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Public Services Committee

Uncorrected oral evidence: The role of public services in addressing child vulnerability

Wednesday 7 July 2021

3 pm


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Members present: Baroness Armstrong of Hill Top (The Chair); Lord Bichard; Lord Bourne of Aberystwyth; Lord Davies of Gower; Lord Filkin; Lord Hunt of Kings Heath; Baroness Pinnock; Baroness Pitkeathley; Baroness Tyler of Enfield; Baroness Wyld; Lord Young of Cookham.



Evidence Session No. 19              Virtual Proceeding              Questions 139 - 142



I: Rt Hon Dame Andrea Leadsom DBE MP, Chair, Early Years Healthy Development Review.



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Examination of witness

Dame Andrea Leadsom.

Q139       The Chair: I thank everyone for joining us today at the Public Services Select Committee in the House of Lords. I am Hilary Armstrong and I chair the committee. We have a busy day, with lots of witnesses as part of the evidence-taking in our inquiry into the role of public services in addressing child vulnerability. We are delighted with the range of witnesses we have this afternoon. Because there are so many, we will inevitably be pushed for time.

Our first witness is Dame Andrea Leadsom, who has just conducted a wide-ranging inquiry, involving lots of people, into early years intervention, looking at the first 1,001 days for children. Dame Andrea, we are delighted that you are able to join us today. Several of us have worked with you before in the other place, as we call it.

We do not break too many traditions in the House of Lords, so, as ever, the Chair asks the first question. Because this committee is looking at things across the board, what do you see as the major obstacles to implementing the findings of your early years review, such as agreeing shared outcomes and shared funding allocations? Do you think that is an issue? Do you think the barriers to data sharing are too great? There are issues between siloed departments. What do you think are the real challenges that need to be faced to get an effective early years policy?

Dame Andrea Leadsom: Thank you very much, Baroness Armstrong, and to everybody for having me. It is a huge pleasure to be here.

In direct answer to your question, what every family, parent and carer raised with us during the initial fact-finding phase of my Early Years Healthy Development Review on behalf of the Government was that nothing is joined up. People said, “I was expecting a baby and I had no idea what services were available, what I might need or where I could get them”.

At the heart of my review was putting the needs of the baby and the family who advocate for that baby at the centre of everything we do. If you turn it on its head, and in the context of your inquiry, why is it like that? Of course, we have Whitehall silos. I chaired an inter-ministerial group under Theresa May’s Government to look at the 1,001 critical days—the period from conception to the age of two—and on it there were eight different Whitehall departments: the Home Office, DWP, health, education, local government and so on. Therein lies part of the problem. Although Whitehall departments try to work cross-departmentally, it is very difficult to do that. In the year I chaired that inter-ministerial group, I found quite often that Ministers had come up against a blank wall and could not progress their bit of the work, or they were behind because they had other priorities. Actually getting joined-up services is quite difficult when faced with silos in Whitehall.

The same is true in local authority areas. We heard from directors of children’s services, who said, “We have a great offer for three year-olds”. I would say, “Yes, but we want to talk about babies and conception to age two”, and they would say, “Oh, you need to speak to the local health group. We can’t speak for babies”. Those silos are the biggest problem.

What are the solutions? Obviously, that is what our vision for the 1,001 days is all about. One of the solutions is leadership. The Prime Minister has agreed that he will appoint an existing Cabinet Minister to have responsibility for overseeing the Start for Life services. We are in the process of putting together a Start for Life unit that for the time being sits within the health department. That might move, but a Cabinet member with responsibility for conception to age two in its entirety—soup to nuts—will be key.

We are also proposing that in every local authority area there should be a local leader who is accountable for the Start for Life services in its area. It could be the director of children’s services; it could be the chair of the health and well-being board; it could be the chair of the equivalent of Public Health England. That would be for the authority to decide, but there needs to be somebody who will be responsible.

To ensure that continues, our other recommendations are on the publication of a set of Start for  Life services, both universal and universal-plus, and the bringing in of family hubs, which will be multidisciplinary centres where professionals and volunteers work together to support families. In addition, there will be a digital version of what is currently known as the red book, which will put in everything from the maternity notes to babies’ immunisations, to whether there were mental health issues, previous terminations, perhaps a partner with mental health problems and whether there is any social work involvement, so that we do not allow GDPR and the problems of data sharing to stop us helping a baby who may be vulnerable.

The Chair: Thank you, Dame Andrea. We have been told different things by different people from government about the likelihood of cross-departmental bids being accepted and delivered in the spending review. Do you think that sort of thing is important? Are you looking for government departments to make a joint bid for the nought to two year-olds?

Dame Andrea Leadsom: Yes. It is absolutely essential. The Start for Life unit will eventually have 25 civil servants drawn from right across Whitehall, as well as from the early years sector. A big part of our work, possibly a third of our work next year, will be bringing together cross-departmental spending review submissions. There is a lot of work to be done, because as we work in silos different departments have different bits of information. The DfE might have information on school readiness, whereas the DWP might have information on poverty, and the Home Office might have information on domestic violence, for example. Bringing together the information we have for a shared spending review bid that makes the case and provides evidence of why this will transform outcomes and costs to the Exchequer is a huge challenge on which we are really focused.

The Chair: There are lots of things I would like to follow up because, as you know, I did quite a lot of work on this too. We have even done some work together on it in the past. However, lots of colleagues on the committee need to ask you questions.

Q140       Lord Bichard: Dame Andrea, thank you for being with us this afternoon; it is really helpful to us.

I want to unpack the collaboration a little more. You must be absolutely right. Some of us have been frustrated for decades about the inability of government to work across departmental boundaries. Frankly, as I was once a local government chief executive, I was delighted to hear you acknowledge that among the reasons why local services find it so difficult to cooperate and coordinate is that central government finds it so difficult.

The outcome of all that is that we are being told constantly that vulnerable people are falling through the gaps between school, social care, the NHS and the justice system, so the cost of this is immense. I probably know your answer, but as this has been going on for so long and is almost part of the fabric of central government, do you really feel confident that the changes you have talked about today will be sufficient to shift the dial?

Dame Andrea Leadsom: I do. I feel confident for the reason that the focus is on conception to the age of two. We know that every parent wants to be a good parent; we know from every family and carer we have spoken to that they just want to know what is available to them. Our No. 1 action area is a set of joined-up Start for Life universal services to include midwifery, health visiting, mental health support, breastfeeding support, and statutory protection and SEND services. Every family should have access to those.

For families, just being told what is available to them and how to access it would already be quite transformational. Just today, we had a round table with a group of parents and carers, all of whom had horror stories—not being diagnosed with postnatal depression, or dads with high-risk behaviours because they were suffering from undiagnosed PTSD as a result of the appalling experience of wives being in labour and in agony, and so on. Some of the measures we are putting in place are very early on, so they are very much about prevention.

You have mentioned the intractable problems of knife crime, mental health issues, family breakdown and so on. The work just published by the Royal Foundation, in conjunction with the London School of Economics, puts the cost in 2018-19 at £16 billion for the problems of young people with knife crime, mental health issues, self-harming, suicide, school developmental delay and so on. We know from a recent Education Select Committee report that 40% of the inequality in the achievement of young people is already there by the age of five. I would argue that it is already there by the age of two.

The earlier you get in, the better the support you give to families, all of whom want to be good parents. That involves education, support services, the universal services that are not currently universal, and the extra services for smoking cessation and alcohol use reduction for families who do not know that, if they drink excessively in pregnancy and their baby suffers foetal alcohol syndrome, it predisposes their baby to 75% of the IQ of a normally healthy infant. Likewise, smoking can lead to low birth weight, with a much greater likelihood of future obesity, diabetes and congenital heart disease. Some of these things are simply about better education, but it is absolutely about prevention and getting in early, and providing services early that will lead to better outcomes. I feel confident that implementing that would make a material difference.

Lord Bichard: Like you, we have been hearing some horror stories from families and young people. One of the things we are beginning to feel quite passionate about is that the lived experience of these people is not used to design our services, whether central or local. Having consultation meetings and forums is important and tells us what is wrong, but if we are to change that we have to find ways of ensuring that lived experience has greater impact on the way we design services. Have you had some thoughts on how that could be done better?

Dame Andrea Leadsom: We have. The round table with parents and carers that we held today was part of a series. One of our actions in the early years vision is to create parent and carer panels. Our first act is to create a national parent and carer panel. We will establish a kind of standing panel for the next year or so that will help us to create the design principles for local parent and carer panels. You can think of it as a local Tripadvisor.

If, say, you have a baby in my county of Northamptonshire, you might be asked, by virtue of having had a normal birth, or being a single parent, or perhaps being part of a migrant family that does not speak English as a first language, or you are in social deprivation—people of all sorts of diverse backgrounds—to join a parent and carer panel to provide feedback on your experiences. That will be publicly available. What went well, and what did not go so well? It is something the local authority area will establish. It will bring along its own listeners to take heed of the feedback from the parent and carer panel and act on it. That lived experience, learning from what has gone well and badly and sharing best practice, is very much at the heart of what we are doing in this implementation period.

Lord Bichard: Earlier, you mentioned data, which we have been increasingly concerned about, because it is absolutely key to targeting resources effectively and identifying vulnerable children and families early enough. A lot of people have been telling us that services often struggle to access the data they need, particularly data held by the NHS. You mentioned the red book—the health record. Was that your experience? Do you have thoughts on how central government should address that problem and ensure that services have access to the information they need to be effective?

Dame Andrea Leadsom: Data is a problem. Various pieces of data are required to be collected but are not being collected. We know it is difficult to collect data, again partly because of the silos and partly because nobody has overall responsibility for data collection.

Our solution to that is to put forward a digital version of the red book that NHSX has committed to delivering for every new baby from April 2023. That digital version of the red book will collate everything from the birth notes on the birth experience through to weaning, immunisations, health visitors’ notes, any mental health support, the history of the family, previous experiences and so on. Importantly, it will also be the opportunity to gather data at source on an anonymised basis to provide some of the information we need to collect on things like birth weight, breastfeeding, the state of family relationships and so on that will enable better targeting of services. That work is proceeding apace, but I totally recognise what you are saying. Data collection is not being done properly at the moment and there are genuinely very difficult reasons for that.

Lord Bichard: Who do you think should have access to the red book? All the issues you have listed are health issues. What about education? At the moment, we are told that sometimes schools do not even know when a child is being looked after or cared for by a social worker. Do you envisage this red book being more widely available than it has been traditionally? Do you envisage some resistance to that?

Dame Andrea Leadsom: Data is obviously a very complicated issue, and protecting it is absolutely vital. I am talking about a digital version of the red book. I am not talking about schoolchildren; I am talking about foetuses and infants up to the age of two, so there is no schooling going on, although they might be in nursery. We envisage that the data is owned by the family as the advocates for the baby, so that would be the parent or parents of that infant. It might well become a lifelong health record for that child as they go on; it will be a central place for information to be recorded, with appropriate safeguards in line with all of the legislation.

The key point is that families say to us all the time, “Why don’t people ever talk to each other? I’ve had to give my name and address and the fact my partner left me last year six times today, and you are all in the same building. Why can’t you ever talk to each other?” Conversely, there is the health and emotional development work. I am not only talking about health; you might have a social worker, a midwife, a health visitor, a mental health worker, a family centre worker and a Home-Start volunteer. The parent might say, “Yes, they can all have access to this section of my red book so that I don’t have to keep saying that my partner left me, and I had a stillbirth two years ago, et cetera”.

That is music to the ears of the professionals and volunteers, because they say, “If only I’d known that this parent had had that traumatic experience a year ago, I wouldn’t have had to spend half my session with her with a box of tissues trying to calm her down because she has had to tell the story over and over again”. Data sharing is something that professionals long to do and often feel they cannot; families long for them to do it, with the right checks and balances in place. We are determined to find a way through that for the perinatal period. If it goes on to become a lifelong health record that is useful for schools it will be excellent, but working on that spec is not in our brief.

Lord Bichard: I would love to carry on the conversation about how you actually achieve that. I think the intention is absolutely right, but it will be exceptionally difficult, from where we start, to achieve what you want and I want, too. I will not carry on the conversation because the Chair will become irritated.

The Chair: I do not get irritated with you, Michael. Can we move on to Lord Davies?

Q141       Lord Davies of Gower: Good afternoon, Dame Andrea, it is nice to speak to you again.

Dame Andrea Leadsom: Hi, Byron.

Lord Davies of Gower: On the theme of integration of services, we have just heard you lay out plans to digitise by 2023 the red book that parents are given to record each child’s development milestones. You believe that a digital version would help join up the different professionals. What role do you think family hubs should play in facilitating the integration of services and early intervention support as part of a national strategy for vulnerable children?

Dame Andrea Leadsom: Family hubs are absolutely integral. If the joined-up Start for Life offer is the No. 1 thing parents want, very closely behind it at No. 2 is that they want somewhere to go where they can be heard and listened to. That is not just about vulnerable children. In many ways, the fact that family hubs should be universal means they destigmatise the whole of support for vulnerable children.

As part of our review, we very much advocate open access and universally available family hubs for every family in England, so you do not have to be invited in because you are a difficult, troubled, problematic family. One thing for sure is that the feedback we get is that the families who are the biggest danger to themselves and their babies avoid targeted services like the plague. They are afraid their babies will be taken away, and all too often they are. The key point is to have universal services. It is bit like a GP surgery where everyone goes, so it does not stigmatise you. Family hubs are at the heart of that.

Our vision for family hubs is a big, multidisciplinary service centre with open access so that I can come in off the street with my toddler; it is universal, so it is available to all families who want to go there; and it is open for long hours. Very often, we hear from people, “There is a Sure Start service at two o’clock on a Tuesday afternoon, but I have a baby and a toddler and it is a five-mile round bus trip. I haven’t even had a shower by two o’clock on a Tuesday. How am I supposed to get there?” The family hub needs to be open at the hours when families need it.

Personally, I do not believe that we need them all over the place. We need sufficient that there is a core big offer for families where they feel welcome. I would like to see birth registration offered in family hubs, because if everybody is going there to register their baby’s birth everybody gets a look at the dad and baby drop-in, the mum and toddler rhyme time, the mental health support parenting classes, et cetera.

Family hubs are absolutely at the heart of it, but really importantly what we learned during lockdown is that families value the virtual support they have had. In the 21st century, we absolutely should not lose sight of that. I see family hubs as a physical and virtual network in every local area. You can go there physically, but if you are not feeling up to it and you need breastfeeding support, or you have mastitis, or you are afraid of your partner, or you feel that he or she will leave you, or you are worried about your baby because the baby will not stop crying, or you are worried about yourself because you just think you are going mad, you ought to be able to phone in and get virtual support, whether it is for breastfeeding advice, weaning advice or mental health advice.

For many families, the silver lining of lockdown, if there was one, was that they found access to virtual support very helpful to chat to a midwife on Zoom or to access online support from apps such as Baby Buddy, which has done some great work in providing advice to families in lockdown, and for dads who feel, “It’s not really about me”. Many dads feel, “I can’t ask for help because it is all about her. She’s been through this trauma”, and blah, blah, blah. Very often, dads are the key. If dad is in a good place and is not feeling depressed, frustrated and under pressure, he can be much more supportive at a difficult time. Support at all levels, both virtual and physical, is critical, but to underpin that it must be universal.

Lord Davies of Gower: You have more or less answered my next point, but I will ask it directly, if I may. How many family hubs would you like to see across the country to ensure that the needs of every community are met?

Dame Andrea Leadsom: As I understand it, at the moment there are about 3,000 children’s centres of different types in England. We would want to see a family hub in most communities. I do not think it would be anything like 3,000 in total, but those children’s centres, Sure Starts and the amazing work that goes on there cost a great deal of money. I would like to see every local authority area bringing together that estate—all the excellent work they already do for families—under the big, inclusive, universal, open access family hub concept. We would probably have fewer than we have today, but with a much bigger offer, much more focused on the services that take place within them and the needs of families, rather than counting the number of family hubs that there are.

Lord Davies of Gower: Thank you very much.

Q142       Lord Young of Cookham: Good afternoon, Andrea. There will be quite a tough spending review in a few months’ time, or it may have started. Listening to your description of family hubs, they are a fantastic idea, but with open access, multidisciplinary services and longer opening hours, what do you think the prospects are of getting collective agreement, against a background of restraint, for this very exciting idea, which I am sure would indeed be transformative if you could get the money for it?

Dame Andrea Leadsom: You have absolutely hit the nail on the head. That is why a huge part of the implementation phase—the next phase of the rollout of the early years vision—is focused on the spending review submission. It is focused, first, on proving the case for investing earlier and saving money down the line. I am sure that all of you will roll your eyes. All of us are very much aware that there are many in the Treasury whose view is, “Yeah, but no”, so there is a lot of work being done on persuading the Treasury that investing in this area can genuinely save money. I refer back to the work of the Royal Foundation with the London School of Economics showing that £16 billion in just one year was spent on children and young people who have serious problems that were all traceable back to their earliest experiences. You cannot say that you will save £16 billion by investing earlier—of course not—but you can certainly argue that you will save a good portion of that.

A lot of work is going on now specifically to enunciate what the saving would be by investing earlier and, very importantly, how quickly you would save that money. For example, we know that, if you talk to your baby, your baby’s vocabulary will be up to 10 times as great as the vocabulary of a baby that no one ever speaks to or just shrieks at with epithets. We know that, if you want to save money on delayed speech, you could do that quite easily by educating. That is just one tiny example of where you could save money in quite short order by investing earlier, effectively, in teaching parents that you must speak to your baby. The peak period for learning language is about six to 18 months before your baby says anything back. Many parents say, “I didn’t know that. If I’d known, I would have talked to my baby”. Serious cost savings are achievable. That is one thing; we have to make that case.

The second thing is that, as I have alluded to, a great deal of money is already spent by local authority areas on support for families in the early years. It tends to be in quite a scattergun way. Some superb work goes on in local authority areas, so part of our rollout during this period is speaking to the best practice in local authority areas—people who are already doing a lot of what we are talking about—and trying to roll it out across other local authority areas by getting them to use the money they are already spending in a better way. Hundreds of millions of pounds is being spent on services in the early years, but not necessarily in a way that brings in all families.

One very important point that I have not made yet is that in order to support vulnerable children—those who most need help—you need to see all of them. Very often, local authority areas choose who might need their help by looking just at issues of social deprivation. You can be as rich as Croesus and have a mental health breakdown when you have a baby; you can have terrible domestic violence problems and not be socially deprived; you can be under extreme pressures and stress but not necessarily fit the mould of those the local authority area is targeting. Universal services are the way to identify the most vulnerable children, so that in a non-stigmatising way you can offer them the support they need. Another big piece of work we will be doing in the implementation phase is to look at why people feel stigmatised when they accept help in that early years period and how to reduce that.

You are absolutely right, George. The spending review bid is very tricky, but I am very optimistic. The Prime Minister is absolutely behind this. It is about levelling up and building back better; it is about giving life chances to the youngest in our society, and it is cheap at the price. It will not be such an eye-watering sum that you cannot make the case for it saving money further down the line. Finally, may I say that I shall be very bloody-minded about it?

Lord Young of Cookham: Thank you very much, Andrea, and good luck.

The Chair: Thank you, Dame Andrea. I hope you are also able to argue for a bit of longevity in the funding. I have been through this. I introduced some long-term programmes that were then cut and pushed out, and the learning as well as the opportunities for the most disadvantaged were lost.

Dame Andrea Leadsom: You are so right. I have had long conversations about this with Lord Blunkett and, before her sad death, Dame Tessa Jowell. I have reached out cross-party. All parties are on the same page. I really hope this will be cross-party and that all the achievements we make will endure for the long term.

The Chair: We all hope that. I had that hope about some of our stuff and it did not happen. You have to work hard to get this in. Thank you very much indeed, Dame Andrea. We are grateful.