5. Using the strength of universal services to deliver prevention and early intervention
The model for transformational change puts the onus firmly on universal services as key agents in delivering improved outcomes. A lot of people doing at least a little to effect change will achieve much more than a few people doing a lot within an early years context.
Antenatal and postnatal support
All families come into contact with health services during pregnancy, birth and in the first few years of life. This contact provides opportunities for prevention, early detection and early intervention and opportunities to connect children and families to supports within their own communities. For those with higher needs, access through the universal service provides an opportunity to work with families in a non-stigmatising way.
A key priority is enhancing the capacity of antenatal and postnatal services to combine excellent medical care with development of parenting skills and wider social supports. Equally Well highlights the importance of enhancing the capability of antenatal services to reach and support vulnerable families. Antenatal booking is the first universal contact and should be the start of a process of dynamic risk management throughout pregnancy. A primary focus of antenatal services will continue to be providing care and monitoring wellbeing of mother and baby.
Evidence on the health benefits of breastfeeding for both mother and infant is compelling and all women should receive enough information and skilled support to let them make an informed decision on how they will feed their baby. Support should be available for all women in initiating and maintaining successful breastfeeding. Additionally, establishing good nutrition and developing healthy weaning practices is essential and will influence children's immediate and long-term health.
Health for all Children 4 advocates access to a set of core evidence-based interventions throughout childhood while identifying and targeting those who need additional support. The purpose of the universal health service is well defined and includes monitoring the physical, social and mental health needs of each child, screening, immunisation, parenting support and advice tailored to the individual needs of each family. The first 3 years of a child's life should set the blueprint for their social, physical and emotional wellbeing throughout childhood and into adulthood. All contact should promote engagement between parent/carer and child and identify those families who need additional structured parenting support.
Pre-school into primary
The concordat already sets out a number of areas where universal services will be strengthened during the pre-school and early primary phase:
- reducing class sizes to a maximum of 18 in Primaries 1 to 3;
- expanding pre-school provision and making substantial progress towards a 50% increase in pre-school entitlement for 3 and 4 year olds;
- improving early years provision with access to a teacher for every pre-school child; and
- developing and delivering the Curriculum for Excellence.
These developments will benefit all children, but they have a particular value in providing additional capacity to allow universal services to play a greater role in early intervention. For example, smaller class sizes mean that teachers will have more time to spend with individual pupils and scope to provide more targeted support to build confidence in communication, literacy and numeracy at this critical early stage.
Councils will have responsibility for bringing these policies together into a coherent package at local authority, cluster and school/centre level that is focused on improving outcomes for children during pre-school and the early years of primary.
West Dunbartonshire Council's Early Intervention Initiative has 2 key aims:
The West Dunbartonshire Council model has clearly made a difference over the course of the project. It had 10 strands of intervention, including 'changing attitudes, values and expectations' and 'identification and support for children who are failing'.
Other key features of the model included:
Another important element of the initiative was the introduction of an individual support package for any pupils in primary or secondary school who continue to have problems with reading.
A continuum of support
Another area that came through in the work of the task groups was the importance of continuity and a coherent approach across all those services which impact on children's lives. Local authorities already have a statutory duty to develop an integrated children's services plan. Building on this, ensuring that it is fully integrated into the community planning process and that it is increasingly centred and focused on the needs of children and families will be key to developing that continuum of support at local level.
Childcare services have grown substantially over the past decade and are now a key part of the early years service landscape. Like statutory services, childcare provides a non-stigmatising environment where there are opportunities to develop a prevention and early intervention approach. This role can be particularly valuable during the 0-3 age range when some children will not be in regular contact with statutory services.
Given the need to target community nursing resources on those families needing additional or intensive support, it is important that childcare services are able to detect development delays and other risks and know how to bring support to the child to address these.
This implies a need to ensure the childcare workforce has the necessary understanding of child development to detect risks and problems and to be able to address these either directly or drawing on support from other services. More than this, we need to move towards a conceptualisation of childcare as a service that delivers high quality experiences and early intervention for children rather than just focusing on its role in supporting the labour market.
Delivering early intervention through universal services
Each local area should have a universal set of supports for every child and family at a level and a quality that meets a set of core needs (family planning, parenting capacity/skills, mental health of both infant and parents, good oral health, nutrition, childcare, education, family learning, employability, play and leisure) and which is based on building self-efficacy at every stage.
Within universal services, there needs to be the capacity to provide additional support and early intervention for families facing greater challenges, whether on a temporary or more long-term basis. Wherever possible, universal services should take responsibility for providing that additional support rather than referring onwards, in line with the principles of Getting it Right for Every Child. This has implications for both capacity and workforce skills/roles, as a higher dose of the same type of service will not meet all types of additional need.
It may also be possible to work towards the co-location of services, which, while not in itself a panacea, can provide non-stigmatising initial access to services, with the potential for more specialist support as a next step.
In some cases, additional needs of vulnerable children and families can be met through an enhanced level of access or entitlement to universal services, for example subsidised childcare or earlier entry to pre-school. These additional entitlements need to be framed within a consistent framework and based on an assessment of local needs and the contribution they can make to outcomes.
Meeting individual needs
Individuals can have different or higher needs for a variety of reasons, including language, ethnicity and disability, as well as social circumstances. Universal access and universal uptake are not the same. If we are to reduce inequalities and embed early intervention within universal services, then services must pay attention to whether they are reaching minority communities and those with higher needs and then meeting those needs. Ideally, this should be reflected in local performance management and accountability arrangements.
We need to ensure that any information for parents and carers is available in a variety of formats to meet these needs. Any written materials should be presented with an awareness of principles of readability and plain English.
Transitions were highlighted as an important issue in the research with parents and children. The major transition points for children highlighted in the research with parents and children were the transfer from midwifery support to community health team support in the days after the birth, the transition into pre-school and the transition from pre-school into primary.
Curriculum for Excellence provides an important opportunity to improve transitions between pre-school and primary. The early level will span pre-school to the end of Primary 1 and the increasing use of active learning in early primary means that there should be a smooth transition in learning style. There are still several challenges to overcome, however, not least creating an effective dialogue between primaries and nurseries (including private and third sector centres) about respective contributions to early level outcomes. Establishing such a dialogue is crucial to delivering continuity of learning, which is a key principle of Curriculum for Excellence.
Transitions in the life of adults can also have a major impact on young children. For example, bereavement or family breakdown can have a profound impact on young children in particular. Mediation and counselling services generally already have a strong focus on the needs of children. It is important that staff in such services have the skills needed to understand children's response to loss and the duration of distress.
Additional Support for Learning ( ASL)
Under the Education (Additional Support for Learning) (Scotland) Act 2004 education authorities are required to identify, meet and review the additional support needs of each child or young person for whose school education they are responsible. The term additional support for learning applies to children and young people who, for whatever reason, require additional support, long or short-term, in order to help them to make the most of their school education.
While most children will have their learning needs met by day-to-day classroom practice, wider planning arrangements may be needed when additional support is required from other services and agencies. This is part of our drive to improve and unify the support systems for all children, to ensure they are supported into adulthood and have every opportunity to achieve the best they can.