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Health Matters - your questions on giving children the best start in life

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We hope our latest edition of Health Matters – this time on the subject of giving every child the best start in life – will help you and other health professionals by compiling key facts, figures and evidence of effective interventions.

Where we can, we’re also committed to answering your questions and taking on your feedback. In this blog we’ve published the answers to a number of Health Matters early years questions we received from professionals across the UK following the launch teleconference (podcast available here).

We’d love to hear from you at

Question 1 (Preparing children for healthy living and effective relationships)

In this Health Matters, there is a heavy emphasis on relationships and what happens at school. Should there have been an element which is ‘pre-pre-conception’, which is about preparing children at school for that conversation about healthy living and effective relationships, before they conceive? Also should there have been something about encouraging exercise at schools to encourage a healthy active lifestyle?

What we have shown you here today is a small section of the child and young people’s life course. That goes at a minimum from pregnancy to 19 and ideally to 25. Some of those young people may be parents. This edition is very much focused on one snapshot up to two years. At Public Health England (PHE) we do have a whole life course approach to our child health work and in terms of our pre-conception work for example, the work of schools and school nurses is very important. Where do you start preconception work? - is it immediately before pregnancy or is it earlier than that at school, communicating in terms of being able to have healthy relationships, being able to manage your choices about sex and contraception and understanding what’s good for a baby? So it is certainly part of our thinking, we do need to do more, and you didn’t see so much of that today because we concentrated on a small part the life course.

We also know that in the wider strategy for how we help children to carry less weight, whether that’s being overweight or obese, that being physically active plays a big part. The sports strategy that was launched towards the end of last year was very much a public health strategy about how it moves from elite sport to anything that gets people moving. The child obesity strategy will hopefully have something to say about that as well about where schools can play their part.

Question 2 (Cutting local services)

Thanks for great presentation today. The work you have shared is very heartening as one of the concerns at the moment, is the decisions that are being taken by some local authorities to cut services. Speaking to local authorities about why they are cutting services it’s not because of the belief that the services don’t do a very important job, it’s just that they have to prioritise statutory services with such a heavily reduced funding level.

Many local authorities are currently reviewing and redesigning their services for children, young people and families in order to commission services which best meet local health needs  within available resources. This includes a range of activities such as developing service specifications, commissioning and procuring new services and taking the opportunity where appropriate to integrate services for 0-19s.

Locally, PHE supports place-based working and healthy places for children and families through system join-up and leadership through networks led by Centre Directors.

Nationally PHE leads on the Best Start in Life programme; this involves system and professional leadership and includes developing a range products so that local decisions can be based on best evidence.

PHE is supporting shared work programmes cross-government and sectors e.g. working with voluntary and community organisations, Life Chances, troubled families and child obesity. PHE offers a range of products and support nationally and locally, including data to support needs analysis, dissemination of evidence and good practice commissioning support tools and resources and professional leadership.

We are managing an interim voluntary data collection to help local authorities to monitor achievements and progress on health outcomes. Routine reporting will run through the maternity and children's dataset (MCDS) from 2017/18. The data is published quarterly at

Question 3 (Family Nurse Partnership)

Thanks for bringing all this evidence into one place and in such a well presented way. How do we do better with less? A lot of what’s described in this issue relates to the family-nurse partnership (FNP). How do we take those messages and get them really well embedded into the wider children’s workforce? What can we do in the family nurse partnership to help that work?

The work of FNP does pick up on a lot of what we’ve touched on today and has an important contribution to make. It’s heartening to see that the Minister for Public Health has come out and publicly acknowledged the work that you do around pregnancy and the first two years. We are looking at the evidence that we have that tells us  how FNP works at the moment and we want to develop it further and learn from what you are doing to adapt the programme, for example, around  reducing smoking in pregnancy. We have a real opportunity now to share some of that across the wider system so that we are getting the best value for money from all of our services. We have established a board to oversee the FNP programme, which reports in to PHE’s Best Start in Life board and we have key partners on the board from local authorities, the Department of Health and the national FNP unit. It provides a good platform to share and disseminate new learning and weave it into the wider work we are doing around Best Start in Life , keeping the Healthy Child programme up to date and as evidence-based as we possibly can.

On the Best Start in Life programme, as a way of disseminating this more broadly, we have local and national people on that programme board, jointly chaired by the Local Government Association, individual LGA members to give us regional representation and also the Department for Education, Department for Communities and Local Government and the Department for Work and Pensions, so that we link in with those big priorities around life chances and troubled families. So strategically that is how we get the reach into other places. But actually we all know that most conversations take place on the ground and by joining in with this conversation today and by going away and talking about it, that’s how we start to get healthy places and healthy communities for our children. So there’s a certain amount we can do and a certain amount we look to people on this call and those like you to build this ‘children really matter’ message.

Question 4 (Who Health Matters is aimed at)

Looking at this Health Matters resource, we wanted to clarify who it’s aimed at. Also is there any room for changes, where things don’t seem to be entirely accurate or to recommend future enhancements?

Health Matters is aimed at anybody who is involved in policy or practice or in teaching, at any level. We have other channels where we do engage in direct to public information; we have the Start for Life programme and Change4Life; we run big campaigns. Health Matters is aimed primarily, but not exclusively, for a professional audience. In terms of teaching, we will be launching the follow up product to this within the next month, part of the All Our Health programme, which is specifically for practice and education. We have some universities that already have that in testing and are finding it more directly applicable to teaching-type work, so we can certainly notify you when that is available.

If you think there is an inaccuracy, then do please share it with us. We have taken extreme care but we’re not infallible and welcome your comments. Please let us know about potential improvements and we can build those into future versions.

Question 5 (Breastfeeding statistics)

Where do you get the statistics on breastfeeding at six months from and how old are those statistics? We collect breastfeeding statistics at birth and at six weeks and then possibly at a year, but not at six months. Who were they asking because in the UK we do not routinely look at people at six months to see if they are breastfeeding or not?

The statistics came from the recently published Lancet breastfeeding series, published in January of this year. There were several papers in there, one of which was a review of the epidemiology. It was an international paper. The information was compiled through research.

Question 6 (Disseminating Health Matters)

You mentioned about communicating about this resource. As a local council commissioner I’d be really delighted to promote this to councillors. Working in local government, it’s so important that the cabinet and the lead members are on board. Could we have this presentation in a format that we can do that? Currently it’s on a pdf and I would appreciate some help.

The presentation is available as a PowerPoint which can be downloaded from within the Health Matters page along with the separate infographics.

Question 7 (Return on Investment)

Given the challenges we are trying to cope with in local government, one of the things that we get challenged on is cost/benefit. We have been doing that for family-nurse partnership (FNP) and that has been really beneficial and we’d value some more cost/benefit analysis.  It would be really very helpful to have return on investment broken down into short-term, medium-term and long-term, particularly as we are working in a political environment.

We are aware of the importance of return on investment evidence to local authorities and other partners, and that partners are keen to understand how any savings will impact on their service or organisation specifically, as well as on the wider system. There is always the challenge where prevention is concerned that savings are delivered far later, but we know that commissioning decisions need to be made now and their effect needs to be felt sooner.

Return on investment is totally at the heart of what we are trying to do and is the most common thing that we are asked to comment about, because people are making difficult decisions and choices and to win the argument ‘if you do this you can expect this outcome’ is a vital part of the supporting evidence.

To support the benefits realisation element of the transfer of commissioning of the Healthy Child Programme 0-5 to local authorities, PHE will be carrying out some return on investment work to evaluate the economic return on investment of universal services, which will be published by March 2017. That’s longer than you want to wait but it is very complex, as measuring something that you want to stop happening is always very difficult; we are getting health economists lined up to support this work.

We have commissioned additional return on investment analysis to evaluate the economic impact of a range of specific public health interventions in the Early Years. We hope within these to be able to demonstrate where savings can be made in the short- and medium-term as well as longer-term. One of these will be an evaluation of the return on investment of interventions to drive improvement in oral health in the early years, which is an area that we hope we will be able to demonstrate savings in the short-term. 

Question 8 (Role of the GP) 

I am a GP who looks after my pregnant mums and their babies. I also chair the adolescent health group at the Royal College of General Practitioners (RCGP). The first point I wish to make is what power do you have to push the case for sexual relationships education with the Department for Education, because it’s important to have an intervention at that stage to improve the outcomes for the next generation of mothers, not only looking at contraception and planned parenthood but also looking at healthy eating, smoking etc? A lot of the gains are long-term and are generational gains.

The second point is that in your final slide you’ve got GPs as the first part of the interventions at 28 weeks of pregnancy but actually the GP is the one professional who is there throughout the life course  and we can be there when providing contraception for teenagers, talking about their own health habits, be there when we’re providing contraception to young marrieds, giving pre-conception advice and then we’re there throughout the pregnancy and the early life of the child, looking out for post-natal depression, then looking after the child after the age of two. So the GP is the thread throughout this.  I appreciate that since the changes in 2013, PHE is now working with local authorities to commission those services but I think it’s important as health professionals that we try to be as joined up as possible.

On your first point, we completely agree with you. In our joint work with the Department for Education we keep making the case why Personal Social Health Education (PHSE) is very important, and why it needs to be taught as a proper subject by the most appropriately qualified person, be that a teacher or a visiting health professional. In terms of any levers we have, the new permanent secretary in the Department of Health joined from the Department for Education a couple of weeks ago. PHE is looking forward to having a series of conversations with him about this and other matters.

In answer to your second point, the infographic is shorthand and shows who is the most likely lead professional and that’s why the GP is showing early on and the reason that it starts at 28 weeks and only goes to two is that in this edition of Health Matters we are only looking at the first 1001 days up to two years of age. The Healthy Child Programme actually only starts at 28 weeks of pregnancy. There is a lot interest about what it might look like if it started earlier, very soon after conception.  As we do the maternity transformation programme prevention work we will be looking to push that 28 weeks back to earlier in pregnancy and it would be really helpful to work with the RCGP as one of our partners in how we do get a much more preventative approach to pregnancy.

Question 9 (Mandatory reviews in the Healthy Child Programme)

Will the mandated functions in the Healthy Child Programme be extended beyond the sunset clause?

The Minister for Public Health, Jane Ellison, has asked PHE to review the five mandated reviews of the universal health visiting service. Throughout this piece of work, we will be bringing together hard economics and softer intelligence as well, because access for parents and parents’ experience is also very important and we will certainly be looking to work with local services around some of that during this year. PHE will report its findings to the Minister in the autumn of 2016 and this will inform her decision as to whether the mandation will be extended beyond March 2017.

Question 10 (Maternal obesity)

We would like to see maternal obesity included in Health Matters as a risk factor in pregnancy and post-natal as this will also influence childhood obesity

We acknowledge the importance of maternal obesity as a risk factor in pregnancy and are planning a separate edition that will cover healthy weight in detail.

Question 11 (Attachment issues in parents)

About 30% of maltreated children may go on to maltreat their own children. Given what we know about the inter-generational impact of dysfunctional attachment in children and the emerging evidence on the biochemical toxicity of traumatic stress on neurobiological development, are there any plans to review how Health Matters helps practitioners to identify and respond to attachment issues in parents, before it manifests in dysfunctional relationships with their children?

The evidence shows the critical role of parents in supporting their children’s social and emotional wellbeing. We know the importance of secure early attachment in ensuring that every child has the best start in life and that warm, authoritative parenting supports child development. PHE has published a review to update the evidence in the Healthy Child Programme which emphasises the important role that health professionals, led by Health Visitors as the lead professionals for delivering the Healthy Child Programme, can play in providing parenting support. Parenting also forms an important element of the government’s Life Chances Strategy, which the Prime Minister announced in January. By working together across sectors and agencies to support families in developing positive parenting skills and a secure attachment between parents and their children, we aim to prevent this inter-generational impact.

Question 12 (CMO physical activity guidelines)

As I looked through the document, I noticed you did not mention the CMO physical activity guidelines for children under 5.  CMO physical activity guidelines, Start Active Stay Active, is also not mentioned in the supporting references for early years. Will there be another opportunity to enhance this guidance by including the physical guidelines and ensuring that the CMO’s guidance for physical activity is cited as a supporting document.

This edition focuses on pregnancy to age 2 and so we have included information around the importance of physical activity in encouraging a healthy pregnancy, during pregnancy, as well as the importance of physical activity in the early months. We also highlight tummy time – which is outlined in the CMO factsheet.

We acknowledge that promoting physical activity in children is a priority and are planning a separate edition that will cover this in detail.

In the meantime, we are happy to blog about the infographic when it comes out in July and help to raise its profile.

Health Matters
Health Matters is a resource for professionals which brings together the latest data and evidence, makes the case for effective public health interventions and highlights tools and resources that can facilitate local or national action. Visit the Health Matters area of GOV.UK or sign up to receive the latest updates through our e-bulletin. If you found this blog helpful, please view other Health Matters blogs.

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