is provided to reflect the outreach element of Flying Start delivery plans and whether the workforce capacity is sufficient to deliver the programme and its outreach elements

1.3.1         Despite the growing evidence that a greater prioritisation of our resources in the very early years would bring both additional lifelong benefits and a better return on investment for society and public services there is currently proportionally less financial investment made in the early years than across the rest of the lifecourse3.

1.3.2         Funding for Flying Start outreach is set at 2.5% of the uplift from the 2012 funding levels[4] with guidance stating that these funds should be used to deliver elements of Flying Start to children, with an identified need, across the wider local authority.

1.3.3         Analysis carried out by Public Health Wales has shown that 37.5% of poor or income deprived people live within the geographical areas that are within the most deprived quintile in Wales. This means that nearly two thirds of people who are income deprived live outside of geographical areas that are defined as deprived. It is therefore highly unlikely that the relatively small proportion of Flying Start funding available for outreach work is sufficient to meet the needs of families living outside of Flying Start areas.

1.3.4         A further theme identified through the First 1000 Days System Engagement Events held to date has been that Collaborative areas have found that services within a single PSB area can be working to different thresholds and criteria of need. More generally, the Programme has also found that assessments are not based on an assessment of overall risk, which is an essential underpinning to a focus on prevention. Whilst a great deal of information is gathered, it is not routine practice to holistically assess the combined factors in an individual’s situation. This has implications for the effective identification of those families that would benefit most from the limited outreach capacity currently available through Flying Start.

1.3.5         It is also worth noting that many interventions that could improve outcomes for children at a population level not only provide good return on investment but are also relatively low cost.  Language development requires relatively simple action by parents and other adults, in talking to children from birth; reading together and learning songs and nursery rhymes etc.  This work can be supported by early year’s provision such as nurseries and play groups, particularly to support those families which may struggle to provide consistent interaction for children.  We are aware that the work in Bridgend through Flying Start has made a significant difference to language development by working with early year’s provision.  Ensuring that learning such as this is shared and adopted throughout Wales would help to ensure a population level impact across the country.

1.4             The evidence on outcomes for parents and children in Flying Start areas compared to the outcomes for parents and children in areas that are most similar in terms of deprivation levels but are not Flying Start areas.

1.4.1         This question highlights the inherent limitation in the current delivery model of Flying Start. The geographical model of provision means that there are children in Wales who are likely to be experiencing equal levels of need but are not able to access the same support as a result of where they live. 

1.4.2         There are a number of factors that make evidencing the impact of Flying Start difficult. There is a great deal of activity and a number of services working with families in the first 1000 days, offering a wide range of provision. When families access a range of services and support it can be difficult to provide evidence of the causal links between specific interventions and improvements in outcomes. Further work could be undertaken to ensure consistency in recording interventions across areas through the development of a common taxonomy.

1.4.3         It is also difficult to measure the impact of programmes and initiatives designed to improve outcomes if insufficient focus has been given to evaluation from the outset or where evaluation approaches have not included a comparison group.  This has been a challenge with the Flying Start Programme and we are aware of very little analysis that has been able to compare outcomes for families in Flying Start areas with outcomes in areas experiencing similar levels of deprivation which are not Flying Start areas[5]. Any adaptations to the future delivery of Flying Start should build in consideration of the evaluation of impact from the beginning.

1.4.4         Currently, the Healthy Child Wales programme is being implemented and this will see an increase in the quality, consistency and availability of outcomes data for families receiving health visiting services outside of Flying Start areas. There would be benefit in ensuring that the metrics recorded across both Flying Start and health visiting services are aligned to allow for a more effective measurement of impact across these services in the future.

2                   Conclusions

2.1.1         Public Health Wales welcomes the greater attention and focus that this critical period of child development is gaining. 

2.1.2         Evidence suggests that universal service provision should be the starting point for action to address inequalities. In Wales our midwifery and health visiting services, delivered through the NHS, provide the core universal service during pregnancy and the early years.

2.1.3         While the rates of poorer outcomes are higher in certain populations; individuals and families with the same level of disadvantage will also be present outside of those communities and often in larger numbers.  Targeting of support such as Flying Start at geographical communities has the potential to create a different sort of inequality, where families in high need do not get the same access to support because they live in the wrong area.  Ensuring that universal Health Visiting and Midwifery services have the capacity to provide enhanced services according to need; building on the current Healthy Child Wales Programme offer could improve our ability to intervene early and prevent problems developing, but would require investment.