Public Services Committee
Oral evidence: Role of public services in addressing child vulnerability
Thursday 9 September 2021
Members present: Lord Bichard (In the chair); Baroness Armstrong of Hill Top; Lord Bourne of Aberystwyth; Lord Davies of Gower; Baroness Pitkeathley; Baroness Wyld.
Evidence Session No. 33 Virtual Proceeding Questions 252 - 256
I: Elina Pekkarinen, Ombudsman for Children, Finland; Elisabeth Dahlin, Ombudsman for Children, Sweden; Naomi Eisenstadt CB, Independent Chair, Northamptonshire Health and Care Partnership and Honorary Research Fellow, Department of Education, University of Oxford; Professor C. Kirabo Jackson, Abraham Harris Professor of Education and Social Policy, Institute of Policy Research and School of Education and Social Policy, Northwestern University, Illinois, United States.
Elina Pekkarinen, Elisabeth Dahlin, Naomi Eisenstadt and Professor C Kirabo Jackson.
The Chair: This is the second panel of our inquiry today, and some of you may have heard me say at the beginning of the first that both the panels today are really important to us. Personally, I am very anxious that we learn as much as we can from overseas experience, and sometimes we Brits do not do that, so we are delighted to have you with us today. As I said to the other panel, it would be good if you were able to briefly introduce yourself when you make your first contribution. That may be the best way of us moving forward quickly, because you will realise that we do run out of time, so I am not going to give everyone’s name. Introduce yourselves when we get to you. You are immensely welcome.
Q252 Lord Bourne of Aberystwyth: I echo the big welcome to the panel. Thank you very much indeed. It is very important to us to hear from other jurisdictions, so it would be great to hear from Finland, Sweden, the US, and Northamptonshire. But, seriously, Naomi will also be able to tell us something about Scotland, which we look forward to immensely.
To open, it would be good to hear examples from your work as to how early intervention, and indeed prevention, measures have improved outcomes for vulnerable children in the jurisdictions you are familiar with. That would be really helpful to us and informative as we go forward. Perhaps I could turn, first, to Elina from Finland.
Elina Pekkarinen: Thank you very much, Lord Bourne. I am the ombudsman for children here in Finland. I have a background in research. I am an adjunct professor in the University of Helsinki and I have been doing a lot of research on child welfare, child protection and youth crime issues. Today, I thought about the example that you forwarded me and asked me to think about before, and unfortunately I must say that there is no shortcut to the well-being of children. Vulnerable children benefit from strong basic services where their problems are identified in a timely manner and where their parents are also supported.
Finland has the best well-being of pregnant women, new-born babies and pre-school children in the world, and there has not been an increase in the number of babies in child protection, even though we have had a huge increase in the number of teenage children in our child protection and child welfare institute. That is why I want to give you an example of our maternity and child health clinics.
Visits to the maternity and child health clinics are based on the work of specially trained nurses. They are very cost effective. Actually, they are very cheap. The clinics were founded in the 1920s, so they have been here for a century already, and the clinics are based in strong national legislation, which is supplemented by national guidelines. There is monitoring of the system and it is continuous, and I must say that it works very well.
Actually, 99.8% of our pregnant women go to the clinics. They have a minimum of nine health check-ups that are performed during the pregnancy. In Finland, the mortality rate of women in childbirth is the lowest in the world. We only have zero to three deaths per year in total. The perinatal and after‑birth mortality of infants is also the lowest in the world.
After the pregnancy, the visits to the clinic continue until the child enters primary school, at the age of six to seven years, with a minimum of 15 visits. The clinic’s nurse also makes home visits and a vaccination programme is implemented through the clinic. In Finland, now that we have the pandemic here, the children’s vaccination coverage is world class. By school age, 99.5% of Finnish children receive vaccination in accordance with the basic vaccination programme.
That is it. It may be a bit boring, but it is very important. For example, Japan is implementing the Finnish style of maternity and child health clinics.
Elisabeth Dahlin: Thank you very much for this invitation. Our antenatal and early childhood care is very similar to Finland, and it is free of charge, so that means that everybody can attend it. That includes dental care until the age of 19, and free medical care and medicines for children.
However, one indicator that we have seen is that an increasing number of children are not appearing for the compulsory oral check-up at the age of three, and we have found that that is a very good indicator to use to find children at risk, because parents who do not bring their kids to the dentist for the three-year check-up are usually the parents of very vulnerable children. We can see that when we correlate those figures with kids between 10 and 15 who are in alternative care. We have roughly 35,000 children in alternative care in Sweden from a population of 10.5 million.
As Elina said, strong national protection systems for children are the best thing that we can do. The whole system, with social work, health work and early interventions in school, is where we can reach most children, but if one of the parts of the chain around the child breaks, that is when children can be in very early vulnerable situations.
We are now pressuring for a law in Sweden that I hope will be approved by Parliament in the next month or so, so that social services can intervene, even if the parents say no, because we know that children who can be reached before they reach their teens can usually get a much better future, but that means also moving the parental rights to the child’s rights.
We are also struggling with the measures concerning the integrity of the adults. The police might know with an early intervention in a family that, for instance, one of the parents is in touch with the police, but they have not yet been subject to a measure. It could be that the medical services know that one or both parents are struggling with drug addiction or psychological health problems, et cetera, but they are not allowed to inform the child protection workers about that. We are, in a way, safeguarding the integrity of the parents to the cost of the children, and that is also a legal change that we hope will take place very soon.
Again, I really want to underline, like Eleanor said, that when early interventions and good national protection systems, particularly on the municipality level, all work together around the child, we can see results. We can find vulnerable children at a much earlier age, and good interventions can be made before the child is formally in contact with the social services.
Lord Bourne of Aberystwyth: Thank you, Elisabeth. If we could turn to Naomi to hear from her experience, perhaps particularly as adviser in Scotland, that would be very interesting.
Naomi Eisenstadt: I assumed that I was being asked because I was the first director of Sure Start, the major early years programme that was brought in under the Labour Government. I was also the independent adviser on poverty to Nicola Sturgeon.
I want to start by saying that it is always terrifying to be on a panel with people from Scandinavia, because when I worked at Sure Start I used to say, “If you want to feel good about Britain, look west. If you want to feel bad about Britain, look east”. I have a perfect example that underlines exactly what my colleagues have said.
First, I want to say that I do not like the expression “vulnerable”. It is very unclear, because there are huge differences in the way it is defined. I am very uncomfortable with it because, in a lot of the measures of vulnerability, the common feature in most vulnerable children, not all, is poverty. If we allow poverty to be left out of the picture, we miss out on the most important thing that Governments can do, which is improve family incomes. It is interesting, because, if you look at Sweden and Finland, the inequality between incomes is much lower than in the UK, so they already start from a better position for children, even without their fabulous services.
An example that I can give you, which really makes the point, of an early intervention programme that worked in the UK, but did not work as well as in the United States, was family nurse partnerships, which was targeted at teen mothers and provided the kind of intensive services from minus nine months—the booking-in period in pregnancy—to two years of age of the child, where a home visitor, nurse or midwife-trained, visited every two weeks for all that time.
In the United States, they had fabulous results over 30 years of family nurse partnerships. Our first results in Britain were really disappointing, I think because in Britain we have a National Health Service, so you were comparing a Rolls-Royce to a reasonably good Ford, and in the United States a Rolls-Royce to nothing, because in most of the United States there is no home visiting service or a free maternity service; you do not have the underpinnings of a universal service.
My last point, which I learned from the work in the UK and Scotland, is that the best approach to early intervention and prevention is a high-quality universal platform that applies to all children, where you can identify risk early and put your resources where they are needed the most. We have some of that in Britain. The United States has less of it, but certainly Sweden and Finland have more of it, and I am jealous.
Lord Bourne of Aberystwyth: Turning to Kirabo, could I reassure you that we have not just asked you to make us feel good about the record in Britain? We really are very determined to hear what the experience is in the US, for good and for bad. I know that you have vast experience and knowledge of that, so let us hear from you, please.
Professor C Kirabo Jackson: I am professor of education and social policy at Northwestern University here in the United States. In speaking to early intervention, I will pick up on a few themes that I have already heard spoken about by previous witnesses. First, it is important not to think of this thing as being early versus something else. Everything happens in concert with everything else. The particular intervention I have studied is Head Start, which has some similarities to the Sure Start programme in the UK.
Specifically, the Head Start programme in the United States was introduced in 1965. It was a compensatory programme aimed at lower‑income children, and it included not just things that were educational in nature but things like literacy and numeracy skills targeted to children between the ages of three and five. One of the main aims was to get children to be kindergarten ready, but it included additional services as well, so it had things like health screenings, dental screenings and vision screenings to ensure that the children in there had access to the services they needed, so that, if there were problems, they could be easily identified and, hopefully, remediated by the time they entered kindergarten.
It was a system that was relatively holistic. It involved counselling, numeracy and literacy, as well as a large dose of what we could socioemotional learning techniques designed to teach these young children the skills that would be helpful: executive functioning skills, the ability to wait, patience, how to ask questions, how to listen, and how to sit still, in so far as they can do that at that age. It was a relatively holistic and well-thought about programme, and it was first rolled out in 1965.
In research I have done in conjunction with Rucker Johnson at the University of California, Berkeley, we examined individuals who were exposed to this programme, but we were interested not just in whether the programme was effective at improving the outcomes of these lower income children, but in whether the extent to which it was successful depended on the schools in which they were enrolled.
Specifically, we compared the outcomes of cohorts of individuals who were exposed to this Head Start programme but then subsequently enrolled in underresourced public schools, and then those who were enrolled in the same programme but then were subsequently enrolled in high-quality, well-funded schools. The cost of the programme ended up being somewhere around $3,000 or $4,000 per child, which is not as well funded as some of the Cadillac plans that you might have heard about. The Abecedarian spends three or four times that, so it is a much more modest intervention.
Students who were enrolled in the Head Start programme who went into schools that were underfunded had relatively small gains, if you looked at their outcomes later on. The outcomes we looked at in the study were things like high school completion and earnings later on in life. We tracked these individuals from birth all the way through adulthood, and we found that those who were exposed to Head Start and were enrolled in underfunded public schools did not see much benefit, but those who were enrolled in the programme and subsequently enrolled in very highly resourced schools that were able to build on the gains that were developed early ended up doing much better.
They were much more likely to graduate secondary school. They were much more likely to have more years of education in terms of university enrolment. They earned more money. They were less likely to be poor themselves. They were able to cut their rate of poverty considerably, among populations that were very poor to begin with. They were much less likely to be involved in crime as well. These were populations that, based on their income level at the time, would be very likely to be involved in crime later on, and that combination was able to cut that down considerably, to about half.
The takeaway from that is that the model can be quite effective if you couple not just educational interventions but education in addition to health and additional services, to treat the whole child and make sure that, when children are outside of that early intervention, they are put in environments that will sustain the gains that will be facilitated by those early interventions. That combination can be quite fruitful and quite successful.
Lord Bourne of Aberystwyth: Thanks indeed to the whole panel for some really interesting perspective there.
Q253 Lord Davies of Gower: This is really interesting. Thank you to the panel, and good afternoon to you, or good morning in one case. We are, in this inquiry, seeking to gain experience through examples of successful collaboration on behalf of vulnerable children between national, devolved or state governments. I just wondered whether you could give us any examples of voluntary groups or whatever that collaborate well. I do not know who would like to start. Shall we start with you, Naomi?
Naomi Eisenstadt: It was a really important point made by my American colleague. We had exactly the same results with the evaluation of pre-schoolers in England. If they went on to a good primary school, the results lasted, but we got much higher fade if they went on to poor schools, so our evidence is very similar. I just wanted to make that point. It is a really important point that you just lose on your investment if early intervention is not continued throughout.
On examples of good collaboration, I have to talk about Sure Start, which had some similarities with Head Start, but it certainly was very interagency. The other part of Sure Start that was important was to do with the local programmes. To begin with, we had 450 local programmes in local areas, but it was area-based. It was not targeted at individual families in poverty. It was targeted at areas with high levels of poverty, and all children who lived in the area could use the services, so it was not very good for rural areas, but very good for intense poverty in poor areas.
The point about collaboration is that every management board for Sure Start had to have local parents involved, and 40% of the programmes had local fathers involved in the management of the programme. They had to have health, education and social welfare all involved.
One of the important points about that kind of collaboration, which came up in your earlier session, is that the most successful programmes were led by health, because health had the data on where the vulnerable children lived. Health knew where new babies were born, so we could do home visiting. So the involvement of health and the sharing of data was absolutely critical, and a barrier to joint working was always about health withholding data.
Programmes that were led by voluntary organisations, which was a very strong part of the programme, were much weaker on that reach, because they did not have access to the data. They were much stronger on roots in the local community, and on getting participation in deciding what the programme delivers and how it would deliver it, because they had much stronger roots in the community.
In terms of working together at micro neighbourhood level, it was enormously successful, so much so that Jack Straw, who was Home Secretary at the time, said to me that one of the parents in his constituency assumed that it was a charity, because he could not believe the Government could do something so good.
Lord Davies of Gower: This data-sharing issue keeps cropping up all the time.
Naomi Eisenstadt: It is massive.
Elisabeth Dahlin: First, I want to echo, Naomi, what you said about child poverty. We might not have such a wide gap in Sweden and some other countries, but it is increasing, and we can see both the economic divide and the educational divide. Here it is so important that there is generalised support that targets all children, but also, in areas where we see that children are in much worse circumstances, that there is generalised support to the municipalities working together with civil society. We have some of those areas in Sweden where we are seeing some good results.
I could not agree more about starting with health and health workers, with increased home visits of new and to-be mums to build trust in the health system, in many cases for mothers who are single, who might not have been born in Sweden themselves and who have had little trust in the government system. It is then about working together with the pre-schools to make sure that kids really can get a good start. Pre-school is not yet compulsory in Sweden, but most children start when they are one or one and a half up to two years of age. Then we have the formal pre-school from the age of six, which in two years’ time will also be compulsory.
We can see the educational divide for children who have not attended pre-school and do not have access to the full language. That is when we see a lot of increased targeted support with national money, but working together with the municipalities and a lot with civil society to encourage parents to really make children get into pre-school.
Thirdly, it has been very important—this has been so clear during the pandemic—to have the cultural interpreters who really reach out to families and work inside the community. You do not get somebody from the outside going into the community; rather, you use all the good forces of the community to encourage people to have vaccinations, to test themselves, et cetera. The pandemic has, in a way, been a catalyst in increasing this collaboration between national, regional, municipality and civil society levels.
Lord Davies of Gower: Thank you for that. That is really interesting. Elina, would you perhaps like to give us your experience in this?
Elina Pekkarinen: Thank you, Lord Davies. That would be a pleasure. I have thought about this a lot, and I agree with Naomi and Elisabeth that health and education are the best roads to well-being and the best ways to implement different methods for the families and children who need it more. In Finland, we have a lot of different programmes and methods that are led by NGOs with the state or with the municipality agencies. We have 308 municipalities with very different sizes, numbers of young people and children, and so forth, so it was impossible to think of one example.
I thought I would tell you a few words about a website that we have by a children’s foundation called Itla, which was founded by the Parliament of Finland. It received €52 million of stocks, which it has been investing very well and it is really wealthy. It published a site called Early Intervention. This service scientifically evaluates various methods and publishes information, as well as implementation guidelines for evidence-based methods. The site is open to everyone and it is available in Finnish, Swedish and English. I would be happy to send you the link to this website.
All actors can offer their methods for scientific evaluation. The foundation also looks for good methods to evaluate around Finland and around the world. On this site, you can find numerous domestic and international models that help and support families. Any municipalities and organisations can apply these different methods in their work with families and children. This is an excellent example of a service that benefits everyone who is working with children and families. In there, you can find several good methods that can be implemented for the families in need as well.
Lord Davies of Gower: Thank you, Elina. Perhaps you could let us have that information. It would be quite useful if you could.
Elina Pekkarinen: Yes, of course.
Lord Davies of Gower: Kirabo, could you give us your thoughts on this, please?
Professor C Kirabo Jackson: My response is actually going to be very similar to Elina’s, because the United States is the United States, in the sense that we have multiple states. Each state has its own set of rules, and within each state the individual school districts all have a lot of autonomy. There are roughly 13,000 school districts in the country and each district can decide how it wants to do things. The levers of control start at the federal level, but then it goes all the way down to the state and then the local level, so the entire system is a collaboration across these three levels of government to some extent. It is difficult to even think about what that means in the US context.
One successful model that has worked is one where the federal Government or sometimes states provide grants that individual districts or groups can apply for in order to implement new models. Head Start is very similar to that, which is early childhood. The way that is funded is that the money comes from the federal Government, and individual groups, sometimes schools or school districts, may decide, “We want to have an early childhood programme in our district, so we’ll apply for a Head Start grant”, and the Head Start grant comes from the federal Government, but it is all implemented locally. They have to make sure that the programme is within certain parameters of quality and there is some fidelity to it. It is implemented locally and funded from the federal level, but it has a grass-roots feel to it.
There are a lot of different programmes that are of the same vein. The Institute of Educational Sciences—the IES—has money for exactly those kinds of things and partnerships between local governments, local education agencies and private organisations to try to partner up in order to come up with innovative ideas. The idea is that a lot of these things have to be evidence-based. The organisation will have to show, maybe through some sort of pilot intervention, that this thing is going to be efficacious, and it would have the access to the money to roll out these programmes in districts. As you would expect, some of them are successful and some of them are not necessarily as successful, but that is a model through which collaboration can take place.
There is another model, which is separate, which is perhaps less organised by the Government in cases where private organisations just decide they have a pool of money and they will try to roll out an intervention in a local school or in a set of local schools. One such example is one that I researched a while back, which was an advanced placement incentive programme. That was basically a programme where a large donor with quite a lot of money decided that they wanted to fund a programme that provided a little more rigorous instruction to individuals in low-income schools that were geared towards college readiness.
Specifically in the US, there are these programmes called advanced placement, which are at a little higher level than you would typically get in the traditional public school. It is more similar to A-level coursework. This organisation went into schools and said, “We’re going to provide external money to pay teachers to implement this programme, and we’re also going to provide a little bit of money to train teachers to implement the programme with fidelity”. They had some incentive payments as well whereby, if students did well on these advanced placement exams, they got a cash bonus themselves.
The programme I found in research was pretty effective at getting kids to graduate, and once they graduated they would go to college, graduate college in greater numbers, and make more money later on as adults, so it was not just something that we saw in terms of academics. We saw benefits in terms of real economic outcomes later on. That was another successful model where the laws allowed for there to be some collaboration between the individual organisations and the schools.
I have also seen cases where that kind of collaboration can be hindered. There is another example in New York City where an organisation wanted to do something very similar and, because of labour laws in New York State at the time, the teachers’ union basically shut that down and did not allow that to happen, versus the other one, which was in Texas, where the teachers’ unions were much more open to this sort of experimentation. The model where there is some possibility for experimentation, possibly with supplementation of money, could be quite successful at finding successful models, which then could be replicated in other settings as well.
Lord Davies of Gower: We could talk about the US model for quite a long time. There are quite a lot of questions coming out of that, but we do not have the time. We have some more questions to come up. Thank you very much indeed.
The Chair: I agree with Lord Davies. All of those four contributions produced some really interesting ideas. Naomi, on our side of the pond, will know about them. We do not necessarily know about them, so I would encourage you to send us some material. That will be really helpful.
Q254 Baroness Pitkeathley: Thank you so much for your most interesting answers so far. I would like to understand a little more about the role of the ombudsman for children in both Finland and Sweden. Could you say how much of your work is focused on child vulnerability, for example? How do you try to influence government policy? It is clear that you have a lot of influence. How does that work? Would you like greater powers on behalf of children? I will come to you first, Elisabeth, if I may.
Elisabeth Dahlin: Thank you very much. Those are very interesting questions. Very briefly about the ombudsman for children, we are based on the Paris principles of independence, which means that we work as a government agency that is independent, but we do not report to Parliament. That might be the natural thing, but it is because our parliamentarians said, “Hey, we already have three authorities reporting to us. We can’t receive more”. It is the Cabinet that appoints the ombudsman and, basically, you cannot fire the ombudsman unless you do something illegal, which gives us some clout.
We have five things that we are supposed to do. One is to follow up how the UN Convention on the Rights of the Child is adhered to. When it is broken on any level, we may call those responsible for consultations but we do not have the rights to intervene in individual cases. .. We review all new laws and we can propose new legal measures, which we do pretty often. We are the only government entity that by law—this law is from 1993, which might explain it—is supposed to participate in the public debate and advocate, so that is what we do. That means that we have a very active role when it comes to the legal standard of children.
We do our own investigations, and every year, by law, we have to produce a report to government. That is not a report on everything we have done, but it is usually very focused on children at risk. Our whole focus is on children at risk and children in vulnerable life situations, as we usually say, rather than “vulnerable children”. That could be LGBTQI children, migrant children, children on the move, children in alternative care, children with mental health issues, et cetera, where we do our own investigations and we propose usually very radical changes, either to the lawmakers or to different government institutions. When we produce our report every year, we always hand it over to government first and then we present it in Parliament, usually the same day.
To your last question, yes, I really wish that Sweden would sign the third additional protocol to the UN Convention on the Rights of the Child so that children actually could claim their rights, which they cannot do today. We can do it on a systematic level, but as of now we cannot intervene in individual cases. However, if there have been individual cases, as we have had in recent years where children in alternative care died when they were turned back, and where the parents won the child back, we could propose a legal change, but, yes, it is a very good idea to be able to intervene more hands-on.
Baroness Pitkeathley: Thank you very much indeed. That was a very comprehensive answer.
Elina Pekkarinen: There is not too much to add to what Elisabeth said, because in Finland when they brought in the law on an ombudsman for children in 2004, 10 years later than in Sweden, we copied quite a lot of the law that was written in Sweden. There is one difference, however, to what Elisabeth said. We do report to Parliament every fourth year. We also report to the Government every year, and then we report to the UN Committee on the Rights of the Child. Those are the three reports that we have to give regularly.
When it comes to vulnerable children, our work is very much about reminding people of their rights, but it is our job to work to promote the rights of all children too. In this way, we can also prevent vulnerability. This year we have focused on promoting the rights of children with disabilities, children belonging to linguistic and cultural minorities, and children who have, for example, committed crimes.
We seek to influence decision-making and national policy through statements. We give around 60 statements each year. I give around 100 presentations a year. We also make studies of different subjects, just like Elisabeth said, and we too have to take part in public discussion, so I spend a lot of time on Twitter too, which is a little bit annoying, but at the same time it is one way of making a change and making people more aware of children’s rights.
We in Finland do not need more mandate at the moment for a historical reason: we have the parliamentary ombudsman that can react to individual cases and to which the children themselves can appeal. The parliamentary ombudsman does very good work on this. We do not have the manpower to deal with the individual cases. We have citizens contacting us 500 to 700 times a year, which is quite a lot, but all we can do is guide them to the ministries and agencies that can help them.
Even if we did not take care of the individual cases, we would need more manpower here in our office. We currently have a staff of only six people, including me, so we are one of the smallest state authorities here in Finland. The UN Committee on the Rights of the Child has given Finland a note on this issue and, Elisabeth, you could probably tell us how big a staff you have in Sweden, taking into consideration that you have the same tasks as we do.
Elisabeth Dahlin: I am also complaining, but we have 38, which is too little.
Baroness Pitkeathley: I might echo Naomi and say that I am jealous about some of these things that we have been hearing. I am now going to come to Naomi and Kirabo and ask if they think there is anything in the Swedish and Finnish approaches which the US and the UK, including Naomi’s work in Scotland, could find useful. Naomi, perhaps I will come to you first. It is very nice to see you again, even at a distance.
Naomi Eisenstadt: It is lovely to see you as well, Jill. I am afraid my answer is not within the gift even of the House of Lords. The difference between Scandinavian countries and Anglophone countries, including Australia and the US, Canada less so, is a tolerance for higher taxes. All the things we are talking about take a lot more public money, and there is a fundamental problem with trust in government in spending our money well. Until we solve that, we will not have the kinds of social support systems, for young people and for older people, that are common in the Scandinavian countries, including Denmark.
In terms of the specifics, I agree with the combination of a universal platform and being highly targeted. Intensive visiting in the first two years is really important. One of the things about universal is that it is not stigmatised. As soon as you begin to target, people feel uncomfortable. The other thing about targeting is that you miss the families on the cusp, who, with a little help and support, you can push to the right side of the dial, rather than leaving it until their problems are so deep and so serious that it takes much more money to intervene appropriately.
Fundamentally, it is about the tolerance for high taxes. The debates that we have been hearing in the last few days about the adult social care system are identical to the debates about early years. It just takes more money, higher-trained people and better-trained people with better incomes.
Professor C Kirabo Jackson: That was very well said. For sure, there are a lot of things that we could implement in the United States that would be beneficial. The health services being universal and childcare being universal are excellent things. It is perfectly identified that a lot of the pushback against that has to do with a general aversion to higher taxes, but there is some movement towards more universality in some of these domains, so I will speak a little bit to that.
For example, there is a move now, in New York City for example, where universal pre-K is a thing. In Chicago, where I live, that is also being rolled out, so there is a move towards greater universality of provision of these services, not just for low-income individuals but for the population writ large.
As we think about evaluating these things and figuring out whether they are a good idea, one thing that has been found again and again is that, when these interventions start being rolled out, for example universal pre-K, the outcomes are very good for individuals who did not have access to very high-quality care otherwise. When you start providing it to higher-income individuals, for example, who may otherwise be going to a private pre-K, you may not find much of an effect.
People look at that and say, “You see. This thing’s not very effective”, but, in fact, the problem is that we are not identifying exactly what the counterfactual is. One thing I want to keep in mind as one thinks about moving towards greater provision of services universally is what the standard of care and provision was for individuals before this thing became universal. You may find that some individuals, albeit not many, are actually worse off through the universal system. Ideally, you want a universal system that has some flexibility, allowing people to opt out if they really wish to, but the other solution is to make sure that the universally provided care is of high quality.
In essence, the issue of quality is really important. That is one lesson I have learned from a lot of the research in these countries. If we can implement it here, do not expect too much for everyone. It is perfectly reasonable that we would expect very good things for the “vulnerable populations” and maybe not so much for the less vulnerable populations. Even for the more affluent populations, there are benefits to having access to free care and being able to use that money for other things, which is just good for the family welfare overall.
Baroness Pitkeathley: Thank you all very much for those wonderful answers.
Q255 Baroness Wyld: My questions are primarily to Naomi and Kirabo, but, if anyone else wants to jump in, please do. I was going to ask you to evaluate Head Start and Sure Start, but you did that very comprehensively, so I wanted to move on to family hubs, which, as you will know, this Government are very keen on. A lot of us on the Committee are initially very keen on them. I would like you to set your evaluation of Sure Start and Head Start respectively in that context. Do you think family hubs will be a good thing or not a good thing? How do you see the evolution, if you like? Can we start with Naomi?
Naomi Eisenstadt: Family hubs are a really good idea if they are properly funded. Most of what was suggested in Leadsom’s last report I completely agree with. The only thing I disagree with is that it is all over by two, but otherwise the range of services and the quality of staff she was looking at was all really good, except that it takes a lot of money.
I just want to pick up something that Kirabo said, which was really interesting and I really agree with. The Treasury used to call the money that you spent on children where they did not need it “deadweight costs”. They probably still call it “deadweight costs”. It is an amazing expression. You will not get as big results on the children who are less poor, but that is the whole point. The whole point is levelling up, and levelling up is what the Government want to do, so that is a good thing.
I just want to make one point about evaluation, because we have not covered it all. Sure Start was very good on social and emotional skills for young children, but did not have any impact on cognitive skills or educational attainment. One of the reasons that we suggested that was the case is that by then we had a universal pre-school service, so there was not a big difference between the children getting Sure Start and the other children.
The most remarkable thing happened within the last two years and I just have to say it because I am so proud about it. The Institute for Fiscal Studies has now done research, 10 years later, on the Sure Start children, who are up to the age of 15. They only looked at health and they found massive health benefits. There was a 30% reduction in hospitalisations by the age of 15, in severe mental health problems but also in physical health problems. For younger children there were fewer infections, but older children, particularly poor boys, had fewer broken bones.
Sometimes these evaluations take a very long time. I was completely startled by the results and I am glad that the IFS did the study, but it is very difficult in real time to judge the benefits and it takes a while. Family hubs could redesign some of the things that we did very well for Sure Start, but also pick up some of the mistakes we made, so I am all in favour. Andrea Leadsom is a Northamptonshire MP.
Baroness Wyld: Thanks. That is really helpful. I take your point. There is some confusion in the policy arena that I am picking up, because my understanding, which may be me missing something, was that family hubs were meant to see the child through from birth to 19. That was the whole point of integrating services, so I do not know what I am missing there.
Naomi Eisenstadt: In the way that Andrea Leadsom is describing them, she wants them very much for the early years space. What I do not like about the way they currently operate, which goes to universal versus targeted, is that a lot of what were children’s centres that are now family hubs are highly targeted on children requiring social services intervention, so you begin to get to stigma. Zero to 19 is for highly targeted services, not a local community-based service that anyone can use. Andrea Leadsom is certainly wanting a universal service.
The Chair: Can I just pick up, Naomi, on one of the points that you made in answer to Laura’s question, which was your throwaway line that family hubs could deal with some of the mistakes we made? Could I ask you to expand a little bit on that? What do you think we got wrong?
Naomi Eisenstadt: We made loads of mistakes.
The Chair: Yes, I know. Give me the few that you really feel—
Naomi Eisenstadt: We did not pay enough attention to how hard the job would be to run an interdisciplinary centre at a local level from an early years base. Early years staff have no respect within a set of professionals, so to expect them to be able to pull together statutory services and to expect doctors to listen to them was just ridiculous. We did not pay enough attention to training and development for the people who were running these centres, which were getting a lot of public money.
The other big mistake we made is that we gave them a lot of capital money and we did not realise how much time it takes to build a building, so we expected activity to be happening much more quickly than it did, hence our initial results were quite poor. That is because there were virtually no services running when we first did the evaluation. On the assumption that you just turn the tap on and everything happens quickly, it took three years to get a programme up and running, so there were those kinds of mistakes. Another time, take me for lunch and I will tell you all our mistakes, or read my book.
The Chair: I look forward to it.
Baroness Wyld: Building on that, Naomi, how would you respond to the most obvious critics of Sure Start, who would say that it did not actually get to the children who needed it most? It was there for the middle-class mums to have a coffee morning.
Naomi Eisenstadt: The evidence does not show that. The evidence throughout shows that we had a very good participation in the poorest areas. We had incredible brand recognition and we had incredible fights for people wanting the services.
My response is that this is the first service ever set up by government that rich people wanted. Is that not success? Is it not good that everybody wanted it? The problem with everybody wanting it, which I am sure Kirabo will understand, is that we spread the money too thinly. You need to have a universal service, but put most of the resource in the poorest areas. In trying to have a service for everybody, the poorest areas lost more money because we tried to spread it too thinly. I am incredibly proud that David Cameron’s mother was on the picket line to save their local Sure Start centre. That is extraordinary.
Baroness Wyld: Kirabo, do you want to elaborate on your evaluation of Head Start? Do you have a view on family hubs in the UK?
Professor C Kirabo Jackson: I do not know all the details about the family hubs, but my understanding of it is that it is supposed to be a comprehensive support for children from cradle to 19, and that is a great idea. That is very much in line with my view of how we should think about early childhood in general. It is not just a time that we focus on children and then we forget about them. Everything has to be very much integrated.
The basic idea behind the model makes a lot of sense to me, because I found in my research that, again, if you start early and then you basically follow up those early interventions with additional support, you get much more success later on. You start with basically Head Start and you go to a well-financed kindergarten through 12th grade school. You will get individuals who are more likely to hold down jobs. They will earn more money. They have more secure families. The boys are much less likely to have committed crimes and much less likely to require support from the Government later on.
These are benefits that you do not see immediately either, so the second part of it, which is part of your question, is how we evaluate these things. The idea is that this is supposed to be holistic. There are a lot of components to an individual and you can measure them in various ways. A lot of my research outside the intervention space basically critiques the idea that test scores are a good measure of skills. They are certainly a good measure of a certain kind of skill or very particular skills, but those are not necessarily the entire set of skills that are required to be successful as an adult.
I was handling a recent paper in my editorial roles that looked at the crime effects of Head Start and other early childhood interventions. They found that just using the dollars saved by having fewer individuals in the incarceration system alone ended up paying for a large chunk of the benefits, so even if there were no test score and educational effects, just having fewer individuals committing crimes and being victims of crimes as a result of these interventions could actually pay for itself in the long run.
I always stress that any evaluation of these things needs to take the long view, which is very difficult, because you want to know whether something works today or tomorrow. You cannot wait 50 years or say, “I will wait until 2060 and see whether this thing is going to be effective”.
There are ways to try to come up with metrics that, at least in the short run, will give some indication of whether this thing is likely to be successful in terms of the adult lives of the individuals. I am not saying that the socioemotional measures that we are coming up with are all perfect, but they tend to capture sets of skills and dispositions that children tend to improve when they enrol on these programmes and, even though test scores fade away, you often see these socioemotional measures persist over time and that translates into better outcomes later on.
As far as intervention goes, I would say two things. We should broaden the set of short-run things that we use to measure success well beyond just the academic outcomes, and we should be willing to not make any large or major judgments on whether this thing is successful for several years, which I understand is a challenge, but that is going to be necessary if we really want to make sure that we understand whether things work. At the end of the day, we want to make sure that our children are well taken care of and that is really what it is going to take.
Baroness Wyld: Do we have time to bring Elina in? I could ask so many more questions.
The Chair: We certainly do and she has her hand up anyway, so let us do that.
Naomi Eisenstadt: Can I just say that I have to leave because I have to chair a meeting at 5 pm? I am terribly sorry, but I have to go. Thank you very much for having me. It was really interesting.
The Chair: As ever, you have left us with lots of stimulating thoughts. Thank you very much.
Elina Pekkarinen: I have a very short comment on the expenses, because I actually checked out how much this system of maternity and child health clinic in Finland costs. Kirabo, you talked about the expenses of your system. In Finland, the nine visits to the nurse during the pregnancy are €1,200 per mother and the 15 visits by the child from the age of zero to six are approximately €1,700, so that adds up to €2,900. If you have to go to the extensive care or to the hospital because of a broken bone, it is about a three-day visit in that hospital. It is a very cost‑effective and very cheap system.
The Chair: Elisabeth, is there anything you want to add to the comments on this question?
Elisabeth Dahlin: One thing that has been interesting, into which we have done research, but also where the national enterprise’s think-tank SNS, Centre for Business and Policy Studies, Sweden[i], came to the same conclusions as we did, is that it is better to be rich and well than poor and sick. It was interesting that it was industrialists that brought out this big study.
When we looked at the health of children in child poverty, which were the risks? First of all, who are these kids? They are usually kids of single parents and parents born outside of Europe. If you are in Sweden, a child with a single parent born out of Europe has more than a 50% risk of getting into child poverty, and that is where we see that the transfers for children are so important. If we look at health for this group of children in child poverty, which is at an aggregated level rather than the individual level, the risk of high blood pressure, obesity, being underweight, heart and lung problems, stunting, not finalising primary school and not finalising secondary school is much increased. This group of young people is more at risk of being bullied and being a bully, and not entering secondary education and the labour market.
It was so interesting, because civil society had found these figures and we have seen it over the years, but now even the think tank of the industrial association found the same things. This has such a high cost to society if we do not address it early and we can see it on a certain scale in Sweden. We are worried because of the effects on children, and we are talking about the effects that can be seen on children already at the age of seven or eight. To echo what Elina said, maybe we should not see it as a cost, but rather as an investment and a preventive measure.
The Chair: We all have Treasuries that find it difficult to understand the difference between cost and value. I suspect that is something we all share. You could not have been more helpful, Elina, Elisabeth and Kirabo. We are really grateful for your time. Kirabo, I hope you manage to go and get a good breakfast now, because I suspect you may not have got one earlier. Thank you very much. I know that our researchers will want to follow up on many of the discussions that we have had this afternoon and ask you for a little bit more if we can draw upon your knowledge. Thank you again very much and I now formally call this meeting to a close. Thank you.