Introduction

1. We welcome the opportunity to contribute to the Children, Young People and Education Committee consultation on the First 1,000 Days. The First 1,000 days of a child’s life is key to a child’s future health and well-being and has the potential of impacting on a person’s future intellectual development and lifelong health. The Welsh NHS Confederation and our members are more than happy to provide further information to Members of the Committee if required.

2. The Welsh NHS Confederation represents the seven Health Boards and three NHS Trusts in Wales. The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work.

Overview

3. Improving health outcomes for children, young people and their families, and reducing the health inequalities that exist within our communities, are key priorities for the NHS in Wales. There is clear evidence that one of the most important things we can do to improve the health of our population and reduce inequalities is to ensure children are provided with the best possible start in life.

4. Influencing the development of children to maximise their health, social and educational development is most effective when done as early as possible; the first 1000 days being critical. There is also a strong economic case, as return on investment in the early years is higher than at any other stage of a person’s life course.

5. Rates of stillbirth, preterm birth, low birth weight, neonatal deaths, admissions to neonatal units, infant mortality, child mortality, injuries and teenage pregnancy have all been shown to be significantly higher in areas with high levels of deprivation. Across Wales, there are variations in health outcomes and life experiences due to economic deprivation. This includes the unacceptable variation of low birth weights of babies across our communities and the fact that children from the most deprived fifth of the population have a rate of child death 70% higher than those in the least deprived fifth.^{^[i]} Giving every child the best start in life is the highest priority recommendation in Professor Sir Michael Marmot’s recent strategic review of health inequalities.^{^[ii]}

6. Globally, there is an increasing body of evidence purporting to show how experiences during childhood have long-term impacts on a person’s health and life chances. In January 2016, Public Health Wales NHS Trust published the first ever study in Wales of Adverse Childhood Experiences (ACE’s)^{^[iii]} which found that 47% of the Welsh adult population are estimated to have experienced at least one ACE and 14% have experienced four or more ACEs. ACEs are stressful experiences occurring during childhood that directly harm a child (e.g. maltreatment) or affect them through the environment in which they live (e.g. growing up in a household while suffering domestic abuse). A baby’s brain grows from 25% to 80% of its adult size during the first 2 years of its life, hence the importance of the first 1000 days in determining a person’s life chances simply cannot be emphasised enough.

7. Preventing ACEs can improve health across the whole life course, enhancing individuals’ well-being and productivity while reducing pressures and costs on the NHS. Tackling Poverty programmes, such as Flying Start and Families First, promote behaviours which support positive parent child relationships to bring about secure emotional attachments and positive maternal and family emotional health and resilience.

8. The Public Health Wales Observatory report “Health of Children and Young People – Wales Report”,^{^[iv]} shows that health and behaviour developed during childhood and adolescence is often carried through into adulthood and can affect health later in life. Supporting children to adopt a healthier lifestyle from early years is therefore critical and providing parents with the skills and knowledge around healthy lifestyles is key.

9. NHS strategies and plans therefore have focused on preventing ill health, promoting health and well-being and intervening early by improving access to services. These actions place the child, their family and their carers at the centre of the approach, ensuring that the health, well-being and safety of children and young people are safeguarded.

10. Our response to the inquiry provides an overview of the current programmes, policies and areas of work in relation to the first 1000 days, and recommendations for future key areas of focus and consideration. The following themes are considered to be significant:

- Evidence based programmes;

- Programmes with clearly identified outcomes at the outset;

- A future policy direction to equitable provision based on identified need; and

- A focus on early intervention to improve outcomes and opportunities, to change potential life courses and make long term health improvements.

Terms of Reference

The extent to which Welsh Government policies and programmes support the early parent role, before birth and during the first 2 years of a child’s life, how effective these are in supporting children’s emotional and social capabilities and development;

11. The policy development and guidance from the Welsh Government, and the implementation of new programmes in recent years, has led to a greater focus on the principles of the first 1000 days. Even though the first 1,000 days have been a priority for the NHS for some time, there has recently been a significant increase in focus on pre-natal care, as well as the health, well-being, lifestyle choices and significant benefits it has on both the mother and the unborn child.

12. The all-Wales maternity record was revised and the new version introduced in June 2016. The record includes recommendations from Public Health Wales NHS Trust and outlines a significant refocus on healthy lifestyles. The revised version also highlighted a focus on substance misuse, domestic abuse screening and issues associated to health and well-being, including diet and healthy physical activity.

13. The benefit of programmes such as Flying Start and Families First are instrumental to delivering the significant changes required and additional targeting of resources. Flying Start provides a real opportunity to embed health promotion messages to families. For instance, in Blaenau Gwent, Aneurin Bevan University Health Board has established an Antenatal Support Project delivered at Ysbyty Aneurin Bevan. This is a collaboration between Blaenau Gwent Flying Start and wider health staff, Families First, Communities First and the Family Information Service. The project provides health promotion information and advice on the support services available during the pre and post-natal periods. It also signposts mothers to multi-agency services when specific needs are identified.

14. While these programmes have had an impact, they do require complete trust and true partnership working across sectors to ensure effective delivery for all, and outcomes for the future. If the relationships across organisations are not sufficiently strong, then the organisation holding the money often decides on its implementation and usage, which is not always aligned to the areas of greatest impact. However, across Wales, partnerships and commissioning decisions are seeing the significant benefits and outcomes for mothers and children.

The effectiveness of Welsh Government policies and programmes that:

a) Promote and protect the health and well-being of children from pregnancy (for example through positive parenting, high immunisation rates and tackling smoking in pregnancy).

15. The effectiveness of policy and new programmes is clear to see when partnership arrangements are clear and consistent with what is expected to be delivered. Over recent years, the combined impact of the Healthy Child Wales programme, Flying Start, Families First, as well as a clear focus on school nursing services and health visiting, has seen an increased emphasis on promoting the health and well-being of children from pregnancy. However, without further resources, pressure is put on the NHS and other partners to deliver on all these areas.

16. All services, not just those provided by healthcare providers within the local community, are starting to consider the real impact and positive outcomes of investing time, support and intervention at the pre-natal stages. By targeting these issues during pregnancy (e.g. promotion of diet nutrition and healthy weight and physical activity, alcohol reduction and positive physical activity) improved health outcomes can be achieved for the mother, the unborn child and the wider family network, which in turn sets the principles of health and well-being for life.

17. The Welsh Ambulance Service NHS Trust (WAST) are in a position to contribute positively to the many and various influences on a child’s health and development. WASTs Emergency Medical Services (EMS) provides first line care to patients and families in their homes and communities. This enables unique and valuable opportunities for contact with vulnerable children and their families. The Non-Emergency Patient Transport Service (NEPTS) provides a key service for those children who require transport to hospital appointments, providing another medium of interaction with children and parents. NHS Direct Wales provides frequent contact with parents requiring clinical triage, leading to referrals to the wider NHS in addition to health information and advice.

b) Deliver improved child health outcomes across Wales (for example prevention of obesity and the promotion of health-enhancing behaviours for every child such as eating a well-balanced diet, playing actively, and having an appropriate weight and height for their age and general health).

18. Health Boards recognise the importance of a child’s early experiences on future physical and mental health and well-being and they aim to provide all parents with the support they need to be the best parents they can. Core services and new programmes are starting to make a positive impact as well as the targeting of support and awareness raising within core midwifery, health visiting and school nursing services.

19. The Healthy Child Wales Programme has made a positive step in ensuring a universal framework of consistent health promoting messages, of holistic family assessments, standardised assessments of child development and of delivering evidence based interventions.

20. Specific public health interventions have been targeted that align with identified public health priorities, including immunisations and smoking cessation. The programmes have a wider aim, namely to improve the overall health and well-being of children by supporting improved resilience within families. Specific programmes within Health Boards include;

- Baby Buggy Walks, which offers mothers-to-be and new parents the opportunity to get together to exercise and share stories, thereby benefiting not only their physical health, but also their mental health;

- Healthy eating messages begin during the antenatal period, with Health Visitors exploring parental eating habits and food choices;

- Weigh and Play sessions are delivered within communities by Health Visitors and Health Family Support Workers. These encourage and enhance child development and demonstrate to parents how to support their children in order for them to reach their development milestones;

- Through WASTs community engagement and experience work, there has been a demand from the wider public for information around health promotion and health improvement. WAST used to promote ‘Birth to Five’ in line with Welsh Government/NHS guidance, and since 2014 they have been promoting ‘Bump, Baby and Beyond’. Elements of this are linked to Health Challenge Wales, especially the benefits associated with breastfeeding;

- The Designed to Smile programme is considered to have been key in the gradual improvement in oral health and evident reduction in dental caries. It provides a structured framework for practitioners to work within the clear guidance for promoting oral health improvements. The impact of the programme has been significant: the prevalence of dental caries amongst five-year olds between 2008 and 2015 has seen a 12% reduction. This improvement has happened across the social gradient, showing that childhood oral health inequalities are not widening. The Designed to Smile programme is therefore hugely valued and needs to continue and strengthen interventions aimed at the first 1000 days; and

- UNICEFs Baby Friendly Initiative (BFI) has been pivotal in the start of cultural change and attitude with regard to infant feeding and particularly breast feeding. With the unequivocal scientific evidence of the physical and emotional impact of breast feeding and long terms health outcomes, BFI provides clear guidance, a framework for training and quality assurance via audit programmes.

21. The majority of policies and programmes implemented are part of Welsh Government strategies and programmes. However, without effective funding and commissioning arrangements, it is down to local discussions and commissioning to inform opportunities for real change and pilot projects. It is recognised that while Health Boards are delivering a range of interventions to promote and protect the well-being of infants and children, it is often difficult to attribute any impact they make on the wider public health outcomes. One explanation for this is that data collection has been challenging, but Health Boards are hopeful that improvements to the child health system and implementation of the Welsh Community Care Information System (WCCIS) will provide the mechanism for more robust data collection in the future.

c) Tackle child health inequalities, with a specific focus on child poverty and disabled children.

22. Having a prosperous Wales, where we have strong and economically-resilient communities, is key to health and well-being. As highlighted in the Welsh NHS Confederation’s briefing, “From Rhetoric to Reality – NHS Wales in 10 years’ time: Socio-economic Deprivation and Health”,^{^[v]} the socio-economic inequalities in life prospects and health are stark. Socio-economic deprivation has a significant impact on a child’s survival, development, future health and happiness. Socio-economic deprivation also has an impact on people’s lifestyle choices, on healthy life expectancy, including living with an illness or chronic condition, and life expectancy.

23. As the evidence highlights, a child’s development and chances of survival are heavily influenced by the social and economic circumstances into which they are born. This is discussed at length in the Royal College of Paediatrics and Child Health’s report “Social and economic inequalities are matters of life and death for children”.^{^[vi]} It is important that all sectors work together because children and families need to be empowered with the knowledge, skills and resources for the best start in life.

24. Staff within Flying Start targeted areas actively work with parents where poverty has been identified as impacting upon their child’s health and well-being. Health Visitors are uniquely positioned to work alongside parents, using a solution focused approach, to explore and identify areas that may be impinging upon themselves and their family. Each Health Visitor teams understanding of local health and community resources enables families with children with disabilities to access appropriate and timely support. Staff make use of the Family Information Service and signpost clients to community resources, e.g. Food Banks and Credit Unit. Furthermore, the Healthy Child Wales Programme aims to reduce inequalities through the efficient and effective use of resources and Health Board staff deliver this programme to ensure timely interventions determined by the family’s level of need.

25. Support for siblings of disabled children is also high on the agenda for the NHS as their well-being can suffer in those early days. Families of young children with disabilities benefit hugely from care co-ordination particularly in the early days, particularly if the child has very complex needs.

d) Reduce child deaths and injury prevention, particularly in the most deprived parts of Wales where infant mortality is much higher than the least deprived.

26. There are numerous research reports that highlight how poverty and social inequalities have an important bearing on a child’s survival, development, future health and happiness.

27. In relation to child mortality, there is a strong correlation between deprivation and the risk of child death, with child mortality rates higher in the most deprived areas than in the least deprived. The Marmot Review^{^[vii]} highlighted how poor health is strongly linked to socio-economic status with children born into poor families more likely to be born premature, have low birth weights and die in their first year of life. Public Health Wales ‘Child Death Review Programme Annual Report’ evidenced that most child deaths (64%) occur in the first year of life and the death rate among children living in the most deprived fifth of Wales is 70% higher than among children in the least deprived fifth of Wales.^{^[viii]}

28. A wide deprivation gap exists in stillbirth rates, with women at higher risk of stillbirth in deprived areas. A study^{^[ix]} from 2012 found that women from poorer socio-economic backgrounds are more likely to suffer a stillbirth than those from more affluent families. There were 1,489 stillbirths in the least deprived tenth compared to 3,043 stillbirths in the most deprived tenth. It concludes that a better understanding of these stillbirths is necessary to reduce socio-economic inequalities.

29. Children from more deprived backgrounds are at greater risk of hospital admission and are more likely to experience multiple admissions before the age of three years.^{^[x]} There is a higher incidence of acute illnesses among children from more deprived backgrounds, with acute infections such as pneumonia, infections, asthma and bronchiolitis, generally higher for children in the most deprived backgrounds.^{^[xi]} Hospital admissions for pedestrian injuries of children from the most deprived fifth of the population is significantly higher than the least deprived. The wider social aspects needs to be considered and initiatives, such as Flying Start, gives the opportunity to provide information on debt and benefit advice services, which helps families to improve their situations and general well-being. It is important that children and families are supported in their early years to mitigate the impact of poverty and also to ensure communities can become more resilient to support local people. The impact of potentially losing Communities First initiatives will therefore need to be considered in this context.

30. In order to identify risks, throughout pregnancy and the pre-school years, Health Board staff continually assess risk and promote safety messages in collaboration with families utilising the Children in Wales – Keep In Mind - Home Safety assessments cards. Health Boards recognise the importance of providing a Health Visitor follow up to all children who attend minor injury unit or hospital to offer further guidance and support around prevention. Furthermore it is important to recognise patterns of frequent attendances and consider whether safeguarding is a concern.

31. Additionally, Health Boards consider how to educate parents regarding preventable death in childhood, include Sudden Infant Death Syndrome (SIDS), drowning, and risky behaviour. Our members acknowledge that this requires good multi-disciplinary relationships and clear pathways of referral from Health Visitors, WAST staff, Social Workers and other members of the Multi-disciplinary team.

32. The benefit of programmes such as Flying Start and Families First are, and could be, instrumental to delivering these significant changes and additional targeting of resources, but this requires complete trust and true partnership working to ensure effective delivery for all. If the relationships across organisations are not strong then the organisation who holds the money often decides on its implementation and usage which is not always aligned to the areas of greatest impact. Greater flexibility is needed to be given locally to use of Flying Start, and other funds. These programmes do not always enable Health Boards to reach the families with the greatest need due to the post code element of the programme, and the significant pressure on other core services.

e) Support effective child development and emotional and social well-being - specifically interventions that are delivered outside the health service which can help to detect and address developmental delays.

33. If we are to meet the growing needs of the population, both now and in the future, it is vital that all sectors work together. The future success of the NHS relies on us all taking a proactive approach to health and ensuring that we create the right conditions to enable people, especially children, to live active and healthy lifestyles. Health Board employees work closely with key partners, including third sector organisation such as Save the Children and Action for Children, who provide one-to-one family support and facilitate group work with families. Furthermore, working and training in partnership with other agencies allows the pooling of skills, knowledge, experience and resource which can be further promoted outside of the health arena.

34. Flying Start initiatives have also been vital in relation to supporting children’s psychological and mental health needs. Psychological and mental health needs of young children and their families has been raised as a key theme by many Health Boards. In Blaenau Gwent, Aneurin Bevan UHB has a Flying Start Community Psychiatric Nurse, who plays a key role in supporting families. Also, there is a particular programme at Aneurin Bevan’s Serennu Centre in Newport, the Helping Hands programme. It provides clinical psychology services to parents and carers of children with disabilities or development difficulties aged 0-18, to support their well-being and resilience. The programme is a partnership between the Big Lottery, the Sparkle Appeal and the Health Board and is funded until 2019.

f) Focus on improving learning and speech and language development through the home learning environment and access to early years’ provision (including childminders, preschools and day nurseries).

35. The years from birth to 2 are critical in helping babies learn all the foundation skills for talking, and parents and carers have a vital role to play as a baby and young child’s first teacher. Early language skills play a crucial role in literacy, a child’s ability to achieve their educational potential, their social mobility, and their life chances. Beyond academic attainment, well-developed speech, language and communication skills are fundamental to the ability to form and maintain social relationships with family, peers and friends.

36. There is an increasing focus on children’s speech, language and communication skills within early years’ policy in Wales. The recently launched Healthy Child Wales programme has a specific focus on speech and language development, and the 15 month health visitor family health review, the ‘Parenting – Give it Time’ campaign incorporates key learning to talk messages throughout the website content. Speech and Language Therapists have also linked into the drafting of the Foundation Phase Profile.

37. Given the strong correlation between disadvantage and early language delay, the Flying Start programme has prioritised speech, language and communication, both with regard to supporting parents and carers, and within the childcare entitlement. The Flying Start programme has notably prioritised this area by publishing guidance and employing a speech, language and therapist in each Flying Start project in a consultative role to support parents and early year’s practitioners. Evidence of the huge impact of the profession within the Flying Start programme is starting to become clear. Part of the role of the therapist is both to up skill the early year’s workforce in these areas and to improve parents’ knowledge and skills to support children’s early language development.

38. While the role of speech of language therapist is clear, there is a shortfall in access to speech and language therapy provision. Whilst acquisition of language development can be reinforced by staff who have been trained it is imperative that the quality of the service model has been assured by the speech and language therapist. Health Board health visiting teams are closely supported by speech and language colleagues who offer regular updates, as well as supervision and joint visiting opportunities as and when they are required.

g) Reduce the adverse impact on the child of psychosocial issues such as poor parenting, disruptive family relationships, domestic violence, mental health issues and substance misuse through effective safeguarding.

39. Health Boards across Wales are ensuring that they are making every contact count” across all service areas. This involves midwives, health visitors, other professionals and the third sector offering and encouraging positive life choices, healthy behaviours throughout a woman’s pregnancy, through to early years, early childhood, into schooling and adolescence.

40. Health Boards recognises the importance of the Public Health Wales NHS Trust ACE report^{^[xii]} as a platform on which to better understand the prevalence of children experiencing ACEs in their area and the adverse impact ACEs are having on children in their area. Once this has been established, the next steps will be for Health Boards to use this information to re-design services that start to address the issues and break perpetual cycles of destructive parental behaviours or identify children earlier who are in need of safeguarding. However for those parents who have experienced ACEs themselves, whilst some joint working with outside agencies begins to enable and empower them to be better parents, further input in the form of additional services that work to support the parent-infant relationship may need to be considered. It is thought that a screening tool would be helpful in understanding the prevalence of ACEs which staff may need training to implement.

41. Health Boards understand the impact of ACEs during the Early Years which informs their Safeguarding Role. All staff across Health Boards are skilled in recognising when children are suffering or are at risk of suffering significant harm and will work within the All Wales Child protection guidelines. ‘Together for Mental Health’ and the Well-being of Future Generations (Wales) Act 2015 are seen as platforms for collaborative initiatives to prevent ACEs in the future. The Welsh ACE survey identified that the prevalence of low mental well-being in adults is strongly related to the number of ACEs individuals reported experiencing as children. Health Boards acknowledge the key role our frontline staff play in identifying safeguarding concerns and we need to strengthen the links between identifying safeguarding children issues and vulnerable adults who are parents of young children with the ACEs and their impact not just on the individual’s health but on wider society.

42. The Flying Start programme is an example of early intervention services that the Welsh Government has invested in to address the issues in the first 1,000 days of life. The positive impact of this initiative is becoming clearer, as highlighted in the recent evaluation^{^[xiii]} of Flying Start and the difference it makes in early years. The challenge however is for practitioners working in the areas outside of Flying Start, where need is still identified but the level of support and intervention is significantly less than for those residing in the Flying Start areas.

43. The MAMMS and Bump Start pilots are showing early gains in areas relating to smoking cessation in pregnancy, healthy weight gain and impact on low birth weight babies, all of which impact on this area and enable a greater and more supportive and positive outcome for babies and pregnant women. As a result of the need to reduce low birth weight babies, smoking and BMI in pregnancy local projects are proving successful and audits are identifying positive impacts in reducing LBW babies in these areas, and increased uptake in MAMMS programme.

44. The concern is that funding for these is not secure long term as it is provided via external partnership grants, as funding does not always follow Welsh Government policies and programmes, and so when funding does come via eternal grants, as outlined above this can sometimes be lost in clarity as to who holds the budget lines and what local commissioning processes are in place. Very often when grant funding changes direction then only the budget holders are asked for input relating to future direction Health play a significant role and also need opportunity to influence service and strategy direction as language across organisations often differ significantly.

Evaluation of Welsh Government programmes

45. It is emphasised that Welsh Government and local programmes, such as those outlined above, need to be continually well evaluated and good information must be collected to assist with prioritisation and sustainability for future years, particularly where funding is provided from a range of sources. There will need to be considerations for the developing Local Partnership Boards in relation to a focus on future generations as part of the Well-being of Future Generations Act 2015 and also to ensure that there is equity of provision based on needs across all geographical areas.

Conclusion

46. The NHS in Wales, with our partners, are working hard to improve the health outcomes for children, young people and their families and to bring about a reduction in the health inequalities that exist within our communities. There is clear evidence that one of the most important things we can do to improve the health of our population and reduce inequalities is to support children to have the best start in life and the NHS will continue to prioritise this.