Sure Start’s Approach To Health Inequalities Does Work
High Infant Mortality Rates (IMR) are a distressing measure, but they tell us a lot about the nation’s health. In the UK today the risk of infant death is about one in two hundred live births. But still seven times as many babies die in some working class Northern towns as do in the wealthiest parts of the South East. The Sure Start programme, alongside the Government’s IMR health inequalities initiative, shows promise in addressing these massive inequalities; but the next step must be to strengthen Sure Start’s interdisciplinary framework.
Fundamental issues such as human health and well-being are rarely a challenge for only one part of public sector services.
The really big problems almost always straddle a wide range of service provision, which can add substantially to the difficulties of resolving them – no one service provider alone ‘owns’ the issue, and it is often unclear who should head up programmes to address the problem.
Differentials in life expectancy
A classic example of this is the challenge in the UK of reducing the gap between the life expectancy of richer and poorer people, to achieve the goal of everyone who possibly can enjoying a long and healthy life.
The better the start in life, the more likely a person is to have a good outcome also in the future. For this reason there has been much emphasis in recent years on Infant Mortality Rates, which are generally agreed to be amongst the most sensitive overall indicators of a nation’s health.
Infant Mortality Rates (IMR) are usually stated as numbers of deaths per 1000 live births. The figures are often broken down into rates for the first four weeks of life (neonatal rate) and then for the rest of the first year of a child’s life (post-neonatal rate), i.e. from the end of week four till first birthday.
Infant Mortality Rates in Britain
The national statistics show that even since the 1970s, in the UK IMRs have fallen by about 60%. In 1978 the neonatal (first four weeks) rate was 8.7 deaths per 1000 live births, and the post-neonatal rate, up to a child’s first birthday, was 4.5.
By 1988 the rates were 4.9 and 4.1 respectively, and in 1997 they were 3.9 and 2.0.
In 2007 the UK neonatal mortality rate was 3.3 per 1000 live births, and the post-neonatal rate was 1.5 – in other words, a child born in the UK in 2007 had a probability of dying before his or her first birthday of just about one half of one percent. (You can see international comparisons here.)
Sadly, these national statistics include both good and bad news. The good news is that decent housing, income and environments can support people in long and healthy lives.
The bad news is that the opposite conditions can be lethal. There are parts of the North of England, for instance, where IMR is about twice that national average, and up to seven times that of the very best outcomes.
Specifically, high IMR and low life expectancy often go hand-in hand in the Spearhead areas; the 70 local authority areas with the worst health and deprivation indicators, and for which a programme of public service interventions has been developed.
High risk factors in health inequality
The target does not however take into account all dimensions of health inequalities in infant mortality. The statistics show e.g. that in 2002–04, the infant mortality rate of babies of mothers:
* born in Pakistan (10.2 per 1,000 live births) was double the overall IMR;
* born in the Caribbean (8.3 per 1,000 live births) was 63% higher than the national average;
* aged under 20 years (7.9 per 1,000 live births) was 60% higher than for older mothers aged 20–39;
* where the birth was registered by the mother alone (6.7 per 1,000 live births), was 36% higher than among all births inside marriage or outside marriage or jointly registered by both parents.
Improving life chances
Obviously, these significant inequalities are just not acceptable. The Government therefore introduced a Public Service Agreement (PSA ) Target in 2007 with the express objective of reducing the IMR gap, so that more babies will live to have long and healthy lives. (Healthy babies also have better long-term prospects, sometimes dramatically so.)
The deal is that the UK Treasury provides the money, and the public sector delivers the agreed outcome, to a clear timescale and against clearly measured outcomes.
Particular emphasis has therefore been placed in terms of health inequalities on achieving a ten percent reduction (between 2003 and 2010) in the IMR deficit between people in routine and manual (R&M) jobs, and the general population.
Practical steps forward
The practical ways in which the Health Inequalities Infant Mortality PSA Target Review (February 2007) can be achieved are focused on two things: sensible day-to-day actions and provisions, and interdisciplinary co-operation. In the words of the NHS summary of the Implementation plan for reducing health inequalities in infant mortality:
‘The plan describes how commissioners and service providers can develop local services to help reduce health inequalities in infant mortality through:
* promoting joined-up delivery of the target with Maternity Matters and Teenage Parents Next Steps. This includes
* improving access to maternity care;
* improving services for black and minority ethnic (BME) groups;
* encouraging ownership of the target through effective performance management;
* raising awareness of health inequalities in infant mortality and child health;
* gathering and reporting routine data, including specific maternity and paediatric activity;
* undertaking joint strategic needs assessment to identify local priorities around health inequalities in maternity and infant mortality;
* giving priority to evidence-based interventions that will help ensure delivery of the target.
It emphasises the importance of partnership working; outlines the role of government departments, strategic health authorities (SHAs), primary care trusts (PCTs), local authorities and Sure Start Children’s Centres.’
Specific, realisable targets for practical action and delivery
Progress may be slow, but none of this is rocket science.
Large-scale studies have demonstrated that just a few health messages about avoiding early years risk can have a big impact. Indeed, the Review of Health Inequalities has been able to quantify four measures, and suggest another one, which would have appreciable impact on the ‘10% reduction in IMR gap’ target. These were:
* reduce prevalence of obesity in the R&M group by 23%, to current general population levels – 2.8% gap reduction
* reduce smoking in pregnancy from 23% to 15% in R&M group – 2% gap reduction
* reduce R&M group sudden unexpected deaths in infancy by persuading 1 in 10 women in this group to avoid sharing a bed with their baby, or letting it sleep prone (on its front) – 1.4% gap reduction
* achieve teenage pregnancy target – 1% gap reduction
* also, early booking and improved teenage pregnancy services – not possible as yet to quantify probable gap reduction, but positive impact on gap anticipated.
Getting it right
The scope for getting this right in very simple ways is therefore enormous. Whilst guidance at national level, such as the Department of Health’s Child Health Promotion Plan (June 2008) is essential to provide a framework, much of the responsibility for success has to lie with the authorities ‘on the ground’, who have to co-ordinate the action.
In reality, only at the local level is it possible to get practitioners to work together well, to ensure that all those – including so-called ‘hard to reach’ minority ethnic familes, travellers and e.g. very young parents or parents with mental health problems – who would benefit from services, advice or support, in fact receive them. Although programmes such as the Family Nurse Partnership (a joint Department of Health / Department for Children, Schools and Families project whereby specially trained midwives and health vsitors work closely with vulnerable, first time, young parents) are starting to reach those with most disadvantage, in some places still this doesn’t always happen.
It is disappointing therefore to read claims in this month’s Regeneration and Renewal that the PSA Inequality target will be missed, despite the many billions of pounds (£9bn in 2007-8) which have been invested in Sure Start services to deliver early years provision.
An expected move
This probably why the Government is launching a public consultation on proposals to give Sure Start Children’s Centres a specific statutory legal basis, as part of the forthcoming Education and Skills Bill.
Such a move was indicated as a possibility when The Children’s Plan (the ten year programme for Every Child Matters) was introduced in December 2007. It would establish Sure Start Children’s Centres as ‘a legally recognised part of the universal infrastructure for children’s services, so their provision becomes a long term statutory commitment and part of the established landscape of early years provision’.
The best way forward
This is a much better idea than the alternatives proffered in some quarters – more Health Visitors as a stand-alone, for instance. (What about the GPs / family doctors? How do they fit in?)
A review of progress has shown (as my own consultancy work also indicates) that the PSA infant mortality target was not known or understood by practitioners (NHS, local government and Sure Start staff etc) despite individual examples of leadership and good practice.
And nor, in my experience, do practitioners and policy makers automatically know that impact has to be measured across the whole relevant population of infants, not just those who attend particular service provision, be this Health Visitor clinics, Sure Start or whatever.
About 80% of early years formal care is actually undertaken by small private concerns, child minders and so forth, a ‘group’ which, whilst of course the subject of statutory regulation and monitoring, it is particularly difficult to bring together in any meaningful way. But what happens in small relatively isolated provision will have a big impact on children’s future lives.
The PSA IMR Review has therefore identified the criticality of making the 10% gap reduction target part of everyday business – integrating into commissioning plans and provider contracts; taking responsibility and engaging communities; matching resources to needs; and focusing on what can be done.
Multi-disciplinary and future-facing
The challenges of equipping professionals to work together across disciplines are complex; not every practitioner would say, if asked, that they actually want to be so equipped and so far out of their comfort zone. But these challenges must be met, as is beginning to happen, with skills audits by NIACE which indicate the centrality in Sure Start provision of effective multi-agency leadership and partnership development.
The National Audit Office reports that, whilst most Sure Start Children’s Centre managers understand they must approach the work in a multi-disciplinary way, this is not always so for local authorities, who ‘had not all developed effective partnerships with health and employment services’.
The onus is now particularly on local government and NHS providers. If it takes more legislation to ensure they all collaborate properly with Sure Start Children’s Centres (and vice versa), so be it. It’s children’s futures which are at stake.
Read also: Early Intervention In The Early Years
See also: ‘Changes for the better?‘ – The Every Child Matters policy, published in 2003, was a landmark proposal for child social service reform. Five years on, Ruth Winchester asks the professionals how things have developed, and what progress has been made (The Guardian, 22 October 2008)