[Relevant Documents: Thirteenth Report of the Health and Social Care Committee, First 1000 days of life, HC 1496, and Ninth Report of the Education Committee, Tackling disadvantage in the early years, HC 1006.]
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.
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 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?
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?
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.
Martin Whitfield (East Lothian) (Lab)
I am grateful to the Chair of the Science and Technology Committee for giving way. He is right to make that point. In the report, we have provided vast amounts of evidence that the collection of data is important, but not the end. The final stage is taking the data and feeding the information it provides back to the individuals affected, so the systems that can and have been identified can be rolled out and attuned to the needs of the young people and families who will use them.
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.
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?
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?
It is a pleasure to serve under your chairmanship, Mr Davies, and to speak as a member of the Science and Technology Committee. I pay tribute to our Chairman, the right hon. Member for North Norfolk (Norman Lamb), for providing the leadership and allowing us to undertake this work on the Select Committee, and to draw conclusions from a wide-ranging gathering of evidence.
I am sure this is not a party political issue. Everyone will agree that it is right to intervene when there are adverse childhood experiences. The evidence, as we have heard today and as we stated in our Select Committee report, is very strong on that point. We know that many of the problems that lead to adverse childhood experiences, whether increasing domestic violence, drug or alcohol misuse, mental health problems or financial stress and money worries, are part of the cycle of harm that can lead to a multi-generational impact of these heartbreaking situations.
In my view—as a member of the Labour party, this is inherent to my political decisions—that is linked to poverty and inequality. That is why, whether on adverse childhood experiences, Sure Start and children’s centres, or any form of investment in the early years, I keep finding myself back in this place talking about those issues, because they are the nub of the cause for many young people, who, through no fault of their own, suffer in their life as a consequence of the poverty in our country.
I congratulate the Chair of the Select Committee on making it clear that evidence, the use of data and investment in prevention are the way to go. I am sure the Science Minister will agree with that, given that he is the Science Minister, but I rather hope that he might share that conclusion with colleagues in his new cross-departmental group.
This is not only an issue of concern to me at a national level; I have a strong constituency interest in the matter, too. Bristol City Council, for example, is leading in innovation in this area of work. On 17 January 2019, my colleagues in City Hall held a conference on adverse childhood experiences in Bristol and how the council’s new vision statement could bring partners together to help tackle the causes. The event was held by the council in partnership with Avon and Somerset police and our clinical commissioning group.
I am grateful to the hon. Gentleman for his work on this subject on the Committee. He mentioned the police; I do not know whether he is aware of it, but there is some really good, innovative work going on, linking police to schools. When the police identify a situation of domestic violence overnight, they will alert the school first thing, so that a child arriving at school who has perhaps experienced the most horrific trauma overnight is given proper support and protection the following day, rather than perhaps being told off for being a naughty child, which can easily happen in ignorance of what has happened to them.
The right hon. Gentleman is absolutely right. Partnership working is a phrase that we often hear in local government, and sometimes it is a bit amorphous, but that is a classic example of why it is so important. I have had cases where constituents have told me stories of when they would go to school, albeit a long time ago now, and end up being treated as if they were ill and having to sleep in the nurse’s room at the school as opposed to taking part in classes, because of the experiences they were dealing with at home. As a consequence they missed out on their education, when instead the support should have been put in place at that time to help them in the best possible way.
The involvement of Avon and Somerset police is important because we know, and the evidence shows, that for children who suffer adverse childhood experiences, especially those who suffer multiple ACEs, the outcomes associated with that cycle of harm include mental health problems and drug or alcohol misuse—criminal activity is therefore connected with that. The police have a role not only in tackling criminal activity but, as I said at the outset of my speech, in helping to deal with the causes.
Martin Whitfield
Does my hon. Friend agree that it is not a question of simply identifying children who have suffered or are vulnerable to suffering such experiences, but that the real importance and the real financial saving is in the interventions that follow; and that the good practice that has been shown in many areas, if it were shared across the country, would prevent this from becoming a tick-box exercise by professionals that does not address the problem?
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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.
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.