Welcome

0 to 5 transformation of children’s public health

services – towards a definition of school

readiness

•Dr Dympna Edwards

•Assistant Director of Public Health

•St. Helens Council

Early Years Healthy Child Programme – the journey so far

Policy Context for Early Years

• Extend early education and childcare for most disadvantaged

• Early Years Pupil Premium

• Quality of early education and childcare

• Troubled Families Agenda

• SEND Reforms 0-25

• Future in Mind

• Welfare Reform

• Healthy Child Programme

Health Visitor Offer - National Changes

•Health Visitor Call to Action - 2011

• Increased numbers (to 2015)

• Increased universal visits •New National Specification 15/16

• Move to resident not GP registered population

• Each GP practice to have named Health Visitor

• Family Nurse Partnership

Healthy Child Programme Universal Visit

• Antenatal visit at 28 weeks

(new)

• New baby visit (10-14 days)

• 6-8 week maternal mental

health assessment (new)

• 12 month visit

• 2-2.5 year visit - integrated

with early years setting

Family Nurse Partnership

• Evidence based intensive health visiting programme - pregnancy to 24 months

• First time mothers under 20 years of age

• Work alongside mothers and partners

• Better outcomes for both mothers and babies

• In place in many LAs

Commissioning Responsibilities

• Health & Social Care Act 2012

• LA to commission Health Visitor Service & Family Nurse Partnership

• NHS England to commission:

6-8 week physical health check

Early childhood immunisations

Child Health Information Systems

These are not part of Health Visiting Specification

Early Years Perspective - School Readiness

• Target doesn’t have a clearly articulated

indicator, it is left to local determination.

• EYFS seen as a proxy indicator for

school readiness – but undertaken when

many children have completed first year.

• Children more likely to benefit from their

time in school if they get off to a good

start.

• Recognise that school readiness is part

of cycle – family ready, school ready, life

ready.

• 2.5 check – opportunity to identify

needs/deficits whilst still time to put in

additional help or support.

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The Local Opportunity

• 0-5 Transition Strategic Leadership Group

• Merseyside (and more recently Cheshire) LAs, NHSE & PHE

• Quality assuring transition via a sector led approach plus adding value via transformation

Transition

Transformation

Improved Outcomes

The Challenge • Good educational outcomes are key to a successful future.

• The early years are a crucial time for children’s physical, emotional and

cognitive development. School readiness proxy indicator through

Foundation Stage Profile.

• % of children achieving a Good Level of Development at the end of

Reception:

England best: 75%

England average: 60%

• Across Cheshire and Merseyside (not ranked by deprivation):

Lowest performing Local Authority: 46%

Highest performing Local Authority: 63%

• 20% gap: What could we do better/differently in order to improve on

this measure through the 0-5 HCP?

So what have we got? • 0-5 Public Health commissioning resource

(predominantly pays for Health Visitor

Service)

• A mandatory universal health check for

every child at 2-2.5 years

• Children in early years settings having an

ASQ3 assessment

• An idea/aspiration to introduce an integrated

review of development/school readiness

• PH requirement to improve the health of

those at risk of poorer outcomes faster

National insight on our local focus

• Significant interest from PHE in school readiness as a health and wellbeing priority, as well as a life chances enabler.

• Recognition from DH Health Visitor Task Force of the evidence base to school readiness and how the child later functions as a young person and an adult.

• By both parties Cheshire & Merseyside have been credited for the work done to date.

Some questions…

• Would we benefit from a common framework for school readiness across Cheshire and Merseyside?

• To what extent would this help or hinder local areas to commission services to reflect specific local circumstances?

• Could this support a shared approach to child’s development between public services and parents?

Some questions… • Should school readiness be a priority for

wellbeing as well as attainment?

• Would a common definition and agreed key

attributes of ‘school readiness’ help parents,

educationalists and health and social care

professionals to share a common goal? Would

this help to inform more integrated delivery

models from pregnancy through to school? If

so, what (3 or so) key attributes would we

choose as the crucial ones?

• Can the assessments undertaken at 2.5 years

be a reasonable indicator of a child’s/family’s

readiness for school?

0 to 5 transformation of children’s

public health services – towards a

definition of school readiness

Family Fun and School Success: Introducing the Brief Early Skills and Support Index (BESSI)

•Naomi White,

•Irenee Daly, Sarah Foley, Rory Devine, and Claire Hughes

Foundation Years Report: Preventing Poor Children Becoming Poor Adults

• In 2010 Frank Field, MP, conducted independent review on poverty and life chances

• Recommendation to ‘establish a set of Life Chance Indicators’

• Measures for nursery (age 3) and primary school entry (age 5)

School readiness

• Term means different things to different groups: – Politicians (and many parents): literacy, numeracy etc

– Teachers: socio-emotional development & ‘daily living skills’

are key

• Shifting goals for measurement:

– Traditional: identify the small number of children who need

special education

– Current: identify more common problems, to ensure that curriculum meets the needs of all children

From tasks to questionnaires: the EDI •Janus and Offord (2000; 2007)

• 5 child scales:

– social, emotional, physical, cognitive and communicative

• Administered to large samples in Canada, Australia, China, Scotland

•BUT:

• Not used with children < 4 years

• 104 items (7 pages)

A new measure – The Brief Early Skills & Support Index (BESSI)

• One page (30 items) – with simple response scale (Strongly Disagree / Disagree / Agree / Strongly Agree)

• Includes (as name suggests) items about family support

• Also includes items selected to be relevant to very young children (e.g., ‘enjoys songs and rhymes’)

Developing the BESSI

• Initial grid of 80 items rated by 23 teachers as useful / not useful

• Focus groups with reception teachers and head teachers

• Reduced set of 50 items completed for 185 children

• Filtered out items with poor sensitivity / unclear item wording

The BESSI contains 4 Subscales

Behavioural Adjustment 12 items

Social skills, Self-regulation

‘Trouble sitting still’

Language & Cognition 6 items

Early literacy/numeracy abilities

‘Enjoys songs and rhymes’

Daily Living Skills 6 items

Ability to dress/feed self ‘Does not need help with

fork’

Family Support 6 items

Parental support for learning

‘Talks about fun activities at home’

• 1473 UK nursery and reception children

• Age Range: 2.50 – 5.50 years

• 49% Male and 89% White British

• 25% Eligible for Free School Meals

Most Frequent Problems: %

Easily Distracted 47

Trouble Sitting Still 35

Needs help with belongings 30

Often interrupts 28

Easily Frustrated 27

(Does not) Enjoy identifying Letters 28

(Not) able to work independently 26

(Does not) Talk about fun at home 26

Common problems were more frequent in boys than in girls…. Item Boys % Girls %

Easily Distracted 56 38

Trouble Sitting Still 45 25

Needs help with belongings 40 20

Often interrupts 31 24

Easily Frustrated 35 19

(Does not) Enjoy identifying Letters 24 15

(Not) able to work independently 35 17

(Does not) Talk about fun at home 31 21

Gender

Age

Free School Meal

Older Sibling

Ethnicity

Behavioural Adjustment

Language and

Cognition

Daily Living Skills

Family Support

.23

.26

.34

.14

Gender effects on all BESSI subscales

Item FSM Not

Easily Distracted 57 43

Trouble Sitting Still 44 32

Needs help with belongings 37 29

Often interrupts 34 25

Easily Frustrated 35 26

(Not) Enjoy identifying Letters 30 12

(Not) able to work independently 33 24

(Not) Talk about fun at home 47 20

Common problems more frequent in children from low-income families

Gender

Age

Free School Meal

Older Sibling

Ethnicity

Behavioural Adjustment

Language and

Cognition

Daily Living Skills

Family Support

.13

.28

.16

.40

FSM effects on all BESSI subscales

Gender

Age

Free School Meal

Older Sibling

Ethnicity

Behavioural Adjustment

Language and

Cognition

Daily Living Skills

Family Support

.58

.56

.45

Family Support explains FSM differences

Behaviour Adjustment

Language & Cognition

Daily Living Skills

Praise .13 -.61* -.42

Punctuality .02 -.02 -.32*

Misses School -.01 .12 .14

Talks about Fun .22* .68*** .46***

Reads Regularly .03 .27 .45**

Sleepy .13 .29* .39**

A closer look at Family Support

Controlling for effects of age, gender, sibs, income and ethnicity

Key findings from the BESSI

• The BESSI works equally well for boys and girls, and for children from 2.5 to 5.5 years

• Boys show more problems than girls (in behavioural adjustment, cognitive development and daily living skills)

• Reduced family support explains increased problems in children from low income families

• No effect of ethnicity

Current work with the BESSI

• How much do BESSI scores change over 6 months? • How similar or different are parents’ versus teachers’ ratings?

• Does observational coding validate ratings of family support?

• Can the BESSI be used to assess impact of interventions to promote

family support?

• Does the BESSI work in a similar way for ethnic minority children?

• Is the BESSI suitable for use in other countries (first step, Singapore)?

Current work with the BESSI - Can you help?

• We’re developing a user manual and scoring guide for teachers for the BESSI

• This will include a spreadsheet that will provide a profile of each child’s strengths and difficulties

• We’d love to hear from any Foundation Years staff who would be interested in test-driving it for us!

Acknowledgements: Westminster Foundation &

Foundation Years Trust – for funding support www.foundationyearstrust.org.uk

All the schools and nurseries in the Wirral – for taking part. njw49@cam.ac.uk

0 to 5 transformation of children’s

public health services – towards a

definition of school readiness

Ensuring Every Child has the

Best Start in Life: Ready to learn at 2 –

2.5yrs, ready for school at 5yrs

Alison Burton – Lead for Maternity and Early Years, PHE

The Best Start in Life - Why is this important?

• Currently 60.4% of children in England (2013/14) achieve a good level of

development at the end of reception as measured by the Foundation Stage Profile. Department of Education

• Around 1 in 10 (9.5%) of children are obese at age 4/5 yrs. National Child Measurement

Programme (2013/14)

• 27% of children have tooth decay at age 5 yrs. Commissioning better oral health for children and

young people . PHE 2013

• 7% of children around five years of age have speech, language and communication

needs. (SLCN) Tomblin JB, et al (1997)

• 1 in 10 women are estimated to experience mild to moderate post natal depression. NICE 2007

• Up to 20% of women develop a mental health problem during pregnancy or within a

year of giving birth. This can lead to disordered early attachment with long term

consequences for mother and baby. The Costs of Perinatal Mental Health Problems, Bauer et al., LSE,

Centre for Mental Health, 2014

• Obesity in childhood increases risks of becoming obese adults. Annual Report of the Chief

Medical Officer 2012. Our Children Deserve Better: Prevention Pays. Department of Health, 2013

• 70% of adults are predicted to be obese or overweight by 2034 From Evidence into Action:

Opportunities to Protect and Improve the Nation’s Health. PHE. 2014

37

Measuring outcomes School readiness: Percentage of children achieving a good level

of development at the end of reception (age 5 years) DfE via PHOF

60.4% in 13/14.

Ranging from

41.2 to 75.3%

1.8X variation

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FSP DIMENSIONS

• Personal

• Social

• Emotional

• Physical

• Communication

• Language

• Maths

• Literacy

Public health outcome frame work data (1)

PHOF indicators Highest Lowest Period

1.01 Children in poverty(under 16)

London (23.7%) South East (14.2%) 2012

2.02 Breastfeeding (initiation)

South West (78.6%) North East (60.3%) 2013/14 – no figure for London

2.03 Smoking status at time of delivery

North East (18.8%) London (5.1%) 2013/14

2.04 under-18s

conception (inc under-16s)

North East (30.6 per 1,000 pop)

South East (20.5 per 1,000 pop)

2013

Tooth decay in

children aged 5 - % of

children with decay

experience NOT PHOF

North West (34.8%) South East (21.2%) 2011/12

39

Regions

Public health outcome frame work data (2)

PHOF indicators Highest Lowest Period

1.01 Children in poverty(under 16)

Tower Hamlets (37.9%) Wokingham (6.6%) 2012

2.02 Breastfeeding (initiation)

Wandsworth (93.0%) Stoke-on-Trent (36.6%) 2013/14

2.03 Smoking status at time of delivery

Blackpool (27.5%) Westminster (1.9%) 2013/14

2.04 under-18s

conception (inc under-16s)

Stoke-on-Trent (43.9 per 1,000 pop)

Rutland (9.2 per 1,000 pop)

2013

Tooth decay in

children aged 5 - % of

children with decay

experience NOT PHOF

Leicester (53.2%) Brighton and Hove (12.5%)

2011/12

40

Upper tier local authorities (ie counties, UAs and LBs)

Best Start in Life:- Local picture Around 58.9% of children in Cheshire and Merseyside achieve a good level

of development at the end of reception compared with 60.4% across England.

This proportion varies from 45.6% to 62.8% across Cheshire and Merseyside

local authorities.

Nearly 6,200 Cheshire and Merseyside children aged four to five years

have excess weight. This equates to 23.6% of the age group, which is

significantly higher than the England average of 22.5%. In one local authority

in the area, the proportion is as high as 29.5%.

Around 91.4% of five year olds in Cheshire and Merseyside have received

their second dose of the MMR vaccination. This is higher than the England

average of 88.3%. In all local authorities in the area the proportion of children

that have received their second dose is higher than 90%.

Source: Public Health Outcomes Framework

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Cheshire & Merseyside: Tooth decay (mean dmft) in

children aged 5

England average

Source: Public Health

Outcomes Framework

From evidence into action: opportunities to protect

and improve the nation’s health (October 2014)

Ensuring every child has the best start in life. Ready to learn at 2 – 2.5yrs, ready for

school at 5yrs

Over the next 18 months PHE will:

• support local authorities in developing integrated children and young people’s

services as they take on commissioning responsibilities for the Healthy Child

Programme for 0-5’s

• promote the importance of high-quality universal services as a foundation for good

health for all our children and as a platform for early intervention and targeted support

• develop and strengthen the evidence, including working with the Early Intervention

Foundation as a ‘What Works Centre for Early Intervention’

• expand the Start4Life Information Service for Parents from 0-2 years to 0-5 years and

sign up over 200,000 more parents

• expand newborn bloodspot screening to include four new inherited metabolic

disorders

• work with NICE on the implementation of the quality standards and pathways for

emotional and social wellbeing in early years

• lead and co-ordinate the Childhood Flu Programme, working with NHS England

• increase coverage of measles, mumps and rubella immunisations for all children at

five years https://www.gov.uk/government/publications/from-evidence-into-action-opportunities-to-protect-and-improve-the-nations-health

43 43

Building on current assets Significant system change and investment in early years over 5 years:

• Health visitor implementation plan – workforce expansion

• Service transformation:

o 4 levels: community, universal, universal plus & universal partnership plus

o 5 mandated reviews: A/N, NBV, 6/8 weeks, 1yr., 2 - 2.5 years old

o 6 high impact areas: transition to parenthood, maternal mental health, obesity,

preventing admissions to hospital, breast feeding, child development

• Family Nurse Partnership – 16 000 places, RCT

• Universal 2 – 2.5 year review

• Transfer of commissioning responsibilities for 0 – 5’s PH to LAs

• ChiMat resources and expertise: analytical capacity, online resources etc

• PHE: Centres’ expertise and local leadership, nursing and midwifery, social

marketing, drugs and alcohol, immunisations, mental health, health equity etc

44 44

Best Start in Life - High level aims • Closing the gap in inequalities in important health outcomes during pregnancy and

early years in particular: transition to parenthood (attachment), maternal mental

health, breast feeding, oral health, child obesity and child development

• Sustaining universal primary prevention services for 0 – 5’s. Able to undertake risk

assessment and early identification of need, including universal assessment and

support to promote sensitive attuned parenting and promote secure attachment

• Ensuring that knowledge and intelligence including evidence of effectiveness, data

and soft intelligence are readily available to inform need, service provision and

targeted support

• Sector led improvement – articulating what “good” looks like, support local systems to

join commissioning of universal public health prevention services with early

intervention and specialist services – a holistic offer

• Workforce development – identify core competencies, shared quality standards,

critical success factors, joint training

45 45

PHE tools • PHE have a number of tools available already which help local areas when they are planning

public health services for children who are aged 0 to 5 years old.

• 2014, published early years profiles which show all local councils how they compare with the

average for England, making it easy for them to identify areas for improvement.

http://atlas.chimat.org.uk/IAS/dataviews/earlyyearsprofile

• in addition, the profiles give trend information so that a council can see whether they have made

an improvement since 2010 on key issues for this age group such as breastfeeding, obesity and

injuries.

• we also published an early years report for each council which gives more background to the

profiles and help with interpreting the data.

• http://atlas.chimat.org.uk/IAS/profiles/profile?profileId=52&geoTypeId=

• alongside these existing tools, we now have estimated data for electoral wards for some of the

key indicators such as teenage mothers, hospital admissions as an emergency in under 5s and

A&E attendances

• http://www.localhealth.org.uk/#v=map4;l=en

• local specialists in child health data

• http://www.chimat.org.uk/default.aspx?QN=CHIMAT_LOCAL

46

Local Authority Child Health Profiles

Official Statistics, 19th March 2014

Standard template

Tailored at a regional level

“We found this information very useful

for setting priorities and assessing

interventions”

A Benchmarking Tool (Outcomes Framework)

for Children & Young People

• See, http://www.fingertips.phe.org.uk/profile/cyphof

• Benchmarked for Local Authorities

• Broken down to greater detail where possible

48 48 48

0 to 5 transformation of

children’s public health

services – towards a

definition of school readiness

School Readiness

www.sefton.gov.uk

The evidence is overwhelming that for optimal effectiveness, intervention should be focused on the earliest years, and ensure that children arrive at school ‘school

ready’ WAVE Trust 2010

“School readiness involves more than just children.

School Readiness, in the broadest sense, is about

children, families, early environments, schools

and communities. Children are not innately

“ready” or “not ready” for school. Their skills and

development are strongly influenced by their

families and through their interactions with other

people and environments before coming to

school.” Maxwell & Clifford 2004

School Readiness

Policy Direction and Drivers

• Sefton’s Early Intervention & Prevention (EIP)

Strategy

• Re-structure of early years services

• Political landscape

• Breadth of partnership work

• Health agenda - Integrated assessment with

health for two year olds

School Readiness

Early childhood services cover integrated provision from pre

birth to the end of the Early Years Foundation Stage

Sefton approach to School Readiness

School Readiness

Education

Health Parenting and family support

School

Readiness

Coherence

Consistency

Collaboration

Challenge

School Readiness

CHILD READY Children happy,

healthy and ready for school

FAMILY READY Effective integrated

working across child and family services with clear

focus on the most vulnerable and earlier

intervention

SCHOOL READY All children

attending good and outstanding

settings

COMMUNICAT ION

F I VE to TH R I VE

Design Fundamentals

• Focus on younger children

• Going beyond education

• Development aware

parenting

• Pedagogical conversations

Toxic Trio Parental

mental health Poor housing

Domestic violence

Family debt

Transient population

Welfare reform

Attachment disorder

Integrated health review

Parental drug and alcohol

misuse Neglect

Family breakdown

CSE LA & Health

re-organisation

• Proportion of children achieving a good level of

development

• Closing the gap between vulnerable children and others

– Gender differences

– Free School Meals

• CHIMAT Child Health Profiles

• Healthy Child Programme

• Integrate services in order to develop, retain and embed

high quality and expertise across the sector

• Parenting programmes

Measures and Performance

Thank you for attending

Presentations will be available at

www.champspublichealth.com

GROUP WORK – KEY ATTRIBUTES

1) Resilient

2) Confidence

3) Empathy

4) Positive

5) Sense of wonder

6) Good communicators

7) Communicators

8) Self worth

9) Sociable

10) Creative

11) Healthy and loved

12) Aspirations

13) Point of difference?

14) Attachment to parents?

15) Independence

16) Able to play

17) Feeling secure with own feelings (internally)

18) Take risk

19) Environment

20) Be happy/joyful

21) Cared for

22) Mindfulness

Four Themes

• Parents

• Communication and Language

• Relationships and Social Interaction

• Self-awareness