A generational change in early years provision?
Tam Baillie proposes the need for a national approach to achieve a generational change for Scotland's children. This would involve developing universal services such as health visiting to effectively identify children who need additional support; improving the approach to supporting parents; and deciding which parenting programmes should be available.
We need to radically re-think our approach to how we support parents. There is a growing body of compelling evidence about the link between parenting styles and the development of attachment, which has a significant impact on a child's social, emotional and cognitive development (The Scottish Government 2007). We need to popularise and normalise support for parents. There is broad agreement that we need to develop both universal and targeted approaches to supporting parents. However, we need to grapple with where to strike the balance, answering the question: what do we want our ideal early years provision to look like?
Midwifery and health visiting are our universal, non-stigmatising services to families. Additional support to parents is most often set up on the basis of targeting vulnerable families. This has taken place in a context where the provision of parental support services has been based on a variety of interventions - most often characterised by a patchwork of local projects targeting vulnerable families on the basis of concerns about their ability to parent. This will not achieve the reach, nor have the impact, a more comprehensive and strategic approach could achieve through a national approach to supporting parents.
So, I welcome the Scottish Government commitment to develop a national parenting strategy.
Support to parents and parenting programmes
It is worth distinguishing between supporting parents and parenting programmes. Supporting parents can address both family and individual concerns; may be informal and/or formal; and can be offered by a variety of people and professionals. Parenting programmes require people who are specially trained and supervised to ensure that there is high fidelity to the programme. Parents require both approaches, although it is parenting programmes I want to address.
There has been considerable discussion about the use of evidence-based parenting programmes. One of the key challenges in providing these is interpreting the evidence against specific desired outcomes for children - which programme do you use? No single programme is likely to provide a perfect match against population needs; however, there is a growing body of evidence from which we can draw. Much of this has usefully been captured by two recent publications in Scotland - one by Angela Hallam (2008), produced as part of the Early Years Framework, and another by Rosemary Geddes (2008) and colleagues through the Scottish Collaboration for Public Health Research and Policy.
There are already encouraging developments underway. Family Nurse Partnership pilots are running in Edinburgh and Dundee, with more in the pipeline: Glasgow is developing the Triple P parenting programme city-wide and NHS Education for Scotland is developing 'Incredible Years' pilots, with ambitions for a national roll out. Rigorous evaluation of these developments will increase our understanding of what makes the difference in improving outcomes for children in a Scottish context.
There are a limited number of parenting programmes with a strong evidence base of improved outcomes for children. A lack of national direction means it is not clear how assertive local funders should be about whether and which parenting programmes they should implement. There is a need to agree nationally about using evidence-based programmes as this will help inform local funding decisions. A strategic approach would increase funds for specific programmes and decrease or cease funds in areas which do not have a strong evidence base.
We need to focus our energies and resources on increased availability of parenting programmes on a national scale.
The crucial role of health visitors
There is a pressing need to improve our universal services in order to identify the most vulnerable children. Otherwise, we will miss many opportunities where support to parents and infants could avert later problems. The position of health visitors and the implementation of Hall 4, which aimed for better targeting of health visiting, usefully illustrate this point. The impact of Hall 4 was to effectively time limit universal health visiting services to six to eight weeks, enabling more time to be devoted to children in families with assessed additional need. Families would be allocated as 'core', 'additional' or 'intensive' based on assessment.
However, changes as a result of its implementation raise significant issues. Evidence from the Starting Well project in Glasgow (Wright 2009) found that fewer than half of vulnerable families were identified by health visitors during the first four-month visiting period, even in the context of routinely-offered monthly home visits. Recent evidence presented to the Cabinet Secretary for Health by the NHS Greater Glasgow and Clyde general practitioners, as outlined by Dr Georgina L. Brown et al in February 2010 in a letter titled 'The universal health visiting service General Practice attachment & child protection', demonstrated that universal health visiting services were missing significant numbers of vulnerable children. For instance, health visitor contact at the 30-month contact revealed that almost half the children with delayed language development were not assessed as in additional need - yet this is an early indicator of later developmental problems.
More recent work in Glasgow has extended these findings, showing that most children with social and emotional difficulties are not receiving any routine universal health visitor input (personal communication, Dr Anne Mullin, December 2011). This is an unacceptable level of 'missed children' in the 'core' category who will not receive routine health visitor support. This needs to be addressed. It is further evidence that a restriction on universal health visiting has led to a failure to identify many of our most vulnerable families, at least in part because it fails to account for changes in child and family circumstances over time.
Recognition of this led to a review of Hall 4. We now require the full and consistent implementation of A New Look at Hall 4 (The Scottish Government 2011) to regain lost ground in universal services.
Health visitors are crucial in protecting children, yet there are considerable workforce challenges. A recent report (Appleton 2011) highlighted the poor morale among health visitors as a result of an undervalued and decreasing workforce. The response to this crisis in England and Wales has been a large scale recruitment drive for health visitors. We need a similar response in Scotland.
The United Nations Convention on the Rights of the Child (UNCRC)
The UNCRC is the cornerstone of everything I do to fulfil my statutory duty to promote and safeguard the rights of children and young people. It places the same obligations to our children on us all. It defines children as those under 18, and there is no differentiation of children's rights by age or stage - if you are a child you have the same rights throughout your childhood.
Although the UNCRC makes no specific reference to early years, it does contain several articles directly relevant to the early years of a child's life. These include the articles relating to general principles: article 2, a child's right to non-discrimination; article 3, a child's right for their best interests to be the primary consideration; article 6, a child's right to life and maximum survival and development; and article 12, a child's right to have an opinion. In particular, articles 5 and 18 outline parental responsibilities and a child's right to receive guidance from their parents in line with their evolving capacities. The key point is that the state is obliged to ensure that appropriate support is provided to parents in order to protect the rights of the youngest children. In 2005, the UN Committee published General Comment 7, 'Implementing child rights in early childhood'. This indicates that the UNCRC has had to evolve in line with our increasing knowledge and awareness of the impact of early years experiences on children. In this, the UN Committee specifically recommends that states ensure provision of early childhood development programmes which empower and educate parents. This describes the combined impact of universal health visiting services, backed up by the approaches taken in parenting programmes.
We have the chance to make a generational change by taking bold decisions on the basis of evidence. This has the potential to better realise children's rights, and by doing so, improve the long-term outcomes for children in Scotland.
About the author
Tam Baillie has worked as a manager and practitioner with children and young people for 30 years, primarily with young offenders; young people in and leaving care; and young homeless people. He has worked in Scotland and England in both the statutory and voluntary sectors. He was director of policy for Barnardo's Scotland from 2003 and worked extensively on children's policy and rights issues. He was appointed as Scotland's Commissioner for Children and Young People in 2009.
Appleton J. (2011). "Safeguarding and protecting children: where is health visiting now?" Community Practitioner 84(11)
Geddes R., Haw S. and Frank J. (2008). Interventions for promoting early child development for health: an environmental scan with special reference to Scotland. Edinburgh: Collaboration for Public Health, Research Chief Scientist Office
Hallam, A. (2008). The effectiveness of interventions to address health inequalities in the early years: a review of relevant literature. Edinburgh: The Scottish Government
The Scottish Government (2007). Health in Scotland, 2006, annual report of the chief medical officer. Edinburgh: The Scottish Government
The Scottish Government (2011). A new look at Hall 4. Edinburgh: The Scottish Government
UNCRC (2005). General comment No.7, implementing child rights in early years CRCF/C/GC/7/Rev.1. UNCRC
Wright C. M. et al. (2009). "Targeting health visitor care: lessons from Starting Well". Arch Dis Child 94 23-27