Under agenda item 4, we return to our early years inquiry, this time to discuss the theme of health inequalities. For our final evidence-taking session, we are joined by two Scottish ministers. I give a special welcome to Maureen Watt, who appears before us for the first time as Minister for Public Health. We also welcome Aileen Campbell, the Minister for Children and Young People, whom we have met before at committee, and the following Scottish Government officials: Alex Young, team leader, tackling poverty; Dr Fergus Millan, head of creating health team, public health division; Anncris Roberts, early years collaborative team leader; and Carolyn Wilson, operational policy manager, child and maternal health division, early years.
I believe that we are going to have a short opening statement from the ministers, and I presume that they have agreed between themselves who will lead off first. Is that right, Maureen?
Thank you, convener, and thank you for your special welcome. If you do not mind, we would both like to make some brief opening remarks.
I thank the committee for this opportunity, and I look forward to working with you all in my new role. I will seek to set the broader context for this morning’s discussions, and my colleague the Minister for Children and Young People will give the committee more detail about the policies that fall within her portfolio. I have been trying to get up to speed with my new portfolio, but I want to say that I and my colleague feel very strongly about the inquiry’s subject and remit.
Scotland’s health is improving across the piece, and people are generally living longer and healthier lives. However, I am acutely aware that, despite the significant efforts of this and previous Administrations to tackle health inequalities, they remain a blight on our society.
The committee has previously acknowledged the complexities of resolving Scotland’s health inequalities and developing policy solutions that can minimise the impact of the differences in power, wealth and resource that underlie the inequalities in health in our society. Committee members will know that the First Minister has made tackling inequalities one of our stated objectives and we remain determined to address the gap in rates of chronic ill health and premature death that impact on communities throughout the country.
The committee has focused on health inequalities in the early years because that is where society can make the most difference in long-term outcomes. We know that getting it right in the early years—and even pre-birth—can have a positive effect on the health and wellbeing of the child and the family. Prevention and early intervention should drive our work and that of our partners.
That is why the Government has had a strong focus on early years right from when it first came into government in 2007. We expect community planning partnerships to have a focus on the early years in their single outcome agreements. Addressing health inequalities in the early years is not a job for the national health service alone; we need all statutory agencies and partners to work with the strength, skill and assets of communities.
We have also focused on developing strong evidence-based policies in the early years that deliver a proportionate or progressive universalism, which we believe will make a difference.
For example, in our work on antenatal inequalities, we have taken on the messages about the need for a universal approach to ensure that we reach all those who are in need of services by focusing on improving access to maternity services. We have developed a robust framework to support maternal and infant nutrition, including breastfeeding, in recognition of the importance of nutrition pre and post birth. We have implemented the family nurse partnership but recognise that it reaches only a specific segment of the population, albeit one that comprises those who are at higher risk of poor outcomes.
There was a clear message from the evidence-taking session with the general practitioners at the deep end group and others that continuity of care and consistency of approach are crucial to reducing health inequalities. All our early years policies strive to achieve that. That is why we have invested significantly in strengthening universal services by increasing the number of health visitors to ensure that all families can access the services that they need through that universal gateway of provision.
However, we also need to be clear that health inequalities cannot be reduced by health interventions and policies alone. They are linked to and derive from the wider inequalities agenda of socioeconomic and welfare policies. As the committee knows, the Government does not yet have all the levers to address those comprehensively and coherently, but that does not mean that we can do nothing, and we must do all we can to address that social imperative.
Good morning, committee. I thank you for allowing me the opportunity to make an opening statement.
It is significant that you have me and Maureen Watt in front of you today. In fact, you could probably have invited a number of our fellow ministers as well because health inequalities in the early years cross all portfolios, as well as agencies beyond the Government, as Maureen Watt said.
I welcome the opportunity to be here because early years policies and issues surrounding the early years are close to my heart—in more ways than one, given the imminent arrival of my bump at the end of the month. The Government wants to make sure that Scotland is the best place in the world for all children to grow up in and has a number of policies that are aimed at doing that. Maureen Watt has already mentioned some of them, and I add the getting it right for every child approach, the Children and Young People (Scotland) Act 2014, our play, talk, read campaign, our commitment to high-quality early learning and childcare and our national parenting strategy, which is the only one in the United Kingdom. All those policies have in common the perspective of prevention and early intervention.
I was pleased that the United Kingdom-wide social mobility and child poverty commission’s “State of the Nation 2014” report commended Scotland’s early years task force and the early years collaborative for their continued focus on prevention and early intervention.
10:00I know that the committee had an evidence session on the early years collaborative, which is a vehicle and method to deliver our evidence-based policies and has the overall ambition of making Scotland the best place in the world to grow up in, by reducing inequalities and giving every child the very best start in life. It empowers practitioners and those who work on the front line to use their expertise to test different approaches for different children and families, initially on a very small scale before scaling them up. Is the venue difficult for some families? Is the form too complicated for someone who cannot read very well? Are we making assumptions about our services meeting people’s needs? Those are the questions that we are encouraging practitioners to ask when they approach their job.
The collaborative is also about co-production: working with parents and children to build on the assets that are available in families and communities. We are proud that the collaborative is world leading. We are the first to use this methodology in a complex, multi-agency environment, and there is a regular flow of requests from around the world to visit or receive further information about what we are doing in Scotland.
Far more important is the fact that we are now beginning to see the small tests of change bearing fruit and delivering for children and families. For example, at one site, the breastfeeding rate among a small group of vulnerable mothers has increased to 86 per cent. According to the Information Services Division, the local average is 25.5 per cent. Work is also going on at some sites to reduce the time that it takes to place a child in a permanent care setting.
At another site, parents are being encouraged to read their children a bedtime story. That scheme started with two parents in one nursery and is now working with 150 parents across six nurseries. Staff continuously evaluate the effectiveness of interventions and have witnessed outcomes that have exceeded their expectations, including increased numbers of parents sharing books at bedtime with their children. In one setting, parents have read 148 books to their children in the past year. The scheme has improved children’s speech and language, which means that they have needed less support in class, and it has established bedtime routines, which has resulted in better behaviour in class. As well as improving concentration and behaviour, it has improved attachment and bonding between parents and their children. Parents have reported improvements in their own reading and confidence, their understanding of child development—and their essential role in that—and their own wellbeing and self-esteem, as they witness their actions making a positive difference for their child and themselves. Other sites are using the model to assess whether they are targeting their resources at the correct place, with some surprising results.
Of course, we still have progress to make and culture can be slow to change, but the enthusiasm and commitment that we see from the 700 practitioners from all across Scotland who attend the learning sessions that are held in the Scottish Exhibition and Conference Centre every few months make us optimistic that progress is on its way and is continually changing our culture.
Thank you for allowing us to make our opening statements, convener. I look forward to answering the committee’s questions.
Thank you both for your opening statements. Our first question is from Mike MacKenzie.
It is interesting that you both said that the early years is an issue that crosses portfolios and should involve all statutory partners. In that vein, do you welcome Sir Harry Burns’s appointment to the Council of Economic Advisers? Does that perhaps signal a greater focus on health inequalities in the early years?
I think that it is an inspiring choice. Much of our work is based on equally well, which I was involved with as the Minister for Schools and Skills from 2007 to 2009. Harry Burns was a key member of the task force, which was where I first learned about how early health and the mother’s health pre birth can impact on children’s early years, and how regular feeding and nurturing are so important to the development of children’s brains.
The appointment sends a clear signal about the desire to align inequality with efforts to improve the economy and keep them closely interlinked. Harry Burns has been instrumental in the development of the early years collaborative. When he was the chief medical officer, he was one of the co-chairs of the early years task force. He has been an early years evangelist for some time, making the case around the country and beyond about the importance of effective intervention in the early years and the policies that we need to adopt to improve brain development.
Harry Burns has continued to be involved in the early years collaborative and has brought about some of the changes that we are seeking to make because of that approach. His appointment to the Council of Economic Advisers is a good move that links social policy and economic policy across the Government much more firmly.
At last week’s meeting we took evidence from a number of witnesses who commented that some of the early years pilots are a bit short lived and that data and evidence that would give an understanding of their effectiveness are not collected. Do you feel that the appointment of Harry Burns will help to ensure that we have an approach that is based on the gathering of evidence and data so that we can understand what the best and most effective interventions are?
I again mention the early years collaborative, which is strongly focused on data collection to ensure that we have the knowledge and the confidence to scale up interventions. It was not designed to be a short-term pilot. The approach of the early years collaborative does not fit neatly into the electoral cycle of the Scottish Parliament or local authorities; it is about ensuring that we make the right interventions at the right time. It involves taking a longer-term view rather than the short-term pilot approach that you describe.
Pilots are important and have their uses, but the thrust of the early years collaborative is about collecting data and ensuring that it is robust so that we can check that what we do is working. If a pilot does not produce the outcomes that we expect, we need to have the confidence to use it as a learning opportunity and to not continue with that approach. It is a case of bringing about change and doing that using the data that is necessary to ensure that we are making the improvements that we all seek. The early years collaborative approach certainly addresses some of the points that you make.
You highlight a problem with pilots. People get upset if they think that a pilot has been working and we stop it because evaluation has shown that it has not delivered what was expected. That has been a problem across Governments.
Therefore, it is important that evaluation is built into pilots. Where feasible, that could be done in house or it might involve bodies such as universities undertaking self-evaluation. We are trying to improve on the methodology all the time to ensure that we are getting the right data so that we can find out whether pilots work. We also want the people who come to the sessions that we run across the country every now and again to share data and experiences, because that is extremely valuable.
Thank you.
I want to pursue the point about research. Is the chief scientist consulted on all the pilots to determine what the baseline data should be before they start? I think that, over both Administrations, the evaluations have been more process driven and have tended to involve self-evaluation instead of being driven by outcomes. Outcomes should be given careful consideration.
We know that the outcomes of the family nurse partnership may well be very long term. Everyone is signed up to that and recognises that that is the case, but it would be good to have a list of the intermediate outcomes of all projects at the beginning. The family nurse partnership programme is expensive, but the committee has been and continues to be generally very supportive of it.
However, I have a couple of questions. When someone drops out from the programme, they are not replaced. Each practitioner has a heavy workload with a small number of families but, overall, other health visitors see the workload as being fairly generous—I will put it as mildly as that. When people drop out, we are told that they cannot be replaced because the protocol does not allow it or because they might come back. There could therefore be a drop-out rate of 10, 15 or 20 per cent and that would mean that the workload would go down. Will the ministers comment on that?
Some families are not eligible for the programme, which has a strict protocol. How do we support such groups? Fife had a programme for families, including those that are now family nurse partnership families, but it is under considerable financial pressure. If someone presents after 28 weeks, for example, they do not get into the FNP programme. If they are over 21 but are very vulnerable, they do not get into the FNP programme. If they have a second child, they do not get back into the FNP programme. Those are three examples. How are we concentrating on them?
That is my first question. I also have a very short one, if I may, convener.
There were a couple of questions in there, albeit important ones.
I agree that the family nurse partnership is impressive. I have been out on some visits, and I believe that the committee has visited some of the health boards that are further down the line with implementing the programme. Some of the indicators for the short term are delays before someone has their next child, and more confidence when they have their next child about the approaches that they want to take to attachment and bonding. In general, there is more confidence from some of the mothers and the fathers. At some of the examples that I went to see in Fife, I was impressed with the fathers who were being more supportive of the family.
The member asked about people dropping out of the programme and not being replaced. Carolyn Wilson might want to comment on that. The approach is strict and the rules have to be adhered to. However, we also have the parenting strategy, which was the first in the UK. Scotland was first to have a national parenting strategy that speaks to all parents beyond those who are eligible to go on to the family nurse partnership scheme. We want to ensure that we help and support parents beyond those groups.
On top of the family nurse partnership approach, we have endorsed a number of interventions through the early years task force, such as triple P—the positive parenting programme—and incredible years. We also support a number of third sector organisations through third sector strategic intervention funding or strategic partnerships. For example, Families Outside uses effective interventions to support families who are affected by imprisonment to do the best that they can.
We also take a collaborative approach to target families who are in a bit more need by empowering health visitors and midwives so that they know where to direct families to money matters services so that they can increase their household budgets, or when to give support with nurture and attachment issues. Bedtime stories is a perfect example. More children than ever before are now being read bedtime stories as a result of that collaborative approach. On the face of it, that might not have the weightiness of the politics that we are used to but it is crucial to a child’s development and their long-term outcomes so that they can flourish as an individual.
Carolyn Wilson might want to comment on the specifics of family nurse partnerships.
Dr Simpson asked about filling gaps that come about in case loads when someone drops out of the programme. That depends on where they are in the cycle of starting the programme. There are opportunities for recruiting to empty spaces in case loads over time, but that depends on how far into the cycle of the programme delivery the teams are. I do not want to go into every single scenario just now but we can provide more detail.
Dr Simpson is right when he says that initially case loads can be lower than anticipated because people might drop out. However, the number of people who drop out is very small at less than 10 per cent overall for the whole programme. You are right that some drop out, but the numbers are a lot smaller than in other programmes.
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An evaluation strategy is being developed and will be implemented in 2015. We are aware of the randomised control trials in family nurse partnerships in England, which are primarily investigating birth weight; smoking during pregnancy; child emergency hospital admissions within two years of families being on the programme; and—as you mentioned—the number of subsequent pregnancies. Those elements, and a number of secondary outcomes, will be evaluated during the programme.
It would be good to get a list of those outcomes when they are available.
Another useful resource is the “Growing Up in Scotland” study, which is longitudinal and gives us some rich information. We can also point to further resources that provide the type of baseline data in which Dr Simpson is interested.
My other question is on quite a different area, but members may want to come in on that issue—
A number of members want to ask questions, so there will be an opportunity at the end to sweep up any issues. Bob Doris can go next.
I am interested to know how the role of the independent adviser on poverty and inequality that the Government has just announced it will appoint will fit in with on-going Government policies. I am thinking about programmes such as family nurse partnerships and the national parenting strategy, and recently announced initiatives such as the new literacy and numeracy drive and attainment officers for primary 1 to primary 3 in each local authority. All those things fit together as part of the early years strategy, but where will the independent adviser on poverty and inequality fit in? Is the adviser’s role to challenge Government when it has not got something quite right, or to suggest changes in how policies are progressed?
There are a variety of strategies, many of which the committee supports. We are seeking an independent expert to look at the thread that runs through all the policies, and to endorse strategies that the Government has got right and point to areas in which policy might be redirected. The committee will scrutinise each individual initiative, of course, but I am keen to know where the independent adviser on poverty and inequality will fit in the early years framework.
The role and remit of the poverty adviser are being developed, but it would be right and proper for that person to challenge Government, as that is where such appointments are most useful.
I used to attend the ministerial advisory group on child poverty, which the former Deputy First Minister—now the First Minister—chaired, alongside Margaret Burgess. That forum allowed us to be challenged on the policies that we wanted to progress, and ensured that we could bring to bear expertise from wider civic society beyond Parliament and Government to enable us to tackle inequality, and child poverty in particular.
More directly, as part of my portfolio, we have the early years task force. One of our most recent appointments is Professor Jim McCormick from the Joseph Rowntree Foundation, who has just agreed to take a role in the task force. The task force sends a signal across Government portfolios and different disciplines that we want to ensure that there is a common approach that enables us to be challenged robustly.
From my experience on the task force, I know that bringing together people such as Scotland’s Commissioner for Children and Young People, John Carnochan and now Jim McCormick means that we are challenged. That ensures that we approach our policies robustly and that they do what we want them to do.
I welcome the proposed appointment of a poverty adviser, and I hope that they will be robust in their challenge to Government, because we cannot afford simply to wear rose-tinted glasses and have nice conversations. There is a real problem affecting families now, and we need to ensure that we are challenged as strongly as possible in order that we are directed to the areas on which we need to focus.
I meant that the adviser would challenge things constructively, of course, but I am interested to know what priorities they will have. I suppose that, as they are independent, they will set their own priorities, but I would be keen for them to start on early years and early intervention, given that the Scottish Government has been focusing on those themes for a number of years.
Perhaps you cannot answer my question, but you could feed the issues that I raise into Government. My follow-up question is on childcare. We have an increasingly qualified early years workforce. However, the remuneration does not particularly reflect the workers’ skill set, so they are quite often low paid. The Scottish Government has planned a huge expansion of provision running through to 2020. We need to ensure that childcare is in the right setting not just for the child, but for the parents who are in work or hoping to get into work. In that regard, there is a relationship with partnership nurseries, too.
There is also a UK layer with the tax credit system, for example, and the need to support people into work, and the minimum wage and living wage have to be at a correct level. Do you see your role, or that of the independent adviser on poverty and inequality, working across different Governments to look at the bigger picture? If the adviser looks only at Scottish Government policies they will miss a trick, because the issue is much more complicated than that.
There is a lot of merit in what you say. I do not want to second-guess the adviser’s remit, but to be helpful to the committee I suggest that, once it is finalised, we will make sure that you are kept up to speed with what that looks like.
We can also keep the committee informed on childcare. We have commissioned Professor Siraj, who is an academic with a childcare speciality, to look at the workforce. You are right to say that the workforce is increasingly knowledgeable and people have qualifications in a way that they did not have before.
One of the drivers for expanding childcare, alongside the economic reasons, is quality. If we want to achieve the outcomes that we expect for children we need a good-quality setting, otherwise the initiative’s effectiveness will not flourish beyond the 600 hours of provided childcare.
Professor Siraj is researching the workforce and what more we as a Government need to do to help with the quality. She is looking at the feminisation of the workforce, pay and a host of other issues. She is due to report back to us in spring next year. We will make sure that the committee is kept abreast of the work.
You mentioned partnership nurseries in relation to the provision of the 600 hours of childcare. We have a mixed bag of different providers. There is a mixed economy—the statutory entitlement is provided not just by the local authorities, but by the private sector, third sector and childminders.
We took the first step towards the 600 hours expansion to increase flexibility. We know that families need that flexibility and the ability to access quality childcare. We are not there yet, but the Children and Young People (Scotland) Act 2014 implemented an expansion that was the first step towards the transformational change that we are seeking. It is frustrating that we do not have competency over tax credits, because that is very much interlinked with childcare and its funding. However, we are embarking on a change that, we hope, will deliver for families, for parents and, importantly, for children. The first step towards that was the expansion that we announced through the 2014 act.
Given the questions that you have been asked, it would be fair if you thought that you were sitting in an education committee rather than a health committee. However, the committee is quite clear—and has been for some time—that the early years are important for lifelong health outcomes. Getting it right in the early years is critical, and that includes childcare, the employability of parents, and good-quality parenting and workplace experiences.
The expansion of quality childcare for two-year-olds is critical, because we need to ensure that those very young children get the best start in life. There are sound economic reasons for expanding childcare, but the quality of that childcare is essential.
As the Minister for Children and Young People, I would add that effective and early intervention is not the same as early years. We can effectively intervene in a child’s life beyond the early years, too. I know that the committee is concentrating on early years, but I make that point because we do not want to write off children just because they are beyond the age of eight.
Absolutely. Thank you very much, minister.
This might just be part of the journey, but my head is in a spin with the number of initiatives, projects, groups and experts involved. There is a comfort in that, because we have heard it in evidence throughout our work on this committee and, indeed, the work that Bob Doris and I did in the previous Local Government and Communities Committee. How do we make sense of it all?
We all enjoy the moments that we have on a Monday or a Friday when we see good projects and come away feeling great. What are the stark figures on breastfeeding among certain groups, and on smoking and drug and alcohol consumption while pregnant? Are the rates improving? Are they static? Where are the indicators? What have we learned from single outcome agreements? How many local authorities have child poverty as a priority in those agreements?
You and Bob Doris make valid points, convener. This will come more to the fore as budgets are challenged. We have to make sure that people do not duplicate work and that best practice is rolled out across local authorities. As you say, we all visit good projects in particular local authority areas, but we need to make sure that where such projects are proven to work, they are rolled out in other areas. We have to make best use of the workforce and ensure that we do not duplicate work or perhaps misuse resources.
I think that that is happening through the coming together of all the lead people in these projects through the early years collaborative. We are seeing good practice rolled out. The leaders who come to the meetings are very keen to make sure that they learn from others and roll out best practice.
The 2014 act sought to embed the consistency that I think we need. We had 32 different levels of progress across Scotland in implementing getting it right for every child. We all understand that the Highland model was furthest along, through the pathfinder. In one of the most recent members’ business debates, in which Dr Simpson took part as well, we recognised that the approach goes beyond party politics—it started with the Labour Administration and we have continued it because it is the right thing to do. However, it has lacked national consistency, which is why we drove forward with the legislation that we passed in the spring.
One of the wellbeing indicators is whether children feel included. The ministerial working group has discussed how we make that meaningful in relation to children who face deprivation and poverty. There is method in driving forward the legislation and linking it into the groups that we are talking about, whether through the ministerial working group or the early years task force. It is important to note that the poverty strategy also now includes an outcomes framework to include more robust indicators on how we are making progress on the issues that you sought assurance on.
We deal with some of the frustration and we have taken evidence over years on some of those issues. That goes across political parties and across Governments. I mentioned single outcome agreements because they have been in place for some considerable time, whereas family nurse partnerships will need to be evaluated further down the line.
Given the importance of local government in delivering many policy initiatives on the ground, what does the single outcome agreement show us at this point, some seven years in, or do we not know?
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All local authorities have single outcome agreements that commit them to reducing inequalities. As Maureen Watt said in her opening statement, we are making progress, and we have ways of monitoring that. However, we realise that we always need to do more, which is why the child poverty strategy now has an outcomes framework. It is not just a case of launching the strategy, which is all great; we also have an effective way of monitoring its progress.
We are working with the early years collaborative. That work is about effective collection of data, which has perhaps not been done in the past, as the convener described. It is about ensuring that we have the confidence to develop policies that will deliver the results that we require.
I am not questioning the ambition of the current Scottish Government, or that of Scottish Governments over the piece. What I am saying is that there is policy coming out of our ears, and there are experts and discussion groups. What difference have the single outcome agreements made to the most vulnerable children in Scotland?
As I said, all local authorities have a focus on inequalities. They have all committed, through the early years task force and the early years collaborative, to focusing on tackling child poverty and inequality, and to ensuring that they make progress. We have ways in which we monitor that. For instance, we have to do a sweep to ensure that the task force is approaching the change agenda in the way that we would expect, given the money that has been put in.
We know—you have pointed it out to us, minister—the importance of the connection between children and parents. It is about more than just reading a book: you referred to 700 children who are now reading books with their parents.
The single outcome agreements have been in place for a considerable time. We set up the policy with the ambition of making life different for the most vulnerable people in Scotland. What was the starting point? I am looking at the officials here. What was the ambition? Have we made progress in addressing some of the issues that the policy was developed to address? What improvements have been made?
Child poverty rates have come down considerably since devolution, so there is a clear indication—
Is that as a result of the single outcome agreements and Government policy? That is what we are trying to get at.
There is a mixture of policies and approaches. You cannot have the same approach across 32 local authorities.
I do not think that you can lay responsibility for the approach solely at the door of local authorities; the approach is integrated with healthcare. NHS boards have local delivery plans, which are now being linked to the community planning partnerships. We tend to think of health and social care integration more in terms of older people, but it will also be rolled out to younger people.
I am not attempting to blame anybody. In health we at least have a list of indicators. That is perhaps the challenge for other Government departments. Whether or not the indicators in health are correct, they are there and we use them to find out whether we are making progress on birth weight, smoking prevalence, mortality and so on. We can measure that up and down. I am looking for other types of measurement that would be available to us, as a committee this morning, so that we can say, “That is where the challenges are.”
You are right about the indicators that we use to identify progress on tackling health inequalities, which are just a handful of the hundreds that we could have used, but they are not specifically applicable only to what the NHS is doing; they show what we are doing across all organisations to contribute to shifting the indicators. Unfortunately, the indicators are not going to change rapidly because although we have broken them down into short-term, intermediate-term and long-term indicators, we do not get quick results.
I will go back to the point about what the SOAs are doing and what difference they are making: they are getting people together to talk about things in partnership. That makes people think about how they might do things more coherently than in the past. When “Equally Well: Report of the Ministerial Task Force on Inequalities” was published in 2008, it set out quite clearly that the CPPs would be critical in delivering on health equality. However, CPPs had not found their feet in that respect until the time of the Christie commission report, and since then they have started to think more clearly about what they have to do and how they work in partnership.
The Government has been quite specific about the priorities that we want to see being reflected in the SOAs. Maureen Watt was absolutely right to say that health boards have their own local development plans; only in the past two or three years have we asked them to say specifically how they contribute to the SOAs and how everything merges together.
We are asking enormously complex organisations in an enormously complex area to try to work together. It is a process, and we want to know that there is confidence among the organisations that are starting to talk and to create among themselves the structures to deliver on policy aims. We are seeing that confidence in a variety of areas; some of the work that has been done around health and social care integration shows that organisations can work together. It is difficult—all such things are—but we sense that progress is being made and that organisations are working towards the priorities that the Government has agreed.
The jury is still out.
We are trying to bring about a shift in the way that complex organisations do business and engage with one another. Bear it in mind that CPPs do not involve just health boards and local authorities; they involve the police and other agencies, all of which have important roles to play. That is also reflected in Government in the way in which officials work across policy areas to identify opportunities to work synergistically—not just in name, but genuinely working with colleagues to join things up. It is a huge challenge and an enormously complex process, but we are making progress.
My questions are on a similar theme to the convener’s questions, but they may be easier to answer. What tests does Government carry out when it is developing policies to deal with health inequalities—in particular, policies for early years provision? We know that that is a cross-cutting issue that does not sit only with health or with education, but goes across all departments.
As I said to Bob Doris, we have relationships with a number of key professionals, stakeholders and third-sector organisations—we do not make Government policy in isolation. We have to ensure that what we are doing will have the impacts that we expect for the child, and that the outcomes will be achieved. The early years task force is a key collaboration of effort from across the third sector, the private sector, the health service, local authorities and others who contribute to what we need to do as a Government. The ministerial advisory group on child poverty is also cross cutting.
Who sits on that?
That group includes Jim McCormick, who has already agreed to be part of the early years task force, and there is representation from CPAG by John Dickie. I am struggling to remember all the names. Alex Young may be able to list them.
The other people on the group are from Barnardo’s Scotland and from One Parent Families Scotland, and we have the Scottish commissioner from the United Kingdom social mobility and child poverty commission. We also have Linda de Caestecker from NHS Greater Glasgow and Clyde and Jane Wood from Scottish Business in the Community.
Jane Wood now sits on the early years task force as well, to ensure that we are bringing to bear all the expertise that we have.
There are other opportunities, as well. For example, the parenting strategy that we have taken forward was developed in consultation with parents, and we engaged with those parents through organisations such as Children 1st and Families Outside, which already have networks of contact with parents, to ensure that what we are doing as a Government is what parents tell us they require. The work is never done in isolation. That is why I pointed to the collaborative. The approaches that we describe are not just about Government, but are about bringing together all the players that can offer input and have a direct influence on the success of the policies that we want to take forward.
How do stakeholders interact with Government when it is developing policies on, say, the budget, the environment and all the other issues that impact on poverty?
Again, it is about making sure that we have, as a Government, the discipline of being cross-cutting. As I said in my opening statement, the committee could have asked one of a number of different ministers to come here to talk about tackling inequalities. I have described some of the ways in which we ensure that we have people coming from all areas and all sectors to influence the policy directions that we take.
I guess that I am looking for the mechanisms by which those people influence the Government. Do they sit at the Cabinet table? Do they look at legislation?
We have set up the ministerial working group on child poverty, and the early years task force. There is also the raising attainment for all initiative, which is the collaborative beyond the early years that is looking towards raising attainment. Key players sit on that in a national sense and in a very local sense. There are a number of initiatives that are not just about Government officials and ministers sitting down and deciding on policy, but are about—I reiterate—bringing together people who have key expertise and influence in areas on which we think we need a sharper focus.
How do those people influence other areas? That is what I am driving at.
Policies are put through equality impact assessments, but there are also, since about 2010, health inequalities impact assessments, which NHS Health Scotland carries out. I do not have the briefing in front of me, but it has done about 30 since 2010, and it put out guidance on the assessment in about 2011. It assesses policies on whether they take into account a range of things that impact on inequalities. I do not have the detail with me, but those assessments are a specific way of looking at a new policy initiative to determine its likely impact. It might be that, when the impact has been determined, the Government will still go ahead, but at least it has information that might influence what it does to make a policy have a less negative impact.
Does that happen with all policy development?
NHS Health Scotland has done about 30 of the assessments—I am trying to remember. There is a list on its website and it looks as though there have been 30 or more since 2010. It has done five or six this year. I do not know whether it is a question of capacity, but an assessment is not done in every case, but will be done on certain policies. Many have been done in the NHS and some have been done within the Scottish Government.
There are a couple of relevant publications. “Long Term Monitoring of Health Inequalities: Headline Indicators—October 2014” shows that progress is being made but that inequalities persist in some areas. There is also Audit Scotland’s report “Health inequalities in Scotland”. A number of publications influence and determine Scottish Government policy as we go forward.
We are also developing a child’s rights impact assessment tool to ensure that we make good on the pledge that we set out in the Children and Young People (Scotland) Act 2014 and that all areas of policy—beyond just education, social work and health—recognise their role in delivering more for children in terms of their rights.
Okay, but that is not going on at the moment. I am trying to find out what happens—
That is part of the new legislation; it follows the legislation that we passed fairly recently.
Will that assessment focus on childhood inequalities?
We are adding the child’s rights impact assessment to complement other parts of the Government’s influence in terms of inequalities. Children have inalienable rights, which include being able to participate in society, so that will have an impact on what Rhoda Grant asked about in her question. We will let you know how that develops further down the line.
I get the impression that health, social work and education all kind of look at this, but we all know it goes much wider than that.
Of course.
At the moment, we seem only to be considering the very narrow area that deals with the symptoms, but not the causes. What tests are carried out on all Government policy to ensure that the causes, and not just the symptoms, are dealt with?
10:45
In addition to the children’s rights element of the Children and Young People (Scotland) Act 2014, getting it right for every child requires a broader approach to ensure that we get it right for each and every child. That requires local authorities, health boards and other partners to ensure that everyone is doing what they can. That goes beyond housing, social work and education. We are therefore about to go to consultation on the guidance that will accompany the 2014 act so that local authorities recognise the role that they must all play to get it right for every child across the country and to make good on the legislation and the legislative changes that we have just taken forward. That is one way in which we can ensure that the influence of those changes goes beyond health and education.
Much of what is going on has been described by the ministers and officials in terms of how the Government is attempting to tackle the issues. The committee is considering health and the various indicators, but we do not see them reflected in all other areas. I think that I am hearing from Dr Millan and ministers that genuine attempts are being made to start that work or to push it on. That is positive. It would be useful to hear more.
On a wider point, a paper was recently produced by Professor David Bell. He gave us evidence on the budget and made the point that Governments can make policy that can unintentionally, almost like the inverse care law, not help—if I can put it in less pejorative terms—in achieving climate change targets, because it puts up fuel bills, which also increases the burden on the poorest people. We are looking for information on that, and for indications that the Government is taking those issues on board. It seems that the Government is starting that process, which is a good thing—that is what we want to hear—but rather than labouring the point and going on as I am doing this morning, perhaps we could be supplied with some further information.
We can certainly get back to you with a list. In addition to what we have all said, the First Minister announced in her programme for government that a poverty impact assessment is to be introduced. All those things can be tied together to provide you with a broader sense of how we are knitting together the actions of Government so that we are not working in silos, and so that everything is pointing towards making improvements to the economy while also making inroads into tackling inequality.
That is where the committee is: having heard the evidence so far, we want to hear more about that and we want to encourage that sort of activity. That is how Government has operated for a long time—not just the Government at this point.
We need to push on.
I wish to consider an aspect of delivery of support. Can the Minister for Public Health update us on progress on deployment of the additional 500 health visitors over four years, which I think was announced six months ago? Can she confirm that they will operate across rural areas as well as urban areas? I ask that as an MSP for a rural area that is not viewed as having significant deprivation, but the existing health visitors are having to deliver classes in basic parenting skills for young people. To what extent does the minister accept the need to ensure that there is appropriate geographical deployment of the new health visitors, taking account of areas more rural than the one that I represent, in order to ensure support for all families across Scotland who require it?
Graeme Dey has made a very valid point. In June this year, the Scottish Government announced that it would provide £2 million of funding in this year and a total of £41.6 million over the next few years for additional health visitors, with the goal of growing the workforce by 500 by 2018. That is to ensure that funding helps all the health boards to ensure that there are enough health visitors to provide universal visits and development checks for children—for example, the 27 to 30-months review—and to meet the obligations under the Children and Young People (Scotland) Act 2014 to provide named persons. That extra money is going in, and since 2007 health visitor numbers have increased by about 22 per cent.
We are committed to ensuring that that the covers all the health boards, and it is up to the health boards themselves to ensure that that happens. There is a tendency to think that inequalities exist in particular pockets in our society, but we must ensure that individuals who live in poverty, especially in rural areas, have access to services.
I welcome that commitment, but how will the Government ensure that that takes place across the health boards? Perhaps there is a risk that they will take those additional resources and target the easiest targets, for want of a better expression—they could be focused on major cities, where it appears that there would be the best return. There are obvious challenges in particular rural areas—the bigger ones—in deploying resources effectively. What guidance will be given to health boards to ensure that we get that right?
I will refer to my notes. We have recommended that NHS boards use a validated case-load working tool to support consistency in determining health visitor numbers across Scotland. That tool, which is based on population data and allows for local variation, would be used in conjunction with nursing and midwifery workforce workload planning tools. That sounds technical, but that explains it.
Obviously, the issue is something that you are mindful of.
Yes.
Nanette Milne wants to ask questions on a similar subject.
I can follow up on that—I will be very brief.
There is in Angus a collaborative test pioneer site to support parents who have children in the early years in tackling substance misuse. That will give comfort that there is a focus not just on urban areas; local authorities and health boards are taking very seriously the impact of rurality and so on in helping parents. I can pass on to the committee information about the improved attachment and child development work in Angus. Angus Council also has, as a local authority, a good case to make on its approach to getting it right for every child in general.
I very much welcome the promised extra 500 health visitors, as health visitors play an absolutely crucial role not only in the early years, but as children develop and in picking out families that need help.
I am a great fan of primary care-based health visitors, having grown up with that approach when my husband was in practice. They really have an insight into local families who face difficulties. I raised the issue last week, when the deep end practitioner agreed with me that, in that sort of practice, a practice-based health visitor would be really useful. However, Theresa Fyffe of the Royal College of Nursing Scotland indicated that things have moved on, and she was not quite so enthusiastic. I would welcome comments on that issue.
Some of the most experienced health visitors have gone into family nurse partnerships, and I am sure that they are doing a tremendous job there, but given the named person role, will 500 additional health visitors be enough? I know that that is a lot, given the standing point just now, but in the fullness of time, will that number be enough to cover needs? I am not convinced that it will be.
We will continue to monitor to see whether it is enough. You are absolutely right that the health visitor will be the named person for the majority of children under five, so we must ensure that there are enough of them.
Theresa Fyffe has said:
“Health visitors make a critical difference to the health and wellbeing of the future lives of children and families.”
She recognises their importance, and has welcomed the increase in investment in that respect. We must ensure that they are fully resourced, but I think that Aileen Campbell is more versed in the named person issue.
I should sound a note of caution, because there is an on-going legal issue about that element of the Children and Young People (Scotland) Act 2014. However, I can say that not every family will need their named person. As a well-known practitioner who has an existing relationship with the family, they will be an important first point of contact but, as I have said, not every family will need theirs.
I also point out that the money that accompanied the expansion of health visitors will be used to increase capacity as well as their training and knowledge of some of the new requirements in the legislation. This is about not just recruiting health visitors, but ensuring that there is quality behind all of that and taking cognisance of the legislative changes that have been made.
Will it involve increasing recruitment in the nursing profession? After all, health visitors need to train as nurses first, and I am not sure whether there are enough trained nurses who are ready to take on the role.
The modelling took account of workforce demographics and the number of health visitors who would naturally be going through the system and then looked at the workforce overall. The situation is being monitored very closely, and it will be down to the health boards to decide what resource they need and where it might come from. We are talking about a four-year cycle; graduates with nursing degrees will be coming out every year, and the hope is that a gap in other nursing services will not arise as a result of people moving into health visiting.
What is very clear is that a lot more nurses are looking to choose health visiting as a profession. For the past couple of years, that has not been as strong, but we now feel quite positive about being able to build on the commitment that we made.
The GIRFEC or named person approach is about embedding the best practice that many health visitors and teachers already do, in the relationships that they have with families and in the help and support that they give children and parents. Given that the statutory requirement for the named person and the GIRFEC element of the 2014 act will not come into force until 2016, things are not going to start immediately. Indeed, we are about to consult on the statutory guidance that will accompany the legislation, and that will provide another opportunity to reflect on the situation and ensure that we have in place everything that we require.
Are things being monitored very carefully? Given the previous cut in the intake of nursing students, it is important to look at the whole situation and to plan well ahead to ensure that people are coming through the system.
The need for new posts is reflected in the budget lines. For example, funding for new posts is to rise from £6.8 million in 2015-16 to £20 million in 2017-18.
Minister, can you pick up the point about the cut in the number of nursing students? I know that it was partly restored, but the fact is that the cut of 20 per cent—or 10 per cent in each of two years—has not been restored fully. The 40 per cent cut in the midwifery intake, too, has been only partly restored; the numbers fell from 180 to 100 and then went back up to 160. The Royal College of Nursing has heavily criticised those two cuts, and they are particularly pertinent in view of the very welcome decision to increase the number of health visitors. If people want to take up the postgraduate training for health visiting, they must have trained as a nurse first. If an increased number of students are not coming through, how will you augment the number of health visitors by 500? I do not follow the logic.
11:00
The cuts in numbers are being reversed so that we are recruiting more and taking the need for health visitors into account.
So the full nursing complement from three years ago, before the cuts, will be restored. Is that what you are saying?
I cannot guarantee that those are the numbers but I can get back to you on that.
Most of the questions that I was going to ask have been answered, but I have two quick ones.
The Scottish Government has increased investment in childcare provision. Most parents require it and we all know how good it is for the child. What impact will it have on early years health inequalities?
As we have said in response to other questions, the increased provision is about giving children the best start in life. We have also increased the skills of the workforce through the requirement to have the BA in childhood practice and more qualifications in other areas. We are trying to improve the quality to ensure that the children who have those 600 hours of childcare get a quality experience.
The expansion of provision to two-year-olds—15 per cent this year and 27 per cent next year—is about taking on board what everyone has been talking about: that if we intervene effectively in the early years, we can improve outcomes in later life. The expansion of provision to two, three and four-year-olds is about not only supporting the child but ensuring that we build proper relationships with families—it is about providing support to the families and increasing their capacity as well, so that not only does the child get a nurturing experience in the 600 hours, but there is increased capacity to ensure that they get the nurturing that they require when they go home.
That is not the end point. The 600 hours of child care will do a lot to reduce the impact on household budgets. Our modelling has suggested that families will make a saving of £700 per child per year. We want to build on that expansion by increasing the flexibility and increasing the hours further. However, we need to do that at a pace that allows us to get the adequate number of people in place to achieve our targets and deliver the quality.
I welcome that. My grandson is now attending nursery; my granddaughter is only months old.
Recently, there was a press report about a lady in a famous hotel in London being asked to leave or cover up because she was breastfeeding. Earlier, you mentioned the rates of breastfeeding in Scotland. The Parliament passed a law on breastfeeding. What action is the Scottish Government taking to ensure that firms and the public know that new mothers are allowed to breastfeed in public?
I guess that it does not help that we have certain politicians making certain claims in public about breastfeeding, but I will leave that for Mr Farage to explain away.
I totally deplore his comments.
Absolutely.
As I said, some of the tests of change from an early years collaborative point of view have been about increasing the prevalence of breastfeeding and providing the support that mums might need. At that point, they are vulnerable. They have just had a baby and are getting bombarded with lots of information, so they do not need to be made to feel guilty. We are ensuring that the support is available for mothers who need the extra bit of help. We are doing that to increase the prevalence of breastfeeding because it offers the best start in life to children.
The legislation to which you referred was passed in 2005. There are a number of initiatives on baby-friendly or breastfeeding-friendly status. We are promoting it through a number of different avenues. UNICEF is developing a number of bits of work to provide accreditation for premises to be breastfeeding friendly.
Maureen Watt might want to talk some more about some of those measures. However, the result of the collaborative example that I mentioned is that 86 per cent of the mothers with whom the services are working now breastfeed. I acknowledge that the sample is small, but the outcome shows that if we work effectively with a group of mothers, we can quite quickly turn things around and get more positive results than we might have seen in the past. The overall result for Fife was 25 per cent, which highlights the difference that can be made through the approach that the collaborative brings to bear.
It is incredibly important—not least because I am about to have a child myself—that we have in Scotland a culture in which the benefits of breastfeeding are accepted and in which mothers feel that there is acceptance around it.
To go back to the point about increased provision of childcare, our aim is to increase not only the provision but the quality of childcare and children’s experience of it. For example, they may learn how to read, play and interact, and they may get better nutrition, which all feeds back to the families.
I heard a discussion about breastfeeding on the radio the other morning and the people involved were praising the Scottish approach. We have Elaine Smith to thank for the Breastfeeding etc (Scotland) Act 2005, which was the first legislation of its type in the UK, and one of only a few pieces of legislation in the world that make it an offence to stop a person breastfeeding. Perhaps Claridge’s and other outlets and organisations ought to be aware of that.
Aileen Campbell mentioned the UNICEF UK baby friendly awards. Scotland has increasingly been at the top of the list in those awards, in comparison with every other region of the UK, and we should be proud of what has happened here in relation to breastfeeding.
In my constituency office, I have a notice up that says that if a mother wants to feed her baby there, she can do so. All mothers need is somewhere that is quite calm and has appropriate seating and water. We could all take a lead in that respect and ensure that our constituency offices offer that facility.
We will take your point.
I am sure that Richard Lyle’s grandson or granddaughter might find that helpful.
On the first day that my grandson went to nursery, he took his jacket off and said, “Bye, Mum” and ran straight in to play, so I welcome the increased hours of childcare, and I also support Elaine Smith’s legislation to promote breastfeeding.
For the key developmental milestones beyond the early years, such as adolescence and the transition from primary to secondary school, it is important to get it right in the early years; it all often points back to a good experience in early years settings.
I do not want to be a pain, and I do not necessarily require an answer, but it would be useful to get some feedback on our earlier discussions about what our objectives are for childcare policy and how we evaluate them.
The concept of proportionate universalism has been mentioned by the minister and other members, and by Professor Michael Marmot, who gave evidence in a previous session. Given that it is a relatively new childcare initiative, it would be interesting to evaluate how it helps with inequalities and to ensure that an inverse situation is not operating. How do we look after very vulnerable children within the whole spectrum of that initiative? Does applying the concept widen or narrow the gap between the poorest and the better off? What evaluation has been done?
Sorry—I am struggling on your question. Are you referring specifically to childcare?
What evaluation has been done of the childcare policy that you have described? How is it poverty proofed? How do we ensure that existing inequalities are alleviated by the policy? What evaluation has taken place?
The document “Equally Well: Report of the Ministerial Task Force on Inequalities” sets out clearly that departments should ensure that they do not build inequalities into anything that they do. For example, and as you know, we encourage cross-departmental approaches. The last task force report mentioned the link up project, which was run by Inspiring Scotland and received funding from both justice and health. It looked to enable asset-poor communities to develop and grow. All departments are well aware that they should ensure that they do not build inequalities into their work.
What has been said today and by the panel that gave evidence to you last week is that a lot of inequalities are a result of things that are not in the Scottish Government’s control.
We have noticed that when people receive the living wage, it has helped to reduce inequalities.
Not to go on about it—maybe I am communicating poorly—but if you implement a universal policy that applies to everyone, rich or poor, how do you ensure that the measure tackles inequality? What evaluation took place to ensure that it would narrow the gap between rich and poor? How does it do it? Why is it an inequality measure?
Going back to childcare—
The 600 hours, the flexibility—why is that an inequality measure?
There is a high take-up of childcare—about 90 per cent—so already we have a good base with which we can compare and contrast. The growing up in Scotland longitudinal study has key data about the improvements that childcare measures can make and the reduction in inequalities that they can bring about. However, those things are dependent on childcare being of high quality. We are not just talking about the economic drivers; the policy is about ensuring that children get quality provision.
We know that the benefits of high-quality childcare early on continue at the age of 14 and may particularly benefit children from deprived backgrounds. We see improved cognitive development and speech and language development in five-year-olds. Key milestones point back to the importance of the expansion of childcare. The more hours we give and the better the quality of those hours, the better able we are to begin to tackle some of the inequalities in attainment in later years.
All children will benefit from the policy, including children who are in an advanced position in terms of inequalities. How does the policy help?
All three and four-year-olds across Scotland are entitled to 600 hours, but we are targeting the most vulnerable: this year, provision is being extended to the most vulnerable 15 per cent of two-year-olds; next year, it will be extended to the most vulnerable 27 per cent. We are making our interventions earlier.
I stress again that the provision has to be high quality, particularly for those age groups, which is why we are ensuring, through Professor Siraj’s commissioned work, that the workforce is as well developed as possible. The Care Inspectorate also has a role to play in making inspections to ensure that quality is there.
We know from the results in later life—some of the milestones regarding speech, language and transitions to secondary school—that if we tackle in the early years some of the deep-rooted sources of inequality, we can reverse some of the inequality trends.
It is important to recognise that in all that work, the early years collaborative and the work on raising attainment for all, which I think takes place in P1 to P7, a thread goes through to ensure that we tackle inequalities in education and are always routing back to the early years.
The Scottish public health observatory today published a report on health inequalities. Although it does not focus only on the early years, it points to the interventions that make a difference to health inequalities.
We need to give health visitors responsibility to make decisions. They know where best to spend their time to make a difference to families who need more help.
11:15
Healthcare is important for every child. We do not just talk about targeting. All children deserve the best start in life.
That is my point. We are talking about inequalities and how we reduce the gap between the most vulnerable and the well-off.
We have a targeted universalism within that policy.
We would be glad to hear some more about how we got to that targeted and proportional universalism—that universalism plus, or whatever we call it—but universalism on its own does not seem to be able to do it all. The committee is examining something in addition to that.
We have heard quite a lot about health visitors during this morning’s discussion, but what about the role that general practitioners will play during the next few years? How will their role evolve as the new policies are rolled out?
GPs are just one part of the jigsaw and they are obviously an important part of community planning partnerships. Hopefully, the main point of contact will be health visitors, and family nurse partnerships are also key. GPs will have a role but, hopefully, they will not be needed in the front line because we are making sure that people are healthier in their early years. Clearly, though, they have a role.
You mentioned community planning partnerships among other things. At the Public Audit Committee last week, the Auditor General was a bit critical of community planning partnerships generally because how they work has not evolved as quickly or as painlessly during the past decade as it might have. Do you see any difficulties with rolling out any of the policies? Is everyone buying into them or is it difficult to get policies enacted at the local level because of the difficulties that local authorities have with NHS boards and others?
I was at a meeting of community planning partnerships last week. Roll-out has been patchy, as you say, and some are much further ahead than others. Work is going on between the Government, the Convention of Scottish Local Authorities and the health boards, however, and that is where we are going. It is incumbent on all those bodies to work together to make sure that CPPs are rolled out.
In my portfolio, the early years task force brought key partners around the table and had a direct link with community planning partnerships. The key change that came from that was the early years collaborative, which has had a huge take-up. There were 700-plus at each learning session in the SECC, which showed in a way that has not been shown previously how keen the community planning partnerships are to tackle the issues that they are dealing with in local authorities and health boards.
All 32 local authorities and community planning partnerships are involved in and taking ownership of the collaborative ways in which they want to move forward. However, that is the key change that has resulted from the early years task force and the change fund. It was the first time that we had a financial mechanism that brought to bear money from the Scottish Government, local authorities and health boards. From that point of view, there is a lot to be positive about around the role of local authorities and health boards and all the community planning partners that are participating, particularly in the early years collaborative.
Dr Simpson, do you wish to ask another question?
I will be very brief, convener.
I am interested in the fact that the membership of the public health review does not include any public health directors, particularly in view of the discussion that we had with the previous cabinet secretary about where responsibility for public health should be placed. In England, it has been placed with local authorities, but I think that difficulties are emerging with that approach and results have been very patchy. Can you supply the committee with the terms of the review, tell us who its chair will be and give us some rationale behind not having a director of public health either from Scotland or, indeed, external to Scotland? After all, it might be quite useful to get in someone from England who has experience of the review there and what has happened with the transfer. In any case, I find it incomprehensible that there is, as I understand it, no public health director on the review team.
We can certainly get you that information.
It might be better if that response was fed back to us instead of our trying to get an answer now.
I did say that my question was a quick one, convener.
That was very quick for you, Richard, but nonetheless important.
I thank the ministers and their team for their time and their evidence, which we will take into account in our report. The area is certainly challenging and complex and one with which we are all struggling.
Have a good Christmas, convener.
Indeed. I need to remember that this is our final meeting before Christmas. Merry Christmas to you all.
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