Too many children still don't get the best start

What progress have we made in improving the health of under-fives over the past decade? Our recent report, Giving Children a Healthy Start, looked at this.

The government has given increasing priority to children’s health over the past 10 years. Between 1999 and 2009, it published over 20 policies relating to the health of unde-fives.

However, except for Sure Start and more recent policies such as the Healthy Child programme, policy statements have largely focused on the 0-19 years age group or on public health in general, rather than on the under-fives. This is surprising, given the importance of early years’ health.

‘Children under five in deprived areas are 9 per cent more likely to be of a low birth weight and 12 per cent more likely to have an accident than those in the rest of England’

Even if the under-fives haven’t always been a priority in their own right, there has been considerable investment. Between 1998-99 and 2010-11 we estimate that £10.9bn will have been invested in programmes aimed in whole or in part at improving the health of the under fives. This includes £7.2bn for Sure Start, which had dedicated funding for health improvements in its early phase.

So it is disappointing that this has not produced widespread improvements in health outcomes.

There has been some improvement, but this has tended to be modest. Infant mortality is a case in point. The overall rate fell from 5.6 to 4.8 deaths per 1,000 live births between 1998 and 2008. However, figures for other countries - such as Ireland and Spain, which spend no more on healthcare than we do - declined further, faster. Our figures still lag behind much of Western Europe.

And no progress has been made on narrowing the gap between rich and poor areas of England since 2005.
Some health indicators have worsened - for example, obesity and dental health - and the health inequalities gap between rich and poor has barely changed. Children under five living in deprived areas are 9 per cent more likely to be of a low birth weight and 12 per cent more likely to have an accident than those living in the rest of England.

We identified a number of problems. Central government sometimes placed conflicting demands on local authorities and primary care trusts.

In turn, local authorities and PCTs rarely focused on or gave priority to children under five, although they invariably knew the health issues affecting their populations. There could be confusion about who was responsible for commissioning local services, and little knowledge about where resources were targeted and their impact.

There are now some 1,400 fewer health visitors than there were a decade ago. Services to young mothers, parents and children in poor areas and from minority groups did not always reach them. Relatively few services seemed to have a rigorous and effective approach for reaching out to these parents.

We held some focus groups to try to find out why parents didn’t use services. Not surprisingly, lack of confidence, a lack of knowledge and language barriers were common issues. But many were put off by the judgemental nature of NHS staff.

But, if the overall picture was disappointing, we also found examples of good practice and promising developments on which to build.

The government has been working with the Community Practitioners and Health Visitors Association on the Action on Health Visiting programme. This aims to define the main roles for health visitors and address recruitment and retention issues. The Operating Framework for the NHS in England 2010-11 also highlights the need for PCTs to monitor workforce and caseloads of health visitors.

The Family Nurse Partnership pilots, an intensive nurse led home visiting service focused on first time parents under 20 years of age who are potentially vulnerable to poor health outcomes, have shown promising results, even if some issues need to be addressed before it is rolled out.

In Hackney, local action produced a fall in the number of deaths of children under one year from 8.1 per 1,000 live births in 2001-03 to 5.4 in 2005-07, just above the England rate of 4.9. Hackney has an ethnically diverse population. Almost 90 per cent live in an area classified as being in the top five most deprived areas in England, but it now has an infant mortality rate that is lower than that of Reading.

In many places, there are great examples of services reaching out to the people who really need them. We featured some in our report. They include a centre in Burnley working predominantly with minority ethnic groups that has significantly increased service use, and one in Redbridge that has successfully reached out to Roma people.

Go to www.audit-commission.gov.uk to find out more about our report, including a video and case studies.

Andy McKeon is managing director of health, at the Audit Commission

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