Evidence-based Early Years Intervention

Debate between Norman Lamb and Paul Williams

Thursday 21st March 2019 Westminster Hall

[Norman Lamb (North Norfolk) (LD)]

I beg to move,

That this House has considered the Eleventh Report of the Science and Technology Committee, Evidence-based early years intervention, HC 506, and the Government response, HC 1898.

It is a pleasure to serve under your chairmanship, Mr Davies—for the first time, I think. We are spending this afternoon talking about a subject that has absolutely nothing to do with Brexit, and which I hope might unite us.

Last year, the Science and Technology Committee held an inquiry into childhood adversity and trauma and the early-intervention approaches that can be used to address those problems. As I said in a statement in November in Westminster Hall, following the publication of our report, this issue is of significant national importance. Around one in two adults in the UK has suffered at least one adverse childhood experience. That may include abuse, neglect or growing up in some other difficult situation, such as a household where someone suffers substance abuse or domestic violence.

Interestingly, the website of NHS Health Scotland includes a list of typical adverse childhood experiences:

“domestic violence, parental abandonment through separation or divorce, a parent with a mental health condition”—

often that can have a significant impact on the child in the household. It continues:

“being the victim of abuse (physical, sexual and/or emotional), being the victim of neglect (physical and emotional), a member of the household being in prison”—

again, that has a significant potential impact.

[Dr Paul Williams (Stockton South) (Lab)]

I apologise for interrupting the right hon. Gentleman’s list. He mentioned that being a child of someone in prison is considered an adverse childhood experience. Has he seen the excellent report published this week by Crest Advisory, which identifies that there are many more children of prisoners than previously expected? It recommends that as part of the criminal justice process, those children should be identified and local authorities should be notified to provide them with enhanced support, because they may be at risk.

[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.

--- Later in debate ---

[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.

[Dr Williams]

I thank the right hon. Gentleman for giving way again. Will he comment on the Government’s prevention strategy? Last November, the Government launched a consultation document on that strategy, saying that prevention was better than cure. Will he reflect on the adequacy or otherwise of the Government’s proposed approach to the kind of primary prevention in the early years that he talks about?

[Norman Lamb]

I welcomed the fact that the Secretary of State had identified the importance of prevention, although I noted that there was not much reference to mental health in the prevention strategy, and I have raised that with him. As I understand it, he plans to publish a Green Paper on prevention sometime in the spring, although the concept of seasons is elastic in Whitehall. I welcome that, but of course it has to have substance to it. We have to think about the social determinants of ill health, on which there generally is not sufficient focus. Poverty, poor housing and so forth are also critical factors, not only in our physical health but in our mental health.

I was going to mention that the Secretary of State has identified prevention as something that he wants to prioritise. It is up to us to guide and encourage him along a route that could reap real rewards, not only for individuals but for Government, in the longer term.

The next part of the proposed national strategy would be the collection and analysis of appropriate data. We believe that can help to identify families who would benefit from early intervention, to provide insight into how well different early intervention approaches are working, to drive continual improvement and to allow local authorities to be held to account. The national strategy should identify what data should be collected and support local authorities in delivering data-driven services. If a service is based on data and its analysis, it is more likely that evidence will be applied effectively and that we will make better use of public money. If we use public money in a way that is not based on evidence, we waste it; we cannot justify that to taxpayers, for whom the amount that they are expected to pay is often a strain. They demand that money be spent effectively in government.

The strategy should make use of the growing field of implementation science—a point that we were struck by in Dr Caroline White’s evidence. She focused on not taking an off-the-peg evidence-based programme and assuming that it will work effectively, and made the point that any programme should be properly implemented by trained staff who are supervised effectively, and that data should be used to monitor performance. Those factors are critical in ensuring that a programme can be effective in its application.

--- Later in debate ---

[Dr Paul Williams (Stockton South) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Davies. I wholeheartedly welcome the excellent report by the right hon. Member for North Norfolk (Norman Lamb) and his colleagues. I thank them for their attention to detail and their superb recommendations. I recently chaired a Health and Social Care Committee inquiry into “First 1000 days of life”—it is listed on the Order Paper as a connected report—and I will talk about some of our findings. I also chair the all-party parliamentary group for the prevention of adverse childhood experiences. The debate has real relevance to both.

In my 27 years’ experience of studying and then working in health services, as I still do, I have realised that if our society wants the most effective interventions that improve health and reduce inequalities, we have to act in the early years—particularly in the period from conception to the age of two, but generally the earlier, the better—because the real seeds of health inequalities are sown during that time. Good physical, emotional, social and language development during that time is crucial to building healthy brains and healthy children, which leads to our having a healthier and better society.

The Health and Social Care Committee’s “First 1000 days of life” report, which I recommend to colleagues—they may not get the chance to read it, so I will highlight a few recommendations later—sets the Government the ambitious challenge of kick-starting the second revolution in early years services, as recommended in the 2010 Marmot report, so that our country can become the best place in the world for a child to be born into. Almost all the research into this subject demonstrates that our path in life is set during the crucial early years. Healthy social and emotional development during that time lays the foundations for good physical and mental health.

However, our current political system invests a fortune in reacting to problems later on in life but is currently disinvesting in early years, leaving a gaping void where we should be warriors and champions for a healthier society. During the first 1,000 days of life, from when a baby is conceived until the age of two, more than 1 million new brain connections are made every single second. Imagine that: a million new brain connections made every single second.

Brains are shaped by their interactions with society, but tragically, more than 8,000 babies under the age of one in this country live in households where the trilogy of domestic violence, alcohol or drug dependency and severe mental illness are all present. More than 8,000 developing brains under the age of one—a crucial age—are exposed to that environment. More than 200,000 children under the age of one live with an adult who has experienced domestic violence or abuse. We have already heard powerful arguments for intervening to reduce that cycle of abuse. Two million children under the age of five live with an adult with a mental health problem.

We know that many children who experience such adversity become happy and healthy adults, but adversity in childhood is strongly linked to almost all health problems and many social problems. Children exposed to adverse childhood experiences such as those that my hon. Friend the Member for Bristol North West (Darren Jones) talked about are much more likely to get physical health problems, such as heart disease. Exposure to ACEs as a child increases the chances of getting heart disease, cancer and mental health problems in adulthood.

[Norman Lamb]

And obesity.

[Dr Williams]

And obesity.

Children exposed to four or more ACEs are 30 times more likely to attempt suicide at some point in their life. They are 11 times more likely to end up in prison. They are even three times more likely to smoke in adulthood than people who did not experience any ACEs. Our politics is currently failing many of these children, and it is failing other families in which children and young people are still living in poverty.

My belief is that we need to devote more attention to and provide more protection during the early years. As we have seen today, many people from across the political divide share that belief, even though we do not seem to have a politics that ends up delivering more resources in this area. It is an area in which politicians should be working together. It was really encouraging to see the announcement last year of the early years family support ministerial group, led by the Leader of the House. That has the potential to take forward some of the Science and Technology Committee’s recommendations.

To conclude, I would like to reflect on some of the parallel and supporting recommendations made by the Health and Social Care Committee following our inquiry. We also, and independently, identified the lack of a long-term cross-departmental strategy for the early years. The lack of strategy means that it is extremely difficult for local authorities to know what they should be doing. That results in some local authorities excelling, and it may well be that they are the ones that most come to the attention of Government, but many local authorities really would appreciate more central direction on this and would welcome it if the Government set some demanding goals to reduce ACEs, improve school-readiness and reduce infant mortality and child poverty. We have to consider all this in the context of increasing levels of child poverty, too.

Our report recommended that a Cabinet-level Minister, possibly the Minister for the Cabinet Office, should have specific Cabinet-level responsibility for the oversight of a national early years strategy. However, it is not enough just to have strong central leadership, although that is necessary; the Government are right to say that all the delivery must be local. The Committee that I chaired heard evidence of fantastic local community collaboration—the NHS, local authorities, the voluntary and community sector, and normal members of local communities working together. They should be the people bringing the Government’s national strategy to life at local level, inspiring improved support for children, parents and families in their areas.

However, that requires money and it requires organisations to pool budgets. We have seen health services and local authorities pool budgets into the better care fund in order to deliver on shared objectives for older adults. I think that we should have a better start fund, whereby local authorities, health services and the voluntary and community sector are pooling all their financial but also human resources around a set of shared objectives for the start of life.

There should also be a named, nominated individual in every local authority who is accountable to Government for that, because without accountability there is a real difficulty in ensuring that every local authority is meeting the required standards. There needs to be accountability and ring-fencing of money. There will always be urgent problems that demand attention and resources. We need to be able to secure this strategic shift from reaction to prevention, from constantly dealing with the urgent problems that are in front of us to investment in tackling the important problems that will reduce the urgent problems in subsequent years.

The Health and Social Care Committee’s report also calls for the existing and very good healthy child programme to be improved and given greater impetus. We think that it should be expanded to focus on the whole family, including fathers, rather than just the child, and that it should begin before conception. At the moment it does not begin until there is a child developing in a mother’s womb, but more work could be done before conception. The science of epigenetics is teaching us that what happens before conception can have a lifelong impact. The healthy child programme also needs to deliver more continuity of care for families. Having a different point of contact every time often leaves vulnerable families feeling isolated and confused. Health visitor engagement should be extended beyond the age of two and a half to ensure that all children are school-ready.

Our Committee heard from Scotland, Wales, Northern Ireland and other parts of the United Kingdom that had enhanced the healthy child programme. However, as the right hon. Member for North Norfolk has identified, there are many parts of the country where the healthy child programme is inadequate. At the moment there are five mandated contacts, and we heard that for some families that contact involves just sending a letter. How can a mum who is experiencing mental health problems, with all the associated stigma and the difficulty of disclosing that, possibly disclose it in the context of filling in a form rather than of having a supportive and engaged individual who is building a relationship with her? We were also told that 65% of families do not see a health visitor after the six to eight-week check. That clearly is not good enough.

Like the Science and Technology Committee, the Health and Social Care Committee identified the need for much better information sharing. Information needs to be shared among the different organisations. One problem is that there are often many different organisations helping to support a family and they are not talking to one another and do not use the same computer systems. Information governance rules can be an issue. Even though we know that the seventh Caldicott principle—sharing information when that is in someone’s best interests—is often the most important one, individuals working in those organisations often think that they are doing the right thing by not sharing information.

We also need to share information to make it possible for the long-term impact of interventions, perhaps in pregnancy or in early childhood, to be tracked to measure their effectiveness. At the moment, because we do not use a single identifier such as the NHS number, we cannot see whether a pregnancy intervention is having a desired outcome.

[Norman Lamb]

On the point about information sharing, it always strikes me that the tragedies that happen, such as that of Baby P, often happen because of a failure to share information and never because too much information has been shared. It is vital to change the culture, so that people understand the principle of the Caldicott rules about the importance of sharing information.

[Dr Williams]

I agree wholeheartedly. The right hon. Gentleman is right to use the word “culture”, because even though the guidance and rules are clear, and there are many circumstances in which it is in a person’s best interests for information to be shared, and actually the public expect us to be sharing information, the culture in health and care services is often one in which very well-intentioned and well-meaning professionals feel that they are acting in a patient’s interests by not sharing information. Perhaps the leaders of organisations are not permissive enough and encouraging enough about such sharing.

Last but certainly not least, the workforce are crucial to this. There must be a workforce strategy to tackle the reduction in the number of health visitors. I do not think that was a deliberate strategy, with the Government saying, “Let’s cut the number of health visitors by 2,000.” I think it has happened by accident. I think it has happened because the commissioning of the healthy child programme for the 0-to-19 age group was taken away from the NHS and given to local authorities, and that happened to coincide with a time when we had a Government who perhaps had less central control of that, and austerity. Of course, austerity was deliberate, but I do not think that anyone ever sat down and said, “It would be better for our country to have fewer health visitors.” Nevertheless, the consequence has been that there are fewer health visitors, and we need to make sure that those massive gaps are plugged.

We also need to make sure that the skills and knowledge of existing health visitors are improved. That is not to say that they do not have high levels of knowledge, but I have met many health visitors in the past year who had only recently become aware of the concept of ACEs, and who perhaps still lacked some skills around motivational interviewing and the ability to put themselves in another person’s shoes—to move towards where people are, rather than following the traditional, slightly more paternalistic approach of health services, which has been to try to persuade people to move to where we are.

If we get early years right, there will be huge benefits for everyone in our society. As politicians we should try to get them right, not just because it makes financial sense, but because every one of us knows that the evidence shows that doing so will create a better society. We should do it because we have a moral responsibility to our country’s children. Every child deserves the best start in life.