Evidence-based Early Years Intervention

David Drew Excerpts

Thursday 21st March 2019 Westminster Hall

[Norman Lamb]

I would be grateful if the hon. Gentleman could refer me to that report; it sounds very interesting, but I have not seen it. That prompts the interesting point that many people in prison experienced bad things in their childhood that led to exclusion from school, involvement in the criminal justice system at an early age, low educational attainment and worklessness. There is an awful risk that the cycle will repeat itself. That sounds like a wise set of recommendations, and I would be interested to explore them further.

The final item in the list from NHS Health Scotland is

“growing up in a household in which there are adults experiencing alcohol and drug use problems.”

One in 10 adults has suffered four or more adverse childhood experiences—a disturbingly high statistic that often goes completely unnoticed. I remember visiting Philadelphia and hearing about the impressive work that was being done to confront the problems of trauma that children experience, often as a result of gun crime, in that quite troubled city. Mapping that city shows up areas of concentration where a substantial proportion of children have experienced repeated traumas, which have a clear effect on them.

The trauma that those experiences cause a child is tragedy enough, but we now know that they are also associated with long-term problems such as mental or physical ill health, worklessness and involvement in the criminal justice system. The prevalence of those problems increases with the number of adverse experiences that a person suffers in childhood. Those associated serious problems make the case for tackling childhood adversity as effectively as possible all the stronger.

In last week’s spring statement, the Chancellor said that he was

“in favour of early-intervention approaches where they can be shown to be effective.”—[Official Report, 13 March 2019; Vol. 656, c. 370.]

I welcome the evidence-based approach. From the inquiry undertaken by the Science and Technology Committee, which I chair, I know that the evidence for the effectiveness of early intervention to address adversity is strong. I encourage the Minister to make the case for such intervention to the Chancellor, along with other ministerial colleagues. The hon. Member for Stockton South (Dr Williams) has written—together with me and the Chair of the Education Committee, the right hon. Member for Harlow (Robert Halfon)—to the Chancellor to ask for a meeting to discuss the clear evidence to support the case for investing in early intervention.

The Early Intervention Foundation—the What Works centre for early intervention that the Government established to promote evidence-based policy in this field—reviewed the evidence for more than 100 early intervention programmes and found that 51 had robust evidence of a positive impact. Several of those have received the Early Intervention Foundation’s highest rating for proven effectiveness, having demonstrated

“a long-term positive impact through multiple rigorous evaluations.”

We have heard from organisations that champion the success of the early intervention programmes that they have delivered locally. One example is the Children and Parents Service in Manchester, led by the immensely impressive Dr Caroline White, who gave evidence to our Committee. Because we were so impressed by the evidence she gave, she ended up acting as an expert adviser to the Committee in the shaping of our report. The service accepts parents and pre-school children with early social and emotional problems. Those parents and children are referred to the service by multi-agency staff from across the early years workforce—for example, by health visitors. The service provides thorough psychological assessment and offers intervention as appropriate.

The service can demonstrate evidence of its positive impact since it started almost 20 years ago, including improvements in child behaviour, parental stress and depression and, critically, the risk that a child will face ongoing abuse or neglect. That is a prize worth grasping. The interesting thing about Manchester is that, despite very strained local government financial resources, it has chosen to prioritise the service. Of course there is an argument about the need to invest more in early intervention, because that is where we can be really effective, but lack of money is no excuse not to target resources in effective interventions. Manchester has shown that it is possible to do that in the most impressive way.

It is of relevance to the spending review that effective early intervention offers the opportunity to save precious public resources and help those who have suffered adversity. Tackling the problems associated with adversity as a child—ill health, domestic or substance abuse, low educational attainment and so forth—costs public bodies enormous sums of money over the course of a person’s life. Imagine someone who has low educational attainment, perhaps after being excluded from school, and ends up as an adult without work and potentially in the criminal justice system. Just imagine the total cost to the public purse of maintaining and supporting that person through their life. Just imagine what they could contribute to society if those problems were addressed at source, stopping the trauma becoming entrenched and giving them the chance of a good, productive life that contributes to the common good.

It is estimated that the annual cost of late intervention is at least £16.6 billion, but that does not capture the economic benefit of people living more fulfilled and successful lives. This is a clear case of investing to save over the long term, but between 2010-11 and 2017-18, local authority spending on early intervention fell from £3.7 billion to £1.9 billion. That coincided with an increase in spending on late intervention, which rose from £5.9 billion to £6.7 billion. It seems daft to me that we spend more on coping with the fallout from children being excluded from school, which of course is associated with the horrific violence we are seeing on our streets. Surely it would be so much better to invest early to prevent those problems from happening in the first place.

Regrettably, we have heard that the provision of effective, evidence-based early intervention is not uniform across the country. Pockets of good practice exist—I mentioned Greater Manchester—but the Early Intervention Foundation told us that there are

“lots of examples where we see a gap between what we know from robust, peer-reviewed literature and what happens in local services and systems.”

Given that early intervention is left to local authorities to deliver, without any clear national support or scrutiny or even data collection, that is perhaps unsurprising.

Bluntly, we have no idea as a nation how substantial sums of public money are spent and whether that has any impact at the most critical stage of a child’s life. We are in an extraordinary position, as a country. We collect lots of data from the point at which a child goes to school, but for their most critical, formative years, we have no national data of any substance that we can scrutinise to understand how money is spent nationally and whether it is having any impact.

That fragmented and unco-ordinated approach to early intervention is why we called on the Government to develop a national strategy—incidentally, the Scottish Government and the Welsh Government have already taken that approach—to empower and encourage local authorities to deliver effective, sustainable and evidence-based early intervention. Unfortunately, in their response to our report, the Government largely dismissed our recommendations. I must say to the Minister that we are deeply disappointed by the response from the Department of Health and Social Care. We really hope that a more considered view will be taken, and that the Government will review what we are actually saying and the case we are making. I hope the Minister—as the Science Minister, he is acutely interested in the application of evidence—will champion this issue in Government.

In its response, the Department of Health and Social Care argued that

“local areas are best placed to understand the needs of their local communities”

and

“to commission early intervention services to meet those needs”.

The national strategy we call for would not run contrary to that locally led approach. Instead, a new strategy could raise awareness and ambition among local authorities, provide guidance to them, and describe best practice and establish metrics against which local authorities could be held to account for the early intervention they deliver—without dictating from the centre exactly what each local authority does, because that is not the approach we argue for. Dr Jeanelle de Gruchy, who represents local directors of public health nationally, told us during our inquiry that an overarching national strategy would benefit those working to provide early intervention locally. That is exactly the opposite of what the Government said in their response.

More positively, however, the Government have established an inter-ministerial group to look at how families with children from conception through to age two can best be supported. I really welcome that. Although early intervention can support children of all ages, we know that that early period is critical to brain development. I urge that group to seize the opportunity presented by early intervention. Having highlighted my Committee’s recommendations to all the members of that group individually, I am disappointed that they are not here to respond to the debate. None the less, I welcome the Science Minister and hope very much that he responds positively to what we are saying.

I should also say that I have been encouraged by the reactions of many of the Ministers on that inter-ministerial group. I know that the hon. Member for Stockton South, who led an inquiry of the Select Committee on Health and Social Care into early years, is happy to work with my Committee to find a way of holding an evidence session with members of that inter-ministerial working group about the work they are doing. When does the Minister expect that group to report its findings? How will the Government move forward with its recommendations? Does the group intend to act on my Committee’s recommendations?

Let me briefly set out what my Committee believes a national strategy should contain. First, awareness of the impact of childhood adversity and how it can be addressed could be greater among those who work with children. The early years workforce needs to be defined, and its training reviewed, to ensure it has the knowledge it needs. We spend a lot of time talking about the prevalence of mental ill health among children and young people these days, but we do not spend nearly enough time talking about its causes. If we focused more on the causes, we might be more effective at reducing the prevalence of the problem, which is very disturbing.

[Dr David Drew (Stroud) (Lab/Co-op)]

I am struck by the fact that each of the various counselling organisations in my constituency has stressed to me how much worse children’s mental health has become since we lost the children’s network, particularly in rural areas. Those organisations are picking up a deluge of children who previously would have received at least some early support. That is not there anymore. It is a great tragedy that what we put in place—one of the things I think the last Labour Government did very well—has been lost. Does the right hon. Gentleman agree that we are seeing the consequences of that?

[Norman Lamb]

I guess the hon. Gentleman is talking about Sure Start centres.

[Dr Drew]

Children’s centres in general.

[Norman Lamb]

I will come on to that, but the hon. Gentleman makes an extremely important point. I mentioned earlier that investment in early years preventive services has fallen. That does not seem very wise in the long run.

--- Later in debate ---

[Norman Lamb]

I thank the hon. Gentleman; it is an enormous pleasure to have him as a member of the Select Committee, when he is not tied up with High Speed 2. He is absolutely right. The point was made that when we train social workers, an understanding and an analysis of data is a terribly important part of the effectiveness of their work. We want to see a central, specialist team set up in the early intervention centre, not to impose anything, but to help local authorities to deliver the national strategy.

The strategy should shift the balance of funding from late intervention, which we know is less effective, to early intervention, which we know can be more effective. The spending review should establish how best this can be achieved. If the inter-ministerial group and the Government more generally reviewed the evidence base for early intervention and took up our call for a national strategy on these lines, it would make a massive difference to children across our country, now and in the future.

[Dr Drew]

One of the groups that I feel most sorry for now is health visitors. To be fair to Prime Minister Cameron, he identified health visitors as one of the key elements in early years intervention, yet all the health visitors who I talk to say that they are very much under pressure. They are struggling to do their statutory work, let alone some of the other things they do. Would the right hon. Gentleman agree, and did he discover something about that?

[Norman Lamb]

The hon. Gentleman must be psychic; I was just about to talk about the programmes that health visitors implement. He is right that the number of health visitors is falling after a significant rise during the coalition years. There was a target set for extra numbers, and they were recruited, but those numbers are now falling back.

The Government must also review some of the programmes that support the provision of early intervention. Foremost among these is the healthy child programme, which is delivered by health visitors and under which every child should receive five mandatory health visits before the age of three. However, Public Health England statistics show that only around 80% of children receive these visits, aside from the newborn visit, which means that 20% do not. That is despite the fact that Public Health England itself acknowledges that without health visits,

“it is possible for children not to be seen by any professional until they start school or not at all if they are home educated.”

I understand the importance of the role of the parent, but if a parent is neglecting a child’s needs and no professional is able to identify and pick that up during those critical early years, that is storing up huge problems for the future and massively letting down that child.

The Government’s response to our recommendation to increase coverage was silent on how that might be done; in fact, it was even silent about whether the Government aspired to achieve that at all. The Minister implied that so long as coverage was better in more deprived areas, it was not an issue to worry about too much, but we know that adversity can happen in any family, regardless of affluence. The Government must now set out a clear strategy for how they intend to increase coverage of the five mandated health visits to 100%, and must also make sure that that strategy does not simply increase the strain on the health visitor workforce, which was mentioned by the hon. Member for Stroud (Dr Drew), diluting health visitors’ impact on each family. I ask the Minister, are the Government really content with the patchy coverage of the five mandated health visits being achieved, and if not, what concrete steps are they taking to improve the situation?

We also call on the Government to address the issue of Sure Start children’s centres—the first point that the hon. Member for Stroud raised. Back in 2015, it was announced that there would be a consultation on the future of Sure Start centres. Four years on, we are still waiting for that consultation to take place, let alone any decision. In the aftermath of the announcement of the consultation, Ofsted announced that it would suspend inspections of children’s centres, so for four years we have had no inspections, either. That is surely a dreadful neglect of responsibility. Local authorities have no idea what the Government’s view is about children centres. Do they support them? Do they believe that they are valuable? Are they choosing to abandon them? Surely it is not unreasonable to expect a decision four years after the consultation was announced.

By now, the Department for Education should have developed an improved framework; it should not have left local authorities to tackle the situation when they do not have any clarity about the Government’s plans for these centres. Delegating quality assessment to local authorities, in the absence of central support or guidance, risks leading to the same fragmentation we see across all other aspects of early intervention. Local authorities are crying out for clarity on the future role of Sure Start centres. Will the Government hold a consultation on children’s centres inspections, or will they not? Sadly, we are seeing a gradual drift of closures around the country. In my county of Norfolk, a 50% cut in funding for children’s centres has been announced, so many of them will close down, without any clear plan of what the alternative should be. Surely that is unacceptable. Is it now established Government policy that the quality assurance of children’s centres has been devolved from Ofsted to individual local authorities, or is that still a stop-gap measure? Are we still waiting for a final permanent conclusion to this?

Returning to the wider scope of my Committee’s inquiry, early intervention used to tackle and ideally prevent childhood adversity can transform lives and reduce costs to Government. That is the great double prize to be won. There continues to be a pressing need for a fundamental shift in the Government’s approach to early intervention, targeting childhood adversity and trauma. The Government should match the ambition of the Scottish and Welsh Governments, and build on the example set by certain English councils, to make early intervention and childhood adversity a priority, and set out a clear, new national strategy to empower and encourage local authorities to deliver effective, sustainable, evidence-based early intervention. The new inter-ministerial group spans multiple Government Departments and has obvious authority. I call on that group to review our report, and to seize the opportunity offered by effective, evidence-based early intervention by making it a focus of its recommendations later this year.

--- Later in debate ---

[Darren Jones]

I agree with my hon. Friend; that was why the conference we held in Bristol was so popular—so popular, in fact, with over 400 delegates wanting to come, that they had to run the conference twice, because they could not fit everyone into the setting to do it together. More than 50 partner organisations across education, policing, probation, the voluntary sector, health, social care, public health and the Mayor’s office have signed up to our vision in Bristol.

This is also a question of political leadership, because Bristol knows that multiple ACEs lead to other factors that make for a negative environment in the communities in which we live. We know they will have an impact on problems such as knife crime and gang activity, and that they cause problems with mental health for people and therefore a lack of positive environment in the community, but also problems for economic productivity. That is why, in our “One City Plan” in Bristol, we have a clear and specific target of ensuring that children,

“grow up free of adverse childhood experiences having had the best start in life and support through their life.”

That particular strategic target for the council is linked to other targets, such as reducing knife crime and gang activity, dealing with period poverty and ensuring affordable childcare.

However, the access point is really important—returning to the comments by my hon. Friend the Member for East Lothian (Martin Whitfield). We cannot just rely on police or a school; we need a way to ensure that intervention, support or just someone being there when you need them are available. I reiterate the comments that the Chair of the Select Committee made about the lack of delivery on the health visitor programme where, as has been said, many people have no intervention or access point for much of their early years.

That is why, in Bristol, we have been able to protect all our children’s centres. The financing has clearly been cut because of austerity funding from central Government, and the services that can be made available have gone down to the bare minimum, but we have kept them all open for that reason. I pay tribute, as I have on previous occasions, to my friends the Mayor of Bristol, Marvin Rees, and the cabinet member for children and young people’s services, Councillor Helen Godwin, for ensuring that sustainability in Bristol.

In a previous debate in this place on the funding of maintained nursery schools, my hon. Friend the Member for Bristol West (Thangam Debbonaire) made a powerful point about a constituent of hers who said that she was in a domestic violence situation and the only way that she could get access to support was by taking her child to the children’s centre, because it was not seen to be going to the police or going to get intervention for the abuse she was suffering from her partner. She was taking the kids to nursery, but because the services were co-located in that environment, she was able to get support.

[Dr Drew]

It is good to hear that children’s centres still exist in some parts of the country. In my constituency we only have two left. Does my hon. Friend agree that the problem is that it is locking the NHS in? That may be only a Gloucestershire problem, or it may happen further afield as well. We seem to have failed with the idea that it should be education, police and children’s services in general; it always seems that the NHS is the weak link. Is that true in his part of the world, or is it just a Gloucestershire phenomenon?

[Darren Jones]

All I know in my part of the world is that the health service and our schools are having to pick up more and more of the work that others used to do in the past. Certainly, if I talk to headteachers in some of the more challenging parts of my constituency, they tell me that they are having to invest more and more in family support staff, who work with families and young pupils in a way that schools were never placed to do in the past. We all know that school budgets are extremely tight, so that particular school is using some of its pupil premium funding to help children in those scenarios. I am pretty sure that the original intention of pupil premium funding was not to offset cuts to children’s centres or local councils; it was to give an extra hand to pupils from poorer backgrounds to get on and do well in life. In fact, it is just covering cuts made from the centre, and is therefore ultimately not having a positive impact on the bottom line, either for individuals or for the country.

However, this is not only about council leadership, because we also often rely on the charitable sector for the delivery of services. In my constituency is the Southmead Project, led by a chap called Dr Mike Pierce, who received an MBE for his work in this space. Mike was born and bred in Southmead and was himself the victim of adverse childhood experiences, and he speaks powerfully on the issue. I have done so before, but I again pay tribute to him. His leadership over the 24 years that the project has supported young people in that area has been quite remarkable.

However, Mike is not optimistic about the future. He relies on generous charitable fundraising, philanthropic donations and sponsorship from local businesses in order to keep his project afloat, in the face of cuts not only to the council but to organisations such as clinical commissioning groups and the police, which previously supported his charitable organisation. At the same time, demand is increasing. The project has a waiting list of young people in households where domestic violence or drug or alcohol misuse—or worse—are present, and it cannot get around to giving those young people the support that they need because it does not have the capacity to do so.

As a consequence—this is often the case when there are cuts to public services—residents end up coming to see their MP because there is nowhere else to go. It really is heartbreaking when constituents are in front of me in tears, with no access to support. Quite frankly, there is very little I can do, as the Member of Parliament, other than raising issues such as this in the House. We must understand that the decisions we make on public policy, funding and national strategies flow through directly to the lives of these young people, whose potential is being lost.