Inequalities in early childhood: proportionate universalism Giving - - PowerPoint PPT Presentation

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
• vercrowded 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
• utcomes for children

becomes evident when their families experience

• nly 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 – Y ear 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

• f 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

• f 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

• f 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 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 1 9 8 8 1 9 9 8 2 2 2 2 4 2 6 2 8 2 1 2 1 2 2 1 4

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

References

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