First 1,001 Days: Policy context

Unfortunately, some children are not afforded these basic but vital ingredients due to the financial or social conditions they are born into. Promoting interventions and programmes that support vulnerable parents who struggle to provide the best start for children has been the driving force behind early years experts, welfare campaigners and policymakers developing the "first 1,001 days" movement.

Evidence base

There is an array of evidence on why the first 1,001 days plays such an important role in child development. The 1,001 Critical Days Manifesto - a cross-party report first published in 2013 that outlined the moral, economic and scientific case for greater policy focus on this period - explains that babies' brains make one million connections per second and that early experiences can have a life-long impact on mental and emotional development.

A pregnant mother suffering from stress can pass on the message to her baby that the world is dangerous, it explains, with the result that the child's response to experiencing fear or tension is set to "danger and high alert".

"This will also occur at anytime during the first 1,001 days whenever a baby is exposed to overwhelming stress within the family, such as parental mental illness, maltreatment or exposure to domestic violence," it adds.

Child-parent attachment takes place in the first three years of life, with research showing how the strength of attachment affects a baby's social and emotional development. Neglect has been shown to have a particularly damaging impact on the ability of children to bond with their parents. It is estimated that one in four babies are living in circumstances that make them disproportionately vulnerable to abuse and neglect and that 80 per cent of maltreated children could be classified as having disorganised attachment.

Studies have also shown that having adverse childhood experiences (ACEs) increases the risk of poor outcomes including health problems, low school attainment, unemployment and offending.

Last year, research by the Office of the Children's Commissioner for England found hundreds of thousands of children under one were living in households where one of the "toxic trio" of domestic violence, substance misuse and parental mental health was present.

The all-party parliamentary group (APPG) for the first 1,001 days, which published its Building Great Britons report in February 2015, concludes that there is strong evidence for children's needs to be identified at an early stage with interventions put in place to prevent harm.

"Without intervention, there will be in the future, as there has been in the past, high intergenerational transmission of disadvantage, inequality, dysfunction and child maltreatment," writes APPG co-chair Tim Loughton. "This self-perpetuating system creates untold and recurring costs for society."

Wave Trust analysis, funded by the Department of Health, has identified strategies and actions that are most effective for improving outcomes. These include:

• Ensuring the antenatal workforce have good skills in relationship-based communications
• Comprehensive early assessments during pregnancy are crucial to primary prevention
• Regular universal assessments should be carried out up to the age of two
• Tackling disorganized attachment must be a top priority
• Promoting wellbeing must have the same priority as preventing harm
• Services must be in place to address identified needs.

National policy

The period up to two is a critical phase of heightened vulnerability, but also a window of opportunity because many of the factors that influence a child's health and development can be shaped by policy interventions. During the late 1990s and throughout the 2000s, early years was a political and policy priority. This was epitomised by the establishment of a network of Sure Start children's centres, and the development of the Healthy Child Programme that shaped universal provision.

Austerity has undermined much of the infrastructure created during the previous decade - there has been a decline in health visiting services, council early years capacity and health provision for vulnerable adults. However, the biggest impact on support for the youngest children has been from the shift in children's services funding away from early intervention towards crisis services.

Health Foundation analysis shows that the proportion of council spending going on crisis services rose from below 60 per cent in 2010/11 to 70 per cent in 2015/16. Over the same period, the proportion spent on early years, Sure Start and early help has fallen by around a third. The funding changes are most starkly seen in the closure and downgrading of children's centres - from 2010 to 2018, the number of designated centres fell from 3,600 to 2,500.

In October 2015, responsibility for commissioning birth to five public health services transferred from the NHS to local authorities. Since then, spending has fallen by nine per cent and is projected to drop by a further 15 per cent by 2019/20.

The Institute for Fiscal Studies predicts total spending per child by the state will fall 12 per cent in real terms between 2010/11 to 2020/21. At a time when funding for councils has shrunk by around 40 per cent, the number of children in care has risen 10 per cent in the last five years and child poverty has risen to the point where one in three children now live in poverty conditions according to analysis last year by Social Metrics Commission.

The Early Intervention Foundation (EIF) has estimated that the emphasis on late intervention at the expense of early help is costing the country £17bn a year in additional social costs. Last October, an EIF report made the case for a 25-year government strategy to develop long-term policies to rebalance state spending more towards prevention (see expert view).

The health and social care committee has also called on the government to tackle the structural barriers that prevent departments from investing in early intervention, and for the Comprehensive Spending Review (CSR) to "shift public expenditure towards intervening earlier".

The large number of government departments with responsibility for services in the first 1,001 days - Cabinet Office; Ministry for Housing, Communities and Local Government; DfE; Department of Health and Social Care; Department for Work and Pensions; and Treasury - has resulted in fragmented policy, the committee says. It recommends a Cabinet Office minister take overarching responsibility for the agenda and drive a cross-government strategy.

There are signs the government is moving in this direction. Last summer, the Prime Minister commissioned leader of the house Andrea Leadsom to convene a cross-ministerial group to develop a set of policies to support children aged up to two and their families. The group is set to deliver its findings later this year with a view to these being considered in CSR negotiations (see expert view).

Meanwhile, the Five Year Forward View for Mental Health set out plans for every mother experiencing mental health problems to be able to access specialist perinatal community support by April 2019. In addition, one of the five key priorities of the NHS Long-term Plan, published in January, is to raise the proportion of the health budget spent on children. Health Secretary Matt Hancock has recently outlined the government's vision to place prevention at the heart of the health service, with the process starting from conception.

Service provision

The variety of issues that can affect children from conception to age two means that the policy response needs to incorporate local and national measures. The health and social care committee report states that services are important in empowering parents to take care of their children and themselves, but that improving such provision will only be a "sticking plaster" if social factors that increase risk and disadvantage in families are not tackled.

The Healthy Child Programme is the key national initiative for monitoring child health, improving outcomes and reducing inequalities. Launched in 2009, it is delivered by local authorities under their public health duties through a combination of universal provision and targeted support.

The programme covers the five mandatory health visitor checks, which are vital for assessing child development and to refer parents for targeted support. The Institute for Health Visiting told the committee inquiry that two thirds of families do not see a health visitor eight weeks after birth. The committee also reported that health visitor numbers in England have fallen since 2015.

As part of its call for a "refresh" of the programme, the committee wants the government to increase the number of health visitor checks in line with other parts of the UK. It also wants the programme to take a more holistic view of children's lives, so that it focuses on the health of the whole family and considers the impact this has on the child's development.

However, analysis of the programme by the EIF painted a mixed picture on the effectiveness of interventions (see research evidence). Last month, the government announced that it is to train 1,000 health visitors to support the early language and communication needs of young children in some of England's most deprived communities. Health visitors will be trained to identify problems during home visits and put in place a package of support.

In addition to universal provision, some families, such as those on low incomes or already affected by one or more risk factors, may need targeted support.

Two key specialist programmes that target support at families with young children include the Family Nurse Partnership (FNP) and Parent Infant Partnerships (PIP). FNP is an intensive, preventive home visiting programme for vulnerable first-time young parents and their babies, that aims to support women to have a healthy pregnancy and improve child health and development.

Based on a US model, FNP was delivered in 132 areas at its peak, but a government-commissioned study in late 2015 questioned its impact and has reportedly seen the number fall. The programme has responded to the criticism by adapting its approach and is reporting encouraging results for increasing breastfeeding and smoking cessation rates among new mothers (see practice example). This new approach has also been backed by a recent inquiry report by the Commons' science and technology committee into evidence-based early years interventions. It questioned the conclusions of the 2015 study into FNP and urged local commissioners to back the adapted programme.

PIP offers specialist psychotherapeutic services, relationships support and a joined up pathway of care for families. It is delivered in nine areas of England by local partner organisations - for example, charity Person Shaped Support is funded by the National Lottery Reaching Communities Fund to deliver the programme in Liverpool (see practice example).

The Lottery is also providing £215m to fund support for families with children aged up to three in five deprived parts of the country (see practice example). Fulfilling Lives: A Better Start is being delivered in Blackpool, Bradford, Lambeth, Nottingham and Southend-on-Sea over a 10-year period with the aim of improving outcomes in social and emotional development, nutrition and speech and language development.

Campaigners and children's services leaders will be hoping the government will take a leaf out of the Lottery's book and start investing more in long-term preventative approaches for supporting young children and families.

EXPERT VIEWS
BREAKING THE CYCLE OF INTERGENERATIONAL DISADVANTAGE

Click on the links to read more:

ADCS view
By Rachel Dickinson, president of the Association of Directors of Children's Services 2019/20

Early Intervention Foundation view
By Tom McBride, director of evidence, Early Intervention Foundation

Government view
By Rt Hon Andrea Leadsom MP, Leader of the House of Commons

WAVE Trust view
By George Hosking, chief executive and research director, WAVE Trust

300k under-1s live with an adult with a mental health problem
200k under-1s live with an adult that has suffered domestic abuse
100k+ under-1s live with an adult with a substance misuse problem
Source: Children’s Commissioner for England, July 2018
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