Proportionate universalism in the foundation years Sarah Cowley 29 th January 2015
Marmot (2010 p 23) Fair Society, Healthy Lives 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.....
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 paradox 1 Caution: figures (next) are Figures are old (2000-09) and for explanation only 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 1 Rose s strategy of preventive medicine
Family Disadvantage Indicators No parent is in work Family lives in poor quality or overcrowded 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 outcomes for children becomes evident when their families experience only 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
Local authorities in England Obesity prevalence and deprivation National Child Measurement Programme 2013/14 Year 6 children Child obesity: BMI 95 th cen6le of the UK90 growth reference 11 Patterns and trends in child obesity (note a similar patternis seen in Reception year)
Prevention paradox A large number of people at small risk may give rise to more cases of disease than a small number of 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) 2 nd 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
Bronfenbrenner s (1986) concept of nested systems Wider community Neighbourhood Family Parent Child Shifting focus of attention to need Situation, resources to meet need Simultaneous assessment, prevention, intervention
Health visiting practice Focus on situation and resources needed for prevention and promotion Community and caregiver capacity 1 Foundations of health 1 Wider community Neighbourhood Family Stable, responsive relationships Parent Safe, supportive environments Child Appropriate nutrition 1 www.developingchild.harvard.edu
Relational process; focused practice Salutogenic (health creation) Person-centred Person-incontext Bidmead C (2013) http://www.kcl.ac.uk/nursing/research/nnru/publications/reports/appendices-12-02-13.pdf
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 Literature review Narra6ve synthesis of health visi6ng prac6ce Empirical study Recruitment and reten6on for health visi6ng AIMS Empirical study Voice of service users 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.
Cowley et al (2014) http://dx.doi.org/10.1016/j.ijnurstu.2014.07.013 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
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 of 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 centrebased) 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) Sure Start Local Programmes Children s Centres 2002/03 2004/05 millions (actual) 2005/06 2007/08 millions (actual) 141 840 1074 838 0 13 656 2205 Health visitors 965 965 900 840 totals 1106 1818 2630 3883 2008/09 2010/11 millions (estimated) Source: Audit Commission (2010) Giving Children a Healthy Start
Whole time equivalent (WTE)health visitors employed in England (1988) 1998-2014 12,000 11,500 11,000 10,500 10,000 9,500 9,000 8,500 8,000 7,500 10,680 1988 10,020 10,050 10,190 9,999 10,137 10,070 10,046 9,912 9,809 9,376 9,056 8764 8519 Target$=$12,292$WTE$$ (May$2015)$$$ $ 1998 2000 2002 2004 2006 2008 2010 Oct$2014$=$11,102$$ Incl.$550$non1ESR$ $ 8017 7941 2012 8385 * 9550 2014 10800 WTE health visitors 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
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