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Chapter 3

THE EARLY YEARS:
the foundation for future health and well-being

Recent research has shown that adverse experiences at an early age can cause significant damage to a developing child’s brain. Children who are exposed to highly stressful situations including violence, household chaos and absent parents are at higher risk of damage, and low income and low education levels can increase the vulnerability of families and communities to these situations.(28) These risk factors are often compounded by limited access to a healthy diet, which can contribute to obesity and diabetes and to a cumulative burden in early life of multiple risk factors for diseases as adults.

Of major concern is that there are serious and ingrained inequalities apparent within the NHSGGC area in children’s health, well-being and life chances. Death in childhood is now rare but infants and children born in families who are living in deprived circumstances are at higher risk.(29) The biggest threats to children’s health and well-being in NHSGGC are the social factors that prevent children from developing the strengths, capabilities and confidence to engage fully in society as children and as adults.

Improving the life chances for children, young people and families at risk constitutes one of the Scottish Government’s 15 National Outcomes. Actions to achieve this outcome include improving the health, well-being, capacity and resilience in children and young people, and research studies urge that early interventions are crucial to reverse early damage and to prevent further problems as the child develops.(30)

The Scottish Government’s Early Years Framework, Better Health Better Care and Equally Well, all recognise that inequalities in the early years must be addressed in order to achieve better health and opportunities for children in the short term and to reduce population health inequalities in the longer term.(31-33) Service strategies including Getting it Right for Every Child, take an integrated approach that puts children at the centre of service provision, and Hidden Harm sets out principles and actions that mainstream and specialist services can take to address the particular needs of children affected by parental drug and alcohol use.(34,35) The
forthcoming UK Child Poverty Bill, is expected to include an emphasis on improving the health, well-being, social circumstances and life chances of children in order to surmount the barriers created by intergenerational poverty.(36) In Scotland, Achieving our Potential, the Scottish Government’s framework for tackling poverty, inequalities and deprivation, includes parenting as a key approach to ensure that children reach their potential and avoid poverty in later life.(37)

This chapter sets out the background to health and well-being in the early years as a priority for NHSGGC, highlights some of the actions currently underway, and proposes further measures to ensure that all of our children have the best start in life.

OUR CHILD PROTECTION

There are just over 285,000 children aged 0-19 in the NHSGGC area which equates to around 20% of the population. This proportion varies across NHSGGC, from 25% in East Renfrewshire CH(C)P to 18% in South West Glasgow CH(C)P and also varies across age groups. For example, between 2005 and 2008 the child population as a whole decreased but the population of 0-4 year olds increased by 5.8%.(38) Projections from the General Register Office for Scotland of future changes in the child populations of the Council Areas within NHSGGC show that this trend will continue as illustrated in Table 1.

Table 1
Projected % change in child population between 2006 and 2020:
NHSGGC and Council Areas by age band

In 2008, only three quarters of babies born in GCC were of British or Irish ancestry. Figures are not currently available for NHSGGC. Babies from Pakistani, other White and African families made up half of the other quarter, with the remainder from a wide range of ancestry groups.(39)

In addition, there may be as many as 1,700 children under six years of age, from as many as 70 nationalities living in Glasgow City, who are from families who are refugees, are seeking asylum or have failed to achieve asylum.(40) In Glasgow City, more than one third of all households with children are single parent households. Clearly, NHSGGC covers a diverse population of children and their families.

RISKS TO CHILDREN'S HEALTH & WELL-BEING IN NHSGGC

A child’s health and well-being can be put at risk due to problems that are specific to the child itself, or difficulties within the family or the socio-economic environment.(41) Child-specific factors include premature birth, poor physical health and disability which are likely to be more problematic if the child is living in a family affected by poverty. Other risk factors within the family and the environment include domestic violence, parental mental health problems or substance abuse, all of which can be compounded by poverty and living in deprived circumstances.

Poverty
While child deaths are at an all time low in Scotland, babies born to poor women have a higher risk of dying or illness throughout childhood and adolescence. Poverty in childhood continues to have an effect throughout the life course and into future generations through pregnancy, and cannot be separated from the circumstances of parents or carers.(41,42) An illustration of the different levels of child poverty across all the CH(C)Ps in NHSGGC is given in Figure 1.

In Figure 1, the bottom row of squares shows the percentage of children living in families in receipt of out-of-work benefits in each CH(C)P across NHSGGC. The top row of diamonds in the graph shows the total percentage of children whose families are on a low income, which is defined as those in receipt of out-of-work benefits together with families on in-work benefits. The graph shows that even in the more affluent CH(C)Ps, there are sizeable proportions of children living in low income families, many of whom are potentially at increased risk of being affected by problems related to poverty. Of additional concern is that the situation could potentially worsen in the current economic climate and there is evidence that children are more likely to experience severe poverty in a recession.(43) (see Chapter 4, Impact of Economic Climate)

Figure 1
Children in workless and low income households within Greater Glasgow and Clyde CH(C)Ps,
2006 Source: HM Revenue & Customs data; SNS

The graph also raises the question as to whether employment alone is able to raise families’ income levels to the extent required to negate the risks of poverty to children’s health and wellbeing.  Sinclair and McKendrick argue that an emphasis on taking parents away from a carer role to increase their income might not always be the best solution for the child. They propose that measures to address child poverty should include a focus on improving opportunities for children as well as pursuing higher income.(42)

Family stress
One of the adverse effects of poverty on a family is the stress it causes parents and the lengths that they have to go to in order to make ends meet. In addition to the physical and emotional impact on the parents, stress can take their attention away from their parenting role, reducing the time and opportunity for the development of a strong parent-child bond, which is crucial to a child’s healthy development particularly in the early months and years as the brain develops.

Other factors that threaten the development of a strong parent-child bond include domestic violence and substance misuse where the parent’s physical compunction for safety, or to feed an addiction, over-rides the ability to develop their relationship with the child.(44) In some cases, parents are unable to take on family responsibilities and children have to be looked after away from home. In Glasgow City, a small study in 2005 suggested that the main factors contributing to children being looked after away from home were neglect and misuse of drugs and alcohol(45) and other research has found that many children in this situation were born into families from lower socio-economic groups.(46) In 2008 there were over 4,500 children looked after away from home in the NHSGGC area. As illustrated in Figure 2, four of the six council areas served by NHSGGC were showing an upward trend in children being looked after away from home between 1996 and 2008 which was in keeping with the trend for Scotland.(47)

Figure 2
Looked after children: rates per 1,000 0-17 year olds, 3-year rolling averages 1998-08
NHSGGC main council areas and Scotland Source: Scottish Government

Research studies from several countries have identified a relationship between being looked after away from home and subsequent problems including loneliness, isolation, poverty, and poor physical and mental health outcomes.(46)

Domestic abuse
Domestic abuse can have a devastating effect on children’s lives and development and there is evidence that suggests that a substantial proportion of children in NHSGGC could be at risk.  The recent Scottish strategy to address violence against women, Safer Lives, Changed Lives, highlighted that one in four women will experience domestic abuse from a partner in her lifetime and that 32% of pupils in one Scottish secondary school disclosed that they were currently experiencing or living with domestic abuse.(48) Scottish figures in 2008 for incidents of domestic abuse recorded by the police were highest in West Dunbartonshire and Glasgow City (1,800 and 1,518 per 100,000 populations respectively) with Renfrewshire and Inverclyde also among the ten council areas in Scotland with the highest rates.

The Scottish Government’s 2008 National Domestic Abuse Delivery Plan for Children and Young People recognises the impact of domestic abuse on children’s family life and development and puts forward a framework of integrated action of protection, provision, prevention and participation.(49) The NHS roles within the framework include better detection, for example, through routine enquiry beginning with maternity services and better service provision and support of individuals and communities affected by domestic abuse.

Substance misuse
There is a significant level of need associated with alcohol and drug misuse across NHSGGC, not least in Glasgow City Council (GCC) where there could be up to 20,000 children affected by parental substance misuse, many of whom are thought to be unknown to specialist services (Addiction services internal report). Children in this situation are likely to suffer from inconsistent, unpredictable or absent parenting, family breakdown, association with criminal behaviour, parental ill health, emotional or physical neglect, learned behaviour from parents, poverty and stigma. In addition, there might be increased risk of domestic violence if alcohol is involved.(44)

Children who experience abuse or neglect as a result of substance misuse are at high risk of developing behavioural and psychological problems with symptoms including aggression, threatening behaviour, use of weapons, cruelty towards animals and vandalism.

Perceptions of society
Additional threats to the health and well-being of children in NHSGGC arise from negative perceptions of adults and a lack of safe social spaces that are attractive and accessible to young people.

A number of responses to questions about children and young people in the vox pop interviews (described in Chapter 2), recorded concerns that there were not enough places for young people to spend leisure time. Local parks can be unsafe and leisure centres can be expensive with activities that do not suit everyone. Consequently, children were often described as running wild in the streets, their location and activities unknown to their parents. Concerns were also expressed about the need for more and better support for families with young children to help parents engage better and spend more time with their children, and also that some such
services were difficult to access, particularly if English was not a family’s first language.

A study carried out in 2006 for the Institute of Public Policy Research, acknowledged that society presents certain challenges in bringing up children, with such factors as the UK having the longest working hours in Europe; marketing of often unhealthy or expensive products targeting ever younger age groups; and the adult population almost always assuming children’s behaviour to be bad or threatening.(50) The study also found a strong association between adults’ lack of contact with young people and their fear of them.

ACTIONS BY NHSGGC AND PARTNERS

There are a number of influential and innovative actions across NHSGGC within service structures, strategic partnerships and integrated working that address some of the difficult problems impacting on early years. Actions include proposals for service and cultural change, specific interventions for young children and their families, and action on social circumstances that impact directly on early child development.

Changing culture
Glasgow City Health Commission, launched in August 2009, recommended that a key goal for the city and its partners should be to become a child-friendly city which would include treating children as an asset, not as a problem, and that all plans and strategies across all sectors prioritise the needs of children and their families. It also recommended that the city should focus more effort on tackling violence, drugs and alcohol-related harm and that this focus should begin by partners investing in early years, thereby prioritising support for young people and parents. Creating a child-friendly city would also have implications for our environment, e.g. 20mph speed limit in all residential areas.

Shifting mainstream resources
NHSGGC Board has agreed that the principle of re-focusing mainstream services towards early years is one that it will prioritise in the future, as proposed in a paper entitled Mind the Gaps: Improving Services for Vulnerable Children. This paper was presented to and fully endorsed by the Board in October 2009. Actions proposed by the paper are to establish more intensive family support for vulnerable families, sustainable parenting programmes and development of the early years workforce. The Board intends to build on this paper by asking CH(C)Ps in conjunction with their community planning partners, to develop action plans for
work on supporting vulnerable families and by promoting these principles among its partner organisations.

Parenting support
Parenting support has been identified nationally and locally as one of the key drivers for improving educational, social and health outcomes for children. A Parenting Framework has been developed for NHSGGC and GCC with the Triple P programme as the programme of choice.Triple P can be implemented as a whole population programme blending universal and targeted approaches. The programme has a strong evidence base, demonstrating improved outcomes for child behaviour and parental confidence and well-being in evaluations from several countries.(51) The programme can offer increasingly intensive levels of interventions
to children and families and is constructed in a way that does not widen inequalities. The evidence has shown that it is cost-effective and that it can reduce child abuse, out-of-home placements, admissions or attendances at hospital for non-accidental injuries and has the potential for preventing severe conduct disorders. It requires strong leadership and multiagency commitment to deliver a consistent and systematic programme. It also requires effective engagement with and involvement of families themselves. We are keen to see a similar approach adopted by all our CH(C)Ps and local authorities.

Early child health interventions

A focus on supporting the best start in life is now a priority for NHSGGC. There are a number of examples of recent developments targeting health in early years which take into account the social circumstances that pose a threat to children’s health and well-being, including the following:

  • Specialist maternity services staff targeting gender-based violence, homelessness, teenage pregnancy and seeking asylum (NHSGGC Maternity Strategy 2006-2011)
  • New models of breastfeeding interventions for women who live in communities with an underdeveloped breastfeeding culture (NHSGGC Infant Feeding Strategy 2008-2010)
  • NHSGGC has set up a new Maternal and Child Public Health Team to ensure a renewed focus on early year’s health and well-being

At a local level, children’s services in Glasgow East CH(C)P have developed a Children and Inequalities Strategy in conjunction with Glasgow Centre for Population Health. The strategy brought together health, education, social, housing and voluntary services and they identified that improvement in poverty and educational attainment would be the most important goals to achieve. All the services have explored actions they could take within core services for children and their families to contribute to meeting these goals.

Another example of successful integrated working for children’s health comes from action to improve dental health in children. Children in the NHSGGC area have historically had high levels of dental decay with a threefold difference between affluent and deprived communities.  A range of interventions has been developed over the last decade across NHSGGC to improve oral health in childhood involving health services, education services, voluntary organisations, parents/carers and children. Interventions included: free supplies of toothbrushes and toothpaste, tooth brushing programmes in nursery settings and for P1 and P2 children; Oral Health Action Teams (OHAT) established in each CH(C)P; general dental practices delivering the national Childsmile programme; health support workers promoting positive oral health activities in the home; nurseries and schools offering healthier foods and drinks; and planning is underway for fluoride application for children in nurseries and primary schools in the least affluent part of Glasgow City. There are indications from the 2008 National Dental Inspection Programme that improvements are being achieved particularly in the least affluent NHSGGC areas, but there is still work to be done to raise the dental health of NHSGGC children up to the Scottish average, as illustrated in Figure 3.(52)

Figure 3
Percentage of Primary 1 population with no obvious decay experience (d3mft) in NHS Greater
Glasgow & Clyde (and previously GGHB) and in Scotland, 1987- 2008
 

ACTION ON SOCIAL CIRCUMSTANCES

Inequalities Sensitive Practice
NHSGGC’s Inequalities Sensitive Practice Initiative (ISPI) was funded from 2006 to 2009 from the Scottish Executive’s Multiple and Complex Needs Initiative and aimed to identify the factors that would help NHSGGC and our partners to improve frontline services to reduce inequalities.

ISPI supported services, including maternity care and integrated children’s services teams, to include sensitive routine enquiry about social circumstances likely to impact on children’s health and well-being, particularly gender-based violence and poverty. ISPI found that maternity service users welcomed sensitive enquiry and that easier referral pathways between adult and children’s services were required to address inequalities in children’s services provision. ISPI also found that a majority of staff in integrated children’s services teams wanted more support with understanding the links between poverty and child health.

Poverty
Child poverty is a key priority for NHSGGC and our partners and Glasgow City’s Single Outcome Agreement 2008-2011 (SOA) has identified child poverty as a priority. West Dunbartonshire and Inverclyde have also included child poverty as a focus within their antipoverty actions and all councils served by NHSGGC intend to use the Fairer Scotland Fund to tackle the root causes of poverty.

Employment as a route out of poverty has been a key area of action in recent years for NHSGGC in conjunction with our partners. Glasgow Works, the employability partnership which includes NHSGGC, has a Child Poverty Subgroup which aims to ensure that employability activity has a genuine impact on child poverty. We have also begun to stimulate further action on child poverty through work to increase uptake of Healthy Start vouchers and to create better links between the NHS and financial inclusion services. In addition, NHSGGC is supporting a group of staff from across its corporate structures to further explore and clarify the roles
NHSGGC can take in strengthening its response to child poverty. The outcomes of a poverty and child health seminar in October 2009 will inform further developments in research, strategy and practice.

PUBLIC HEALTH MESSAGES

  • The early years are important: An increased focus on a resourcing of services and interventions to support families offer the best opportunity of reducing health inequalities.
  • Public sector services must work differently to enable all children to have the best start in life: The challenges inherent in re-focusing total public sector budgets towards early years are acknowledged but we believe that this is a key action.
  • The impact of early stressful situations on children must be taken into account by service providers: The greatest threats to children’s health and well-being in NHSGGC come from living in difficult circumstances that might include poverty, violence or poor education.

PRIORITIES FOR ACTION

Key processes in NHSGGC have helped to identify the priorities for action on early years including Her Majesty’s Inspectorate of Education (HMIE) reports for the local authority areas covered by NHSGGC. Priorities are proposed as follows:

  • Continue to work to change the culture of organisations and agencies towards becoming child-friendly by focusing more resources and energy on early years at Board-wide and CH(C)P levels.
  • Parenting matters. Some cost effective developments remain essential even in times of financial constraints and the evidence for parenting interventions is overwhelming. We can support parents much more effectively by widespread implementation of the agreed parenting programme for NHSGGC, Triple P. Core to the programme should be a strategy to engage parents fully in the process of delivery. There are opportunities to work with academic partners to establish a world-leading research group on parenting programmes and their effectiveness in a Scottish context.
  • Community Planning Partnerships should focus more directly on the causes of health and social inequalities and on early intervention. This will require a shift in use of resources and in priorities, making early intervention and support for vulnerable families at the core of our joint work. A systematic culture of early intervention would include effective systems for early identification of vulnerability in children within core services, clear pathways for information and referral established between core and specialist services, better pathways between adult and children’s services, intensive, practical family support, first-class
    childcare and action on social circumstances.
  • NHSGGC and partners must demonstrate through policy, planning, practice and performance that they take into account the impact of social circumstances of families on children in developing effective, evidence-informed actions to reduce and prevent their adverse impact on children’s health and well-being.
  • All organisations and agencies should aim to challenge the societal cultural influences that perceive children as a threat, nuisance or source of commercial profit. They might contribute to this aim by creating more opportunities for children and young people to engage with their peers, older adults and their local communities.