Written evidence submitted by Alder Hey Children's Charity (FTDOO51)

This submission is being presented from the Family Hubs Group, the 0-19 Partnership between Alder Hey Children's NHS Foundation Trust and Mersey Care NHS Foundation Trust, and Liverpool City Council.

1. What progress has been made since the previous Committee’s 2019 First 1000 days of life report in terms of outcomes for children and young people in delivering integrated early years through Family Hubs? In particular what progress has been made on the calls in the Committee’s 2019 report for a) Proportionate universalism and b) Greater integration and multi-agency working? 

Liverpool City Council awarded a new contract for the provision of 0 to 19/25 Healthy Child Public Health Nursing Services for children, young people, and families in late 2024. The contract was awarded to a partnership between Mersey Care NHS Foundation Trust and Alder Hey Children's NHS Foundation Trust under a new approach and commissioning framework focusing on improving the health of everyone but with a greater focus on those experiencing the greatest need (proportionate universalism). As a result, team structures are developing to reflect an integrated approach to working with families and partners with an enhanced function for those who are most vulnerable. The service also reflects delivery at a neighbourhood level, considering how the skill mix of the team can be developed with staffing resources used more effectively. 

Liverpool has received over £4 million from the Government to open five Family Hub centres, providing centralised support for all families across the city. The hubs are based within the city’s existing network of Children’s Centres, with services for families with babies, children and young people up till the age of 19 (or up to 25 for young people with special educational needs and disabilities). At the heart of each Family Hub are services that help give babies a great start to life, integrating midwifery services and other maternal health support within the Family Hubs wherever possible. Hubs also provide support to parents through parenting classes, learning support, co-location with health visiting services, infant feeding advice and perinatal mental health support.

Family Hubs in Liverpool convene and connect a range of different organisations coming together in one place offering health, education and community provision. The goal is to improve access to these services and enhance the overall family experience and increase the number of midwifery led clinics and ante natal courses delivered at Family Hub and Children’s Centre Connector sites. We are adopting a neighbourhood-model approach with the aim of delivering a service which will feature specialist roles in infant feeding, mental health, as well as a digital offer of online services to complement the in-person support.

However, ongoing workforce shortages across health visiting and midwifery services continue to blight progress on improving outcomes for children and young people, including better opportunities for integrated and multi-agency working. The Institute for Health Visiting describe a national shortage of around 5,000 health visitors in England, with families facing a postcode lottery of support. Similarly, The Royal College of Midwives’ estimates that the NHS in England is today short of the equivalent of 2,500 full-time midwives.

2. What should the Government prioritise in upcoming funding allocations for early years services?

There is a consensus across the children’s sector and within government that children’s health outcomes have worsened over the past decade. It is the case in Liverpool that persistent poverty has been driving the widening of health inequalities. Liverpool City Council’s State of Health in the City: Liverpool 2040 report describes how health in the city has evolved since 1984, the current state of health in 2024, and for the first time a projection of health and wellbeing in the city in 2040 based on current trends. It proposes that the health issues most common in children by 2040 will be related to mental health, obesity and child poverty. Liverpool’s infant mortality rate is significantly worse than in the rest of England, and each year 26 infants do not reach their first birthday.

Early years services are fundamental to providing support to babies and families at the earliest opportunity. Based on the worsening burden of disease for children and families in Liverpool, we propose Government prioritises funding to address the following three issues:

1. Breastfeeding support – under half of babies are breastfed at 6 – 8 weeks of life in Liverpool.
• Breastfeeding is more than just feeding - it provides comfort and bonding. Newborns seek food, comfort, and reassurance as they adjust to the world and breastfeeding can increase opportunities to hold and respond to babies, which in turn helps them feel secure, supporting their brain development and emotional well-being.
• A World Health Organization (WHO) study of 16 countries across Europe found that breastfeeding can cut the chances of a child becoming obese by up to 25%. As babies cannot be overfed at the breast, it may be easier to manage calorie intake.
• Breastfeeding could save the NHS up to £40 million. A report commissioned by the Unicef UK Baby Friendly Initiative estimated that moderate increases in breastfeeding would save up to £40 million in NHS expenditure based on fewer General Practitioner consultations and hospital admissions; the report also highlighted savings to the family as there would be no need to buy formula. It describes if 45% of babies were breastfed exclusively for four months and 75% of babies in neonatal care were discharged home breastfeeding, an estimated £17 million could be saved by reducing the costs of treating four conditions alone: infection of the lungs, gut, ears (approximately £11 million) and necrotising enterocolitis (approximately £6 million); this would also result in 50,000 fewer General Practitioner consultations.
• Respiratory illness is the leading reason for CYP under two years to attend Alder Hey’s emergency department. Studies have shown that breastfeeding duration for 6 months or longer can reduce the risk of lower tract respiratory illness in pre-school children. 
   
2. Poverty reduction for CYP and families - in Liverpool 24,000 (28.9%) children are living in relative poverty.
• The NSPCC Open Doors report (2024) describes that families on low incomes often miss critical support as they face challenges accessing maternity, health visiting and family hubs. Services are often limited, hard to reach, under resourced or unable to support the needs of families experiencing financial hardship.
• Poverty can have a negative impact on a young child’s development, increasing their likelihood of ill health, poor mental health, and putting them at a disadvantage before they start school. But access to high quality early childhood services, such as maternity, health visiting and integrated support in children’s centres or family hubs can significantly reduce these inequalities and provide a lifeline for families on low incomes.
• There are a range of central government policies and systems that contribute to a worsening of numbers of children being in poverty, including:
• Two child benefit cap
• Limited Local Housing Offer
• No recourse to public funds
• Removal of family premium for Housing Benefit
• Below inflation benefit-rises
• The Healthy Start voucher scheme is an important offer for pregnant people and infants, but uptake remains variable.
   
3. Longer-term funding to provide universal and specialist services
• Between 2015 and 2024, the Public Health Grant received by councils was reduced in real terms by £858 million (in 2022/23 prices). Public health teams continue to face increasing demand, and whilst Government has this year increased the Public Health Grant given to councils, there continues to be a lack of long-term sustainable funding plan for public health, which will give councils the long-term certainty they need to plan services that meet the needs of their communities.
• Early Years and public health nursing services provide excellent value for money. Academic analysis by the University of York shows public health expenditure by councils is three to four times as cost-effective in improving health outcomes delivered by the NHS.
• Good development in a child’s early years is fundamental to ensuring their trajectory throughout childhood is positive.
• The Institute for Fiscal Studies has shown that access to a Sure Start centre between the ages of 0 and 5 significantly improved the educational achievement of children, with benefits lasting at least until GCSEs.
• The University of Leeds has demonstrated strong links between a lack of school readiness, and persistent school absence throughout childhood. Early interventions focused on supporting children’s development and addressing any barriers to learning can help mitigate the risk of persistent absenteeism. Addressing both school readiness and school absence is crucial for ensuring children's academic success, social-emotional well-being, and future opportunities.
• Now that evidence is building on the impact of holistic, community based support, including Family Hubs, Government should be well equipped to commit to longer-term funding of these schemes at critical points in policy making.

3. How effective have Family Hubs and the introduction of integrated care systems been in improving early childhood outcomes?

Family Hubs and integrated care systems are still relatively new. However, considerable progress has been made in Liverpool and across Cheshire & Merseyside to prioritise children and families, including through:

1. Cheshire & Merseyside Health & Care Partnership that includes priorities around All Together Fairer (Marmot), Starting Well, and Children and Young People.
2. Cheshire & Merseyside ICB Children’s Committee that takes an overarching population health approach prioritising early intervention.
3. Beyond – NHS CYP Transformation Programme to deliver on NHS Long Term Plan commitments.
4. Improving me – NHS Maternity Transformation Programme to deliver on NHS Long Term Plan commitments.
5. Funding to open five Family Hubs across Liverpool, a key delivery vehicle to take forward the NHS mandate on neighbourhood models of care for CYP.

Family Hubs and integrated care systems are fundamentally good systems to improve collaboration across agencies – both on strategic service planning and towards more local delivery. There is an opportunity through the new NHS Long Term Plan for Health for ICBs to ensure there are specific metrics for achieving the ‘healthiest generation of children ever’, and better mechanisms to ensure that ICSs are held to account for delivery. This should be supported through improvements to how finance can be redirected across systems, and incentives for systems to prioritise children and families.

4. What are the key barriers to delivering high-quality early years services, particularly in Family Hubs and through neonatal and paediatric services, and how can they be addressed?

The biggest challenge we face locally relates to workforce and financial constraints. For example, a lack of long-term funding settlements and an ever reducing financial envelope across public health and the NHS means local systems are having to deliver more (as demand and need continues to rise), with less. This also limits opportunities to innovate and invest in much needed digital transformation to support the identification of need and improved targeting of resource.

Providing inadequate funding for early years services, particularly Family Hubs, can limit the availability and quality of services, especially for disadvantaged families. Securing long-term, ring fenced, sustainable funding for Family Hubs and other early years services, will ensure that partners across the system can meet the needs of all families, especially the most vulnerable. To reiterate, the Institute for Fiscal Studies report on Sure Start provides further evidence that intervening in early childhood to promote child development through holistic family support can yield important dividends when programmes are well designed and funded, especially for families in poverty and among ethnic minorities.

Workforce challenges are apparent across the range of early years services, in public health and in the NHS. Government has an opportunity to develop a workforce plan that is evidence-based and fair, and considers the increased demand and complexity of child health. The workforce plan could take a whole system approach to recruitment and retention with a specific focus on securing more training places for community based roles.

The NHS mandate to develop neighbourhood models of care for children and young people offers opportunities to connect the system and make better use of limited resource. The new 10 Year Health Plan must untangle and unlock many of the barriers in place currently that disincentivise improvements to child health, including poor data interoperability, fragmented workforce provision, and short-term funding envelopes to address major health issues for children and families.

5. How can vaccine uptake be most effectively increased and supported in the first 1000 days? 

A multi-layered approach is required to increase and support vaccine uptake. This includes:

• Better data capture to identify groups who need tailored or specific interventions.
• Better data interoperability to support opportunistic vaccination across a variety of settings – including secondary care and in Family Hubs.
• Access to clinical records across settings – it is the case currently clinical records including vaccine status for CYP are held in primary care, limiting the opportunities to provide vaccines in other settings (for example in pharmacy).
• Long-term funding for public health teams and outreach programmes that are not just seasonal or in response to outbreaks (e.g. measles).

• More capacity in the workforce to focus on increased uptake of vaccines, including through midwifery services and health visiting. There is also the potential for non-clinical roles to support families and signpost to local, easily accessed services.
• Make it easy for families – having easier access to clinical records and providing vaccines in settings that are closer to homes will make it easier for families to take up vaccines. Information that is tailored and presented in a variety of languages will also help.

6. How can the Government most effectively tackle inequalities in access and infant health outcomes for those from underserved groups including those with disabilities, or from ethnic minority or deprived backgrounds?

Continue to invest in Family Hubs, 0-19 services and children’s services, so that families at the sharp end of inequality receive a comprehensive level of support. The principle of proportionate universalism is embedded throughout the services that we run locally, and we are working hard to reduce inequalities with digital tools and partnership across organisations, including third sector. Liverpool City Council is developing an anti-poverty strategy that will seek to address the root causes of poverty, and dismantle it with practical solutions. But it cannot do this alone, and support from central Government to go further faster for people across Cheshire & Merseyside will be needed.

As discussed previously, there are a number of Government policies that bear a negative impact on children (i.e. the two child benefit cap). Government now has an opportunity to raise the healthiest generation of children ever, and we suggest this is best done through creation of a cross-departmental strategy for children and young people. The health impact of poverty on children and young people must be specifically addressed in the forthcoming Child Poverty Taskforce report, and Government must be accountable for tackling the root causes of inequality head-on.

7. What could the Government learn from examples of best practice that exist in local authorities, NHS Trusts, or internationally?

• Complex Households Dashboard – data linkage to identify need early – Customer Success Story Liverpool City Council.
• Parent Champions in Family Hubs to reduce inequality and improve access – contact us for more information.
• Parent Champions at Alder Hey – reducing bronchiolitis risk and admissions to the hospital by 22%. Contact us for more information.