Welcome to the second evidence session in our inquiry into the first 1,000 days. This session will focus on family hubs. Marie Tidball will be in this session, guesting from the Education Committee. Will the panel introduce themselves, starting with you, Dr Christine Farquharson?

It is great to be here. You honour me, but I am not, in fact, a doctor—I would not want to claim a title I do not have. My name is Christine Farquharson. I am an associate director at the Institute for Fiscal Studies, and I lead our work on education and skills.

It is a real honour to be here to give evidence. My name is Rukshana Kapasi, and I am the director of health at Barnardo’s.

My name is Rachel Roberts. I am the strategic lead for early help and prevention at Hull city council children’s services. It is great to be here to bring some of our work in Hull to life for you today.

My name is Alison Morton. I am the chief exec of the Institute of Health Visiting, which is an independent professional body set up to strengthen health visiting as a centre of excellence across the UK.

Thank you all so much for being here this morning. I will start with the first question, which is for you, Christine, regarding your report. Will you tell me a little about the key findings? What were the differences between the family hubs model and the Sure Start model?

The IFS carried out a 10-year programme of work—which makes me blush, when I think how long it has been—into the impact of Sure Start centres on children, young people and their families. We built on existing evidence from national evaluation of Sure Start and the evaluation of children’s centres in England. We provide the first evidence of the impact of Sure Start over the whole span of its life cycle, looking at outcomes in the medium to long term. When we look specifically at health, we find that access to Sure Start in the first five years of life actually increased hospitalisations at ages one and two, but hospitalisations thereafter through childhood—from ages five, six and onwards—fell dramatically. By the time we get to age 11 to 15, access to one extra centre in the first five years of life per 1,000 children in a local authority prevented about 13,000 hospitalisations of 11 to 15-year-olds each year. The benefits are quite long-lasting and grow over time. We can dig a bit into the causes and types of hospitalisations that were affected. In the earliest years, we find an increase in hospitalisations related to infections, but those fell at ages five and six. We find persistent and pervasive decreases in hospitalisations related to accidents and injuries—external causes—and we find that when we look at preventable causes, those hospitalisations also fell through middle childhood. When we focus on mental health, we see significant improvements in young people’s mental health in their teenage years. Across a wide range of types of hospitalisations and types of outcomes, we see that early access to Sure Start makes for a nuanced, but positive picture. In our wider work, we look at a set of outcomes much beyond the healthcare system: education, children’s social care, absences, special educational needs and youth offending. We find fairly substantial benefits there as well. Most notably in education, we see that early access to a Sure Start centre substantially improves GCSE scores at age 16—with the equivalent of about one percentage point more children gaining access to the five good GCSEs benchmark. That is not the hugest result that you will ever see in the education literature, but what is notable is that it comes from a relatively light-touch and very early years programme. Those benefits are being sustained, and again we see the pattern of the benefits growing over time as children get older and more distant from that Sure Start treatment. We take all those outcomes and put them together into a cost-benefit analysis, where we find that over the very long term, taking into account the life cycle of those children and young people, £1 of spending on Sure Start generated around a £2 return to society at large. What this means is that I would not characterise the financial case for Sure Start as a slam-dunk. A two-to-one cost-benefit ratio is good, but there are other programmes out there where the strict financial return materialises more quickly and with more certainty than what we are able to find in our work. That means to me that the case for Sure Start and these early integrated services rests very much on the outcomes that you want to deliver. We are quite confident in those benefits for health, education and absences, so getting that right and looking at the medium-term horizon of outcomes becomes very important when you are making the argument here. I thought it might be useful to touch briefly on what the report cannot say. Because there was very poor access to data—as some of us were talking about in the corridor outside—there is a very poor understanding of what services families used, who specifically was attending the centres, exactly how long they were there, and all that. That means that we cannot directly ascribe any of the benefits that we find to one specific service—to this programme or that intervention. Instead, when we take the whole range of outcomes that we consider into account, and when we combine that with what we know from the theory of children’s development, we find that Sure Start’s superpower was bringing together a wide range of services. There was no one silver bullet service that delivered those returns; it was about bringing together a whole bunch of different things and supporting children’s development in a holistic sense. When we take that forward, the lesson for family hubs is that there is power in integrating these early years services. Our research does not tell us exactly the right model to do that, but it does provide us with a blueprint that says, “This integrated early years service type of intervention, bringing these things together, has benefits, and not just in the short term”—if you had only measured Sure Start’s benefits in the short term, you would have had quite a partial picture—“but those benefits last even beyond the time that children themselves are using the services.”

Thank you for that. You have talked about the benefits and the savings from both, and your report talks about the long-term and financial savings that the Sure Start model delivered. What elements of the Sure Start model led to those benefits and savings?

There are a few things that we can say from the research and the outcomes we have, although, again, I stress that none of this means we can say, “We have data on this service and we can precisely link it to that outcome.” It is based on looking across the patterns of outcomes that we have more widely and bringing theory in to that as well. One thing we can say pretty confidently is the results that we find on infection—a short-term increase in infections, followed by a decrease in infections at age five to six—is about bringing children and families together and having more mixing. It is literally just having a bunch of germy children sat next to one another, getting those infections and passing the bugs around, but then building up their immune support with longer-term benefits. That is one mechanism that we have. Another set of mechanisms that we are fairly confident in is improvements in the home environment, both in terms of improved parenting practices, through services such as parenting support or evidence-based parenting interventions, and safer home environments, through the provision of information on things such as how to baby-proof your home and make the environment safe for a child to be in. We see that in some of the results on accidents and injuries, particularly in the home. A third channel that we are fairly confident in is improvements in children’s and young people’s mental health—a lasting benefit that drives some of the later results that we see. That could come about through more interaction in the early years, through more positive parenting at home, from a better sense of community or from getting early help. We do not know what the silver bullet was to deliver those mental health benefits, but we are quite confident that they are there and that that was one of the channels where we got those long-term results.

I know you did the research over 10 years, but in the report, you talk about how there were 1,168 of the original Sure Start centres left compared with the 3,106 that started off originally. You ended up with only 1,168. My question is: what was the impact of the closure of the Sure Start centres until the new family hubs opened?

We did not specifically evaluate the period when Sure Start centres were closing. The reason is that, quite often, it was not that a centre was open and then the next day it was closed. It was a much more gradual process of attrition, where centres’ funding was cut and services were hollowed out. Perhaps centres stayed open only one day or two, or they offered fewer services. That is all quite difficult to track. What we can say is that our research shows the impact of expanding access to Sure Start, and that having access to Sure Start led to many benefits for health, education, absences, exclusions and a whole range of outcomes. It stands to reason that if you take that provision away without doing something to fill the gap, you are not going to enjoy those benefits any more. In many cases, local authorities put in some additional money or tried to introduce new family services, so we cannot say that we went from Sure Start to absolutely nothing of the kind, but there was a very dramatic fall in funding. Spending on Sure Start was something like less than a third of what it had been at its peak in 2010, by the time we got to the end of the 2010s. That kind of dramatic fall in funding does not come without consequences for some of the benefits we have been talking about.

You will get used to my style of chairing. What would you say were the two things that had a negative impact on Sure Start centres closing?

As in two things relating to Government policy?

Yes.

I see. The big moment in Sure Start was the lifting of the funding ringfence in 2010. Prior to that, local authorities had been required to spend a certain amount of money on Sure Start, and that was then left up to their discretion. Many local authorities did continue to prioritise early years services, but many chose to reallocate that money to other budget lines. That had a major impact on the quality of provision. Beyond the strict funding, it also meant that there became a lot more variation in what services were offered and what the branding of Sure Start was. Many local authorities rebranded those services. That could have been in keeping with their local population and their local needs, but it did mean that you lost some of that national sense of, “This is Sure Start, and we can talk about that in the national press and everyone knows what that means.”

My final question is: what are the two positives that you have found with us moving into the family hub model?

One really positive thing is that it shows that integrated earlier services are back on the agenda. Our research shows that that is a really important tool, particularly in a world where you have something like the opportunity mission, where you want to get five-year-olds achieving that good level of development. If you are looking to focus on early years, integrated family services are a really good place to start, and family hubs take us a step in that direction. Other than that, there are elements of the model that are not tested. Moving from a zero-to-five focus to a zero-to-19 is a difference, and moving from a physical, community-based offer to something more diverse, with more of a digital element, might well fit with families’ needs and preferences today, but is again different to what Sure Start had offered. I am sure you will hear from the rest of the panel on that.

I am sure that we will expand on that. Thank you very much; you did a grand job with your first few questions. I will move swiftly on to Joe.

Good morning. This question is potentially for all of you, or for whoever would like to answer first. Do we have the right core services that all family hubs need to deliver, or is there a case for expanding or changing those core services?

In terms of core services, the way we operate things in Hull is that our partnerships with our midwives and health visitors are fundamental to, first and foremost, reaching the right people in local communities who need the support from our family hubs. By having midwifery clinics, health visiting drop-ins and clinics, we get those families used to coming to our family hubs from the very point of pregnancy, booking in for their 10-week appointment and so on, and then we can introduce them to the centre, show them around, get them used to the staff and get them to see the services that are available. We then identify the families that need a little bit more support and target the wrap-around services in that hub towards the local need. For example, in Hull we have housing drop-ins every week in many of our hubs. We have registrars delivering birth registrations at two of our hubs. That has been phenomenal. In Hull normally, to register a birth, a family living in the north of the city might have to take two buses to our city-centre customer service centre. They can now have the birth registered on their doorstep, which makes a huge difference. Sixty per cent of birth registrations in Hull are now delivered in family hubs, not in our central customer service centre. That just shows how much it has impacted. We also have domestic abuse support in our centres. We have a high prevalence of domestic abuse, unfortunately, in our city. Our family hubs do a lot of preventive and early-intervention work around that. We run FareShare food banks, clothing banks and toy banks. One thing we commenced a couple of years ago, through the family hubs and start for life funding, is a revolutionary GP drop-in clinic at one of our family hubs. We have a fantastic GP, Dr Witney, who comes along to our Rainbow Family Hub in one of the most deprived areas of the city. That works alongside targeted sessions in the centre. Families can just pop along; they do not have to make an appointment. I got feedback from one of the parents who said, “Whoever thought this up and put this in place needs a statue.” They have access to that GP, without having to wait for an appointment. The GP gets to know the health visitors and midwives in the centre and to understand the nature of need in that locality—much better in that place than when he sits in his GP clinic. There is a breadth of services in the hub. We have Citizens Advice for budgeting and financial support for families if they are maybe getting into housing debt and difficulties with loan sharks. We have a lot of support around that in the family hubs. There is obviously parenting support, some of the core things that others have already mentioned. Generally, we very much focus on a needs-led approach. We understand the communities in Hull. The family hubs have a reach area and understand their population—they are very much focused on the needs of the 30% most deprived super output areas in the city. We understand what those families are telling us. We have a lot of parent-carer panels and family feedback. We listen to families and then adapt our services according to the needs of those local communities. Covid gave all of us some big challenges, didn’t it? That was particularly true for women getting pregnant during covid and not having a normal maternity period. It was very isolating, and they were quite scared. Post-covid, we were able to use of lot of the recovery grant that the Government gave us to put on additional activities for those ladies, those women and those families who did not have a normal post-birth experience. Antenatal classes were online; they were not able to engage with those peer support groups. They maybe did not see family as much as they would have done normally. There was a very different type of maternity period. We had a lot of very isolated new mums and dads who had not had access to the services that they once did. Our health visitors did a fantastic job during covid continuing to visit, which was a lifeline for a lot of our families. We adapt, we are flexible and we are agile. It is very much about our partnership with the voluntary sector, as well. Organisations such as Kids support our special educational needs children. There are partnerships with Home Start, which does a lot of volunteer work with our nought to two-year-olds. Big partnerships, with integrated services, as Christine said, are key to all of this. It is about ensuring it is based on the needs of the families.

It sounds like you are already doing a lot of expanded services around the hubs.

Yes, I hope so.

Some of our learning—from our 75 family centres and hubs around the country that serve 224,000 children—is that there is a lot of flexibility on the ground to add to the core, which is already very comprehensive. That flexibility is really important, but one of the things we have found is that there is not a common outcomes framework in relation to that common core of services. Where we have been able to really listen to parents, understand their needs, and think about how we can deliver some of the outcomes that are needed, we have been able to do some really fantastic work. For example, in our family hub on the Isle of Wight, we have been able to work with children whose parents are in prison. In Sandwell, we have been able to work with education providers to really make an impact on school readiness. For example, we have delivered an eight-week programme that has meant that in 16 schools, in the following year when a child starts school, they have achieved outcomes such as 85% of children who were not potty trained are now potty trained and they are able to integrate much more into school. When we assessed the return on investment, it showed that for every £1 spent, there was a benefit to the state of £2.44. The additional services that are really useful in terms of being able to flex that common core of services are things such as meeting the needs of children who have special educational needs and disabilities, as well as children on the neurodiverse pathway through our Cygnet programme, which we deliver in a number of our hubs and virtually. As a result of that, parents have then been able to really understand their child’s emotions in terms of when they get aggressive, agitated or frustrated, and build a much better relationship with them. It has allowed for that. We know, for example, the huge inequalities particularly for black women, who are four times more likely to die in childbirth. In Peterborough, we have been able to develop a MUMMA hub, which has been directly targeted to black, Asian and mixed ethnicity women, with some fantastic outcomes in terms of improving health literacy and addressing isolation and loneliness for women, allowing them to build up some of those really strong networks.

That is fantastic. It sounds like there is absolutely a case for expanding, or there is already the flexibility to expand anyway. Do you have any other comments with regard to that?

Yes. Looking at it from the perspective of health visitors, we would be comparing the family hub model with the Healthy Child programme, which is the blueprint for preventive public health in England. There is actually a huge difference. The family hub model is wonderful, and there is some great work that has been happening, but when it was first launched it focused on four priority areas: breastfeeding, speech and language, perinatal and infant mental health, and parenting support. Whereas the Healthy Child programme is a huge blueprint based on a health service delivered around families, focused on probably a thousand things that could go wrong in your life as a parent—everything from preconception care to antenatal care, the post-natal care pathway, special educational needs and disabilities, immunisations, oral health and genomics. There is a whole raft of priorities that are missing from the family hub model, so I would not want people to conflate them and think they are the same. I think there was a thought that maybe we did not need the Healthy Child programme, and that family hubs could replace it, but I think they need to augment each other. That would be my clear message, because in a modern healthcare system, every child deserves a robust healthcare system. Post-natal care should not be left to chance. What we are seeing is huge variation across the country when women are discharged from a midwife, where some get great care and some get virtually nothing. That cannot be okay. In the uptake of the Healthy Child programme reviews, which I will talk about later, there is huge variation, and as much as we want to have a positive spin on this, I think there is huge work to be done there. The evidence is clear: when we look at children's outcomes across England, they are actually some of the worst in the civilised world. There is a burning platform and we need to do better. My short answer would be: no, the remit is too small; we need to think bigger and be ambitious for children.

I noticed Rachel nodding and agreeing with you there.

Yes, certainly. I just want to respond to that, and absolutely agree with everything Alison has said. With the Healthy Child programme, the role of our health visitors is very much to be our eyes and ears into the family home. They are the people who are going on to the doorstep, knocking on the door and visiting those families in their home at what can be one of the most challenging times in a new parent’s life. It is about delivering that home-based support in a really friendly and approachable way and—as Alison said—giving access to the far-ranging public health approach that the Healthy Child programme delivers. That absolutely complements our work as a family hub and we need to work together, as we do with our midwifery services. The Healthy Child programme certainly goes further and deeper in the public health outcomes for those families, and the families in Hull certainly rely on that. With the different change in the population of Hull, our health visiting service and how they have managed to adapt to that is absolutely brilliant to see and it is most definitely a core universal health service for us in Hull.

To support Alison’s comments, in our 12 family hubs in Essex and the 10 we have in Birmingham, we deliver our Healthy Child programme alongside health professionals and health visitors. It is that co-location and integration that has really delivered some of the best outcomes. They are a hub in the community that can then deliver a healthy child, as well as a whole range of other public health interventions. As we move into neighbourhoods, I think there is a massive opportunity to look at how neighbourhood working can build on that hub model.

Thank you very much.

I would like to start by welcoming our next Committee member, Marie Tidball, who is guesting from the Education Committee.

Thank you; it is an absolute privilege to be here. I was the governor of a former Sure Start children’s centre for six years. Its funding was sadly withdrawn, but we kept it going and kept it alive, and I still have a brilliant STEP centre in Stocksbridge in my constituency. I am aware that you provide a variety of services; you have already talked about school readiness, and domestic abuse support is often there, as well as mental health support for parents. You talked about a big blueprint, Alison, and that was really helpful to hear, but how do you decide which additional services to offer? What information and guidance are available to help those hubs choose and design additional services?

One of the things that we do in all our hubs is work with not only our strategic commissioners but all our partners in education, health and local authorities to look at all those joint strategic needs assessments, as well as population health and health inequality indicators, to think about what you might need in that local area. Another really important part is the experience of parents and children and what they are saying would be most valuable to them. Sometimes it is as simple as them saying, “Actually there is a lot of services that we simply cannot access because we have to pay for them, and it would be really helpful if, as part of your family hub, we could have free after-school sessions on x, y and z.” One of the particular areas that we have found, when families come into our hubs, is that a lot of people feel in limbo because the thresholds for waiting lists have got higher and they cannot access basic services, particularly around autism, ADHD and a lot of neurodiverse pathways. We have created resources on that both in our virtual family space and on the ground. We have also had feedback from education providers, such as the example that I gave on school readiness where it was actually the education providers that we worked with that said, “We are finding that children are just not school ready when they are coming into school. What can the hub do to support this?” It is about that constant dialogue and constant reshaping when things are not working. But I think that is also where having monitoring and a consistent framework, and being able to measure impact, would be valuable to that process.

Just briefly, as I will come back with another question, do you think that kind of framework needs to be set by Government?

I think it needs to be set jointly with professional bodies, ICBs and health providers, and with feedback from families and children. One piece of work we are doing with Sir Michael Marmot is developing a child health equity framework across three ICSs. Sir Michael’s institute looked at the evidence base and came up with the framework, but that now looks different because we had feedback from 300 children about the things that matter to them. That fusion is really important.

Rachel, you provide a range of services that are very holistic in their approach. We know that universality tends to mean that more people will use hubs like these, in addition to the core funded services. From your experience, how does providing those additional services impact on the uptake of the core services?

It might just help if I describe how we do things in Hull. We used to have an inspection framework for children's centres. When that finished, we did not throw the baby out with the bathwater—we continued to operate in that style. We had regular support and challenge meetings, we certainly kept our team and hub development plans, and we have an annual conversation. We used to have an Ofsted inspector come in and conduct those for us. We have now moved to a multi-agency panel approach. We are just going into our next round of support and challenge meetings, which bring together our partners to look at the data and the understanding of need in that local area for the reach of the hub. We have a data pack that basically looks at the needs of the local population—deprivation, housing, poverty, domestic abuse, calls to the police service and all the early years outcomes framework data, so that we understand the gaps in our school readiness data. We look at all that understanding, plus all our family voice; listening to parents is absolutely one of the biggest things that we need to continue. What are parents telling us about our services? What are they telling us the gaps are? What do they like? They love having a health visitor who they can drop in and see, get baby weighed and have that advice and support right on their doorstep—absolutely. What other things are they telling us? What do our parent and carer panels tell us on a regular basis when we talk to them? We develop a needs-based plan that then informs what services we bring into the hub and what we deliver out of the hub. We can scale up or down and be flexible with that as needed. For example, under the Family Hubs and Start for Life programme, with the additional funding we are accessing, we have been able to do a bit more work with dads—reaching more dads and getting more of them into the centres, because inevitably, dads tend to be at work, don’t they? So we have flexed our offer by providing antenatal classes on an evening and we are thinking about how we do some of that parenting work on an evening or a weekend when dads can come along with mums. It is just different things we have heard from parents—“Actually, dad feels a bit left out sometimes”—so we have a big programme for dads. Housing has become a bit of an issue sometimes in Hull, so we have our housing officers down into our hubs to do drop-ins, so families can get housing advice, support with their housing applications and so on. Also, out of our family hubs, we run all our targeted family support staff. We have targeted family support teams who work very closely with our social work teams—really trying to hold families and intervene as early as possible when needs are escalating, so that we do not have to deliver a statutory response. We try to improve those outcomes for our children, because at the end of the day, that is what it is all about: improving those outcomes. No child really wants a social worker in their life. If we can prevent it, we try our very best to do so. It is very needs-led. We use our data and our family voice and we develop a plan with our partners to say, “How can we collectively come together to deliver on the needs in this local area?”

That is really helpful, and it is lovely to hear about the work you are doing with dads. We used to have SaturDads at my children’s centre every Saturday, and it worked really well. Alison, I would like to bring you in to reflect on any of the questions, but in particular, are the right mechanisms in place to allow hubs to learn from best practice in additional services? If not, how could that knowledge be shared? I may bring in Dr Farquharson afterwards.

There is an awful lot of learning across the board, and we all learn from each other. I was really impressed by Rukshana when she talked about how it is important to listen to parents, because there is a huge amount of global research on what needs to happen to get better outcomes for children. We have more evidence than any other generation on the importance of the earliest years of life. We know enough about what works to make a difference now. We now need the impetus to deliver on what we have heard. At the start of the family hub review, Andrea Leadsom did a massive engagement exercise with parents, and they told us what needed to happen. We have a responsibility to parents to not only listen, but act on what they have told us. I would like to see the Government get behind that and deliver on the things that we know make a difference. I will summarise what parents told us. They want services to be accessible; some families will go to a family hub, but others will never, so we need to build services around real people in the complex and messy real world. That was the learning from Sure Start—you can have the best, most shiny family hub or Sure Start centre in the world, but there will be a large group of families who will never access it. Unless we build our services around them, we fail the children whose families for all sorts of reasons do not have the courage to reach out, who feel stigma and shame and who may not recognise their child has a need. It is really important that we have a welcoming family hub where they can go, and a service that reaches out. Parents told us that relationships matter, and that having somebody who understood them and knew them as a person was important to them. That is about the continuity of a carer, and the same person repeatedly seeing you. Parents do not tell you the first time you meet them about the things that really matter to them; it takes time for them to trust you, and then they tell you. Eliciting need is very different from ticking a box on a form; it takes trust, and that is why relationships matter. They want practitioners across the board to work in partnership with them; they do not want to be told what to do. They want the complexity of their real word and lived experience to be understood. If you are living in a hostel and you do not have a cooker or a deep freeze, your healthy eating advice will be quite different. It is about understanding people in the real world where they live and working with them to find solutions together. That is about empowerment. There is all sorts of global research on how you help families to find strengths-based solutions themselves. Services need to be responsive to changing needs over time. We know that how you are in pregnancy will be very different from how you are when your baby is born, then at six weeks and one or two years later. All sorts of side balls hit us. Life is a rollercoaster; things happen. My middle son was born with cerebral palsy; I did not plan that. It blew me sideways. We need services that are responsive to that. We need to be truly collaborative, which is why joined-up support is so important, where services work together. I was talking to Blackpool, and there are some great examples that we have heard today. The success of things like Better Start in Blackpool is the true collaboration between services where they respect each other and understand what unique selling point they bring. Finally—just because we are talking about health services—they need to be safe and effective. This can go terribly wrong if practitioners do not have the right skills, training and competencies. With the best will in the world, this is life-changing or life-threatening if we get it wrong.

I will come in briefly on the evidence point. In this context there are two levels to think about. There is the evidence base around specific interventions, whether that is Triple P positive parenting, stay and play, or health visiting—there are specific elements. In many of those cases, we have a reasonably good evidence base, and we are adding to that. England has particular strength with things such as the What Works centre network or the Early Intervention Foundation really working to build the evidence on those specific interventions and what they can achieve. Then there is a level 1 step up from that, which is how do you design the offer and bring those interventions together? There we have much less good evidence. Our research shows that Sure Start bringing together a wide range of such things was effective as a package deal, but it does not show that, actually, we could have done x per cent. better had we repackaged specific interventions in a specific way. That is difficult to do, partly because of data. One thing I would love to see from the family hubs is a much stronger effort to collect the data not just on what centres are offering and what services families are using, but in a way that that it can actually be used. Many Sure Start centres did collect that information. We tried very hard to get it for many years, but local authorities told us that the paper records had been destroyed and never digitised, or that they were owned by someone else—by a company, and the LA was not the data controller—so they could not be shared. People also thought, “There’s just not much value, so why are we keeping these old hard drives lying around? Let’s get rid of them”, or they had moved over to a new system, and no one had thought, “Maybe this information will be useful down the line.” For the amount of effort and energy that centres put into collecting the information, there was a real lack of understanding of the value that it had, not just in the day-to-day delivery sense, but in the longer-term research and evaluation sense. I hope that that is something we can avoid this time around.

That is really helpful. Others need to come in, but I will just bring in Rukshana. How have you managed to achieve a balance between providing core services and tailoring services to local needs?

That is a great question. We have done it in different ways in different places. Obviously, a lot is dependent on funding and on leveraging partners around the hub where we have identified a particular need, but there is not the funding to deliver that need. We know about funding at the moment—we did a freedom of information request—and centres have reduced by 37%, with much less funding for hubs. To balance out the right mixture of support needed in a particular area, we have worked very collaboratively with people on the ground. Where we have seen that work best is where strategically in a local area, the commissioners have a vision about the outcomes that they want to achieve for the population, where the inequalities are and where they need to make the difference. Taking that and translating it at the service level—how to make it work—is about building partnerships with health visitors, community health services, mental health services, and charities providing domestic abuse services and a whole range of other areas. It is thinking about what we need to provide here within this hub. One of the things that we found is that it takes time. In Sandwell and Birmingham, we saw our numbers increase—double—and, through people and the word-of-mouth network of volunteers and things that we have on the ground, that really demonstrated that we were providing the right type of service.

Marie, thank you. Danny has a supplementary question. Can it be brief, please?

I will do my best, Chair—thank you. I was interested in the discussion of additional core services that hubs offer. There was not a great deal of reference to special educational needs support. Christine, from the document I read about your evidence review, one of the things that stuck out was the Sure Start impact on early diagnosis of SEND need, resulting in lower long-term SEND need for children as they grew up and aged. We saw quite a significant benefit, potentially, but you did not touch on that in your introduction. In constituencies such as mine and in many places in the country, the SEND system is completely broken. Parents are crying out for early intervention, identification and support. Briefly, will you talk about the differences between the Sure Start model and the family hub model in that specific context of identifying and supporting SEND need?

Who do you want to answer the question?

Perhaps Christine can touch briefly on the impact of Sure Start and then Rachel can answer on the role of family hubs.

Very briefly.

Very briefly, we found that access to Sure Start increased special educational needs support at age five and then, as you say, decreased it at later ages. We think that those were not necessarily the same children, so it was not necessarily that children were getting early support and then not needing that support later on, but it does suggest that contact with those centres was preventing the need for SEN support slightly later in life. We found no impact on education, health and care plans, which are the more severe and more high-cost special educational needs support plans. We think that is quite consistent with the fact that, ultimately, Sure Start was quite a light-touch service. With those very severe needs at one extreme end of the spectrum, you are always going to need a more specialist service to help to make a difference there.

In terms of the first 1,001 days, our health visiting colleagues are probably the most important colleagues for the early identification of additional needs. That two to two-and-a-half year check, within the mandated visits, is at a really key time in a child’s life where we start to be able to identify any additional needs; that may be about motor skills or speech, language and communication. Certainly in Hull, speech, language and communication needs are probably one of the big priorities in our working world in family hubs. The early identification by health visitors is then registered—it is a statutory registration that we do within our early years education team. We then have a multi-agency panel. The two-year-old early education offer is really key in Hull. We have a lot of children aged two who qualify for that two-year-old early education offer. We do a really sterling job to make sure that we support families to access that offer, and our nurseries do a brilliant job in then supporting our children who have been identified with additional needs. We have an early years education team—an early years inclusion team—who work hand in hand with our nurseries to help to skill them up. That is really good. Linking back into the hubs, there are lots of sensory rooms everywhere, working jointly with our voluntary sector partner Kids, which is a specialist special needs charity. There is lots of great work, but I agree that it is a very complicated area of work and a very challenging system to work in.

Thank you to the witnesses for an interesting discussion so far. My colleagues will come back to health visiting and all the excellent services that that provides, so I will pull back a bit to look at how your interaction with the Government is going. The Government recently published the third iteration of the family hub model framework, which I am sure you have seen, touched on and thought about. Looking at it, there are three delivery areas—access, connection and relationships—that I am sure nobody would disagree with. Could you give me a sense of how useful the framework is and what you use it for? Then we might come back to how we might improve it. Christine, can I start with you?

I defer to others, as I know we are short on time.

Those key areas around access, connection and relationships are absolutely vital for us to collect data on at the moment. We know that access is absolutely key for inclusion and reducing health inequalities. Connection and relationships are a real strength of the family hub model, because what we are really trying to do is enable parents to develop those relationships for themselves and make them lifelong, and therefore to strengthen communities. There are other areas, though, that would be really useful for us to look at, such as the sort of data that we need to collect to think about reducing inequalities. We know, for example, that there has been a huge, 42% increase in the number of children under four attending emergency departments. We could think about some of the health-specific data to augment that framework. We also know that school readiness is a huge area. Joe, you talked about special educational needs. We know that now children are waiting more than two years to get a diagnosis for that. So I think some very targeted areas in relation to the improvements that we want to see in health and in reducing health inequalities being added to the framework would be really useful.

Thank you, Rukshana. Rachel, do you have any thoughts?

We have worked with the Family Hubs and Start for Life programme; this is our fourth year of the programme. There has been really proactive and collaborative work with the Department for Education. We have a regional relationship officer. We have regular conversations. I think that as long as there is agility and flexibility in the framework—we all recognise the need for the Department to gather information in order to convince and make the case to Whitehall for further investment. That is basically the bottom line. It is the same with every programme. With Supporting Families, formerly Troubled Families, it is exactly the same. What I would like to see from Government is a much more robust, longer-term funding framework that enables us to plan ahead and to recruit on a longer-term basis. As Alison said, parents want stable relationships with their practitioners. We do not want to be chopping and changing people; we do not want people to be seeking other jobs. We need a long-term funding arrangement. Something that I think Government have started to do for the following local government settlement is clump some of the grants together in one place and put some conditions around that so that it becomes sensibly ringfenced to certain things. That is really where we would see a huge benefit. Also important is maintaining agility and flexibility. As I think Christine said, this is not an exact blueprint. None of it is an exact blueprint, because we have to be based on local needs. Hull is very different from Devon, so what Devon will need is very different from what Hull will need. There can be some core things within that; health visiting and midwifery are absolutely core to a very successful first 1,001 days. Then what we wrap around all that needs to be based on local need. I don’t think the framework goes against any of that. We work with it very proactively, but we are very much based on things that give us some flexibility to respond to local need. I understand where people are coming from in making the case for longer-term—

Rachel, I think your comments and Rukshana’s are complementing each other. Basically, Rukshana is saying, “We need some targets, because we need to understand what is working and what is not,” and you are saying, “Of course we’ll do those targets, but we need some local flexibility.” Fine—thank you. Alison, is there anything you want to add?

I totally agree and I think you summarised it really well. It is really important that we have a national blueprint, because the key factors that affect outcomes for children do not vary that much between local authority areas. The intensity varies. You might have a local area that has a much higher level of deprivation, so you will have more children affected, but vulnerable children live in every single postcode across the UK. You just have to be a health visitor for a couple of days to know that. Behind a front door on a high street that you don’t even know, people will be living, as they will up a dusty farm track. There are vulnerable children in every postcode, so we need a national blueprint and high aspirations for them. I think local flexibility comes in as to how the service is delivered, not whether you get a service or not. Actually, at the moment, what we are seeing is variation in whether you get a service or not. If you have a perinatal mental health problem, you should get a service regardless of where you live. If you are in Tower Hamlets, it might be slightly different from the service in Southampton, but you should still get a service. I think that is where local flex comes in.

Lovely. I am just going to pick up, and I might bring Christine in on, the issue of data collection. From what you are saying—I have not seen specifically the data that you collect—it sounds like there is more to do in order to, first, collect the right data, the data that we need to collect, and, secondly, to standardise the data collection systems. Is that right? Does that ring bells?

I can respond a little bit to that. We are collecting some really good data now. The word “spreadsheet” sends shivers down my spine, but yes, I think we are all on electronic systems now. Unfortunately, not every local authority is on the same electronic system. We are not on the same system as our health colleagues. There are many things around data collection that could be refined—definitely—and if you find the silver bullet for that, you must share it with me. We do a fantastic amount of data collection, but in Hull it is about using that data to best effect and understanding the data, not just collecting it for collecting’s sake. Often it is not just the data; it’s the qualitative work, where we get the feedback from parents—the case studies. When I go and speak to my cabinet in Hull, I very much bring it to life with case studies and by telling it how it is. They are the people on the ground who are seeing those families in their constituencies and experiencing the work of the family hubs, so I think it is really important to hear from parents.

When I look at what the IFS analysis has shown, I am looking at time spent using family hub services by household income. That is great, but it is not huge amounts of data, if I am being really honest. Christine, can you summarise what is currently know about family hubs? Perhaps we will then have a clearer understanding of where the gaps are.

At the national level, we have relatively little data that is currently publicly available to give us that national picture. There is an ongoing programme of evaluation, so I hope and expect that, as those results become ready and start to be published, we will start to know a lot more. As I think you have heard, we know a lot more within local authorities or provider centres about what is happening and what is working. The gap is really in taking that and bringing it to the national level. I think Rachel’s point is really important here. We are not collecting data for the sake of it; it is about being much more strategic in what we think we need to know not only on the operational side but the national evaluation side, and what is going to build towards that long term. The final point I would make on that is the importance of being smart about how we collect, such as using things like administrative data sources and linking up child identifiers where we can, so that we are not asking parents and centres to track stuff that we really should know already from hospital and school records.

If I look at one particular aspect of the limited data available, I think it shows that more deprived families are more likely to engage with services that are targeted primarily at parents, rather than children. Is that a fair representation?

This is based on the evaluation of children’s centres in England for Sure Start, and we find that more deprived families particularly take up parenting services, such as things like parenting programmes, Triple P and Incredible Years.

With that data, which seems reasonably robust—going back to Rukshana’s point about inequalities—is that filtering into how family hubs are focusing on delivering parenting support and adult support services? Going back to your point, Rachel, about not just collecting data but utilising it, is that actually filtering through?

One of the biggest data gaps that we have at the moment is that it is not just about the data you are collecting but joining the dots between data in education, health and social care. We have seen that, where we do not have that join-up, children and families really fall through the cracks. That join-up of data is one of the key areas that we do not have at the moment, but the single child identifier can certainly support and help that. It also then means that families are not having to tell their story again and again to different people who they are seeing. In some of our services where we have integrated that data, it has worked brilliantly. However, when dealing with data, it is also about building trust at that local level between partners. You want to know that the data I am collecting, if I am sitting in the voluntary sector, is reliable data, so that you can then build on that, if you are the midwife, health visitor, paediatrician or whoever else along the line. We have seen this work brilliantly in our Solar service, which is particularly around mental health, where GPs and a whole range of professionals input into that. You need to do work at all levels to really make it work.

To carry on with the data for a moment, Alison, you mentioned that health visiting data is held separately to the family hub data collected, and perhaps you did too, Rachel. I am presuming that is not ideal. Alison, do you have thoughts about your health visiting services and how they interact with the family hubs currently? Perhaps you can then answer vice versa, Rachel.

What Rukshana is talking about is kind of the holy grail. With the unique child identifier, fundamentally, there are three big things we need to measure: did we reach all children, did we find their need and did we do something about it? “Did we reach all children?” is fairly straightforward, so we have good data on that one. But eliciting need—I come back to the point I made earlier—is quite different from ticking a box. You have to put good data in, or you get rubbish out. You can have a beautifully filled in tick-box form from a family that tells you everything is fine, whereas what you need is for families to tell you what is really going on and the things that really matter that are going to impact on children. You have to get data collection right at the front end, so you need a practitioner skilled to elicit need and develop trust. Sharing data is really important, but it is just numbers and words flying through the air. There has to be somebody at the other end who is going to interpret it and do something about it, which is why you need practitioners in real time. There is not an AI algorithm you can use to grade a family—“You’re a 10 out of 10, and you’re a six out of 10.” It does not work like that. Adverse childhood experience is a balance of risk and resilience factors, so it will always need a human interpretation of the real context. There are three stages we have to get right: elicit, share, interpret and do something about it. In terms of GDPR, that is where the complexity comes in, because we are sharing child data as well as third-party information about the parent. Most child outcomes are impacted by parental factors, and that is a really crunchy piece of GDPR that is always a stumbling block, particularly for mental health services and substance misuse services. You might have a family who are affected by domestic abuse today, then it is on their record, and somebody has to take it off when their circumstances change. It is putting stuff on and taking it off that brings in layers of complexity—we could have a whole session on GDPR and data sharing. It is not as straightforward as it sounds.

No, fair enough. To return to this idea of the holy grail in terms of GDPR, there is obviously an understanding that you are care professionals—you are qualified, trained people who have been checked for various criminal offences—yet the sharing of data within different professional groups or healthcare—

It does happen in some areas.

It does—it is just not standardised across the country.

No. When I used to work in Southern Health, which is now the big Hampshire and Isle of Wight consortium, we had a box you could tick on the electronic record that says, “Contains third-party information.” If the child then asked for their records at the age of 18, you could redact that; it was quite straightforward. There are simple ways of getting around it, but it has never been agreed at a national level, and there is definitely a piece of work that needs to be done on that, because it would make life an awful lot easier for all of us.

Locally, you have to have a strategic approach to data and understanding, in the context of the first 1,001 days, how we draw together all the relevant data and information that will inform our response on this particular agenda. In Hull, we have a first 1,001 days steering group, which is a strategic subgroup of the health and wellbeing board and the children’s board, and we bring together data from all our partners that collaborate and join together in that space. Together, we analyse it and say, “What is this telling us?” Starting with the early years foundation stage data, our midwifery data and our health visitor data, we pop it all into the pot and say, “What is this telling us for Hull? What does this mean?” We bring all those professionals together to analyse it, and then we throw in what our parents are telling us about the services we are providing in Hull, which is top of the list in terms of importance. We have our targeted family support staff doing an early help assessment, which uses something called an outcome star, which you may have come across. It is a holistic assessment of a range of different needs, from finance to physical and mental health, education and safety for the child. We can then measure the progress we make with those families in our targeted world by putting in that targeted team around them and measuring the progress of that family specifically. There are lots of things, but there is no one-size-fits-all at the moment.

That is what interests me. There are places that are absolutely excellent and places that, frankly—with no disrespect to all the very hard-working people—are not doing so well. As a national Government, how do we address that?

It is also vital that sometimes we look at it from the lens of us as a statutory sector provider. I am a clinical nurse by background, and I have spent many years in the NHS looking at data and health inequalities data. When we did our work in three regions across the country, we thought we knew what data we needed to collect to improve child health equity with Sir Michael Marmot. And then we asked children, and found that the most important thing to them was relationships and connectiveness to their local community. In none of our local authority or NHS datasets do we have any sort of measure of relatedness, which countries like Norway have. There is a lot that we can learn from other countries about the type of data we collect.

There are some easy wins here as well. One real challenge, when I talk to people at the Department for Education about the opportunities mission, is that they are looking at early years foundation stage at age five and saying, “We actually don’t hold records on anything that happens to these children before that point, other than whether they take up childcare.” We have health visitors carrying out checks at age two or two-and-a-half, but that data is not linkable at the individual child level to what we know in the education space. There are all these different places where the fact that services are organised within Departments—where datasets and data sharing is done even at that national level—is a blocker to building up an integrated picture of children’s development in the earliest years of life.

Thank you; that is really clear. It sounds sortable, but it needs a spotlight on it.

Thank you, Beccy—excellent points. May I ask one question, a two-pointer? In everything you have said, I keep hearing that things need to be more joined up, that sectors need to be able to work together more and share data more, and that it is all about how to get the information where everyone can access it. I will ask each of you this; please take less than a minute to answer, if you can: what are the two things that Government need to do for that to happen? If someone else makes your points, I do not mind if you do not answer the question. Alison, what two things would you like to see from Government to support some of that join-up?

The unique child identifier would be top of my list. The other one would be to agree an outcomes framework for the early years. I do not mean wheelbarrows full of questionnaires; I mean specific, small numbers of key metrics that we want to share across Departments, predominantly Education and Health. Health, education and social care—it is like a triangle. We need to have a common ambition for children, and to learn from Nesta and places like Blackpool, with its Better Start and what they have done to streamline what we collect. It is not a burden, and we can track change over time.

I think build on the joint work that the Departments for Education and of Health and Social Care have already been doing under the family hubs and the Start for Life programme. It is great that those two Government Departments are talking to each other and building the programme together, and there is certainly a crossover for us in local government with MHCLG, too, in thinking about all that—

I do not want you to think about it. You sit at the pit face, and most of us here have been in local councils. What would help you to deliver a better job in your family hub?

Better join-up across government, most definitely, and longer-term funding.

That is all I need; thank you.

I think it would be longer-term funding for family hubs that is universal and targeted. We cannot realise outcomes unless that funding is longer term. As Christine knows, it took 15 years to realise the benefits of Sure Start. Also, it is about having a more holistic dataset—really triangulating the data that parents and children want with the data that demonstrates health inequalities and that looks at things like poverty, deprivation and whether the family hubs are making a difference to children’s and families’ lives. That is for those who are living in poverty as well.

No. 1 is absolutely the child identifier, so I echo that point. No. 2 is removing barriers—doing a better job of providing guidance on things like GDPR or data collection systems to help to empower local authorities and local providers so that they feel that they understand what they can do. Those are hard technical questions, and we should not be leaving them up to the individual judgment and work ethic of all those providers around the country.

Excellent. Thank you all for humouring me.

My question is about the workforce. Alison, we have heard that there is currently a shortage of around 5,000 health visitors. Can you tell us what is causing that shortage and how it can be addressed?

Interestingly, when the family hubs were launched, Andrea Leadsom said that health visiting was one of the six priority workforces, but we have actually seen a 43% drop in health visitors since 2015, of which 19% was since the announcement of family hubs. We need to put our money where our mouth is and fix this problem, because it is having a huge impact. The reason for it is funding cuts: the public health grant has been cut significantly and that directly correlates with cuts to substantive health visiting posts. On training availability, we have seen a reduction in health visiting training places. It has been difficult for services to plan their funding because allocations are released very late. Recently, we have just heard of the cut to the level 7 apprenticeship, which will impact on health visitor training. We have had rising demand for health visiting, so families are asking for more support—85% of health visitors said that they had seen an increase in the demand for health visiting over the last 12 months. We have seen attrition from staff leaving for things like retirement, as well as a lack of career progression and a role drift away from preventive public health, which is why they came into health visiting. They are acting as mini-social workers that prop up a social care system that is under huge amounts of pressure. There is work-related stress because they have an unmanageable caseload. Health visitors in England have caseloads of 500, 750 or 1,000 children. In Scotland, they have caseloads of about 200—my colleague behind us, from Scotland, said they have a caseload of 110. In Wales, the caseload is about 250, and Northern Ireland is the same, so England is an outlier. We do not have a safer staffing tool for England, so there is no bottom to this. It will keep falling off a cliff until someone draws a line and says, “That is too many. Nobody can cope with that—it is unrealistic.” There are also huge regional disparities. We have areas doing really well that are providing great care and fantastic services and investing in health visiting, such as Blackpool or Hull, which is fantastic to see. We have others where families get virtually nothing. Some families, by design, will never see a health visitor, because that is what that service model is designed around, and that cannot be okay.

That is a relatively depressing answer, and it seems like it is only getting worse.

On my watch, it has got significantly worse.

What could be done to address this? Is the answer simply funding, or is there something else?

Funding is the backbone. People say, “Oh, you can’t keep just asking for more money.” Actually, we have seen nurses increase by 21% and health visitors drop by 43%, so it is a very different picture. Health visiting is a specific branch of nursing that needs extra special attention. I say this all the time; it is happening across the globe. Global healthcare systems are struggling with diseases that are largely preventable, and they are waking up to this. We need to get it right in the early years. If we have ever needed a specialist branch of public health nursing, we really need it now. Japan has the best health outcomes in the world, which they credit not to fancy drugs and technology but to their public health nurses, who are a highly skilled, research-driven workforce that leads its preventive public health model. England is an outlier—Scotland, Wales and Northern Ireland are different—and it has a lot to learn from Japan. Ironically, health visiting was invented in England, and across the globe countries are copying us, yet we are watching our service become decimated. I think this is a wake-up call. I really hope I have all your ears to bang the drum. We have the support from every single professional body across the UK, including the Royal College of Paediatrics and Child Health, as well as all the leading charities. Two hundred organisations in the first 1,001 days movement have said that we need more health visitors—they cannot all be wrong. Parents are demanding more health visiting support but we cannot provide it to them, and we want to.

I want to come back on a point you made about caseload. What would you say is a safe caseload for a health visitor?

This was modelled under David Cameron’s Government, and what we are recommending is an average of about 250, but it is proportionate to need, so there is a sliding scale. It is in my response to the spending review. The most deprived 10% would have a caseload of about 100 and the least deprived 30% would have a caseload of about 400. That was modelled before, and I would recommend that we do demand-driven workforce modelling again, to see whether we have got it right. The current Government have suggested that they will review the workforce plan, and we are delighted to support them with that. Obviously, we are in advance of the spending review, so I cannot comment on the outcome of that.

Family hubs obviously do not just have health visitors in them. Rukshana and Rachel, are there any other workforce problems with the multidisciplinary team? Where are the shortages, and what can we do about it?

Very clearly there are, yes. In Hull, in the first 1,001 days, we have an opportunity to identify need as early as possible and get in there early—but then there is how we respond to it. We do not have enough educational psychologists or speech and language therapists. We have high waiting lists for ASD and ADHD assessments and diagnosis, because of staffing shortages. We are not training and developing sufficient speech and language therapists and psychologists to fill the spaces available, even if we had the funding. They are very, very key for me. It results in delays for education, health and care plans, which are very important for families with a child with additional needs. It does not enable our speech and language therapists, and their services too, to come down into the family hubs and work alongside us, because they have this very challenging list of children waiting to be seen. So there are some specialisms that we feel sometimes have some blockages along the way that prevent families from receiving the support they need.

The first thing I want to say is that the workforce in our family hubs very much work alongside health visitors and all the health and social care professionals. We would not want the use of family support workers, volunteers and early years practitioners to be used as an argument against addressing the shortage of health visitors in the country, but by using our family support workers and early years practitioners, who have been trained by the health visiting workforce to work in a pathway where there are extreme shortages, to do things like the two-and-a-half-year reviews in a very risk-stratified way, we have seen fantastic results. For example, in Birmingham the number of children and families we were able to reach increased from 49% to 76% in one year, which meant that those families and children were getting the reviews, as opposed to not. So the non-clinical workforce can work in incredibly flexible ways. Alison mentioned earlier, really eloquently, that you cannot just expect families to come to the hub, for various reasons. Families might be experiencing domestic abuse or might not have the confidence. The outreach work that volunteers, early years practitioners and family support workers can do to connect people into the hub is absolutely critical. We see that as adding value to the existing workforce.

Thank you; that is really helpful. The programme guidance for a family hub says that investment will be available for workforce development in the 75 local authority areas where central Government do support hubs. What has the support looked like in practice?

We are into year 4 of a big workforce development programme. I have seen the transformation of our existing family support and early years practitioners workforce. We have introduced something called GroBrain—an evidence-based programme around parent-infant relationships, which is really well evidenced. We do that collectively with our health visiting workforce, and we are really starting to see, within some of the work we are doing, the impact on the child-parent relationship and understanding babies’ brains. Parents very often just do not understand how the brain develops and so on. We have been using something called virtual reality training as well. I don’t know whether you have ever had experience of it, but you put your headset on and you are inside the womb, and you can see how the baby’s brain is developing in the womb. It is very hard-hitting, really impactful, but fantastic to help you to understand the way a baby’s brain grows and the impact of toxic stress on that brain—the sending-receiving kind of information. We have had a whole programme of workforce development. We looked at evidence-based parenting programmes as well. We deliver a whole range of parenting programmes. I think there is something certainly in terms of the work of foundations. What Works, which used to be the Early Intervention Foundation, has done a big piece of work on evidence-based parenting programmes, recommending which ones are more evidence-based than others. There is something there about the fact that if a parent is going to be challenged getting over the doorstep of a family hub, going on a 12-week parenting programme can be equally, if not more, daunting. How we deliver support for parents has to be very flexible. Some parents will adhere to and engage in a 12-week programme, but another way we have done that is to use Solihull—the online guides. We have called them not online programmes, but online guides. We have over 3,000 learners on the Solihull engagement programme. You can sit watching “Coronation Street” on a night and do your online guide, which is about understanding your baby’s brain, or something like that. It is very evidence-based. It links in with broader Solihull programmes that health visiting very much use. It is very accessible and can be used in a range of things. We do short, sharp workshops using the tools. I have seen a social worker use it as part of a child protection plan, working with dad and helping him to understand parenting from that perspective. It is a really flexible tool.

That all sounds absolutely fascinating. I would love to spend more time on it but, to go back to workforce, what does the support the Government give you to develop your own workforce in the hubs look like, practically? Is it just that money is sent and you get on with it, or is there something more to it?

Money is part of the family hubs and Start for Life programme for workforce, but it links to what we deliver. It is linked to local need and to our local delivery plan for the family hubs and Start for Life programme. It reflects what we want to go faster and further with over the period of the programme. We are in the fourth year of the programme. Our staff across the partnership—that is not just staff within the city council, but staff across the voluntary sector and our health visiting and midwifery sectors—have had opportunities to receive additional training and development as part of that. I was in Parks Family Hub yesterday talking to the staff in the office, and they had recently been on some additional training for Peep, our home learning experience programme, which is very much about taking learning into the home. There are lots and lots of things.

In terms of our workforce, we have been able to use that support to increase competencies and capabilities of our family support workers and early years practitioners, and of our volunteers, who do one-to-one peer work and group work around things such as safeguarding and public health prevention. All the upstream work on smoking cessation, nutrition and oral health is vital. In one of our areas we delivered, with the local community health service, 70 dental health pop-ups in Stevenage. Our family support workers were then able to do dental health awareness as a follow-up with families after the dentist had left. Some 600 children who would not normally have had access to a dentist came.

The Chair is telling me that we have to wind up. I defer back to you, Chairman.

Thank you, Greg and witnesses. We will move swiftly on to Andrew, our other Committee member.

Back to you, Alison. On health visitor contacts, I am reflecting on the line of questioning raised by Beccy a moment ago. Five mandatory contacts are required. The statistics say that approximately one in five missed the contact at the appropriate time—the one-to-two week contact, the six-to-eight week contact and so on. Is that cohort of missing contacts primarily a group that we should be most concerned about or least concerned about? Or, is it a mix of failure to make contact?

There are a number of points in that. First, the national data masks significant variation between local authority areas. In the evidence that I submitted, the range is somewhere between 2.6% in the lowest performing local authorities to 100% in many. What that tells me is that this is possible, and somewhere high in the 90% to 100% range is an achievable target. I used to work at Public Health England, and it would say, “Why is it not 100% everywhere?” The answer is because families move, we have ghost children and all those reasons. We should go to the ends of the earth to make sure we find those children. We only see those children five times between pregnancy and when they start school. If you compare that to the number of days a school-aged child sees another adult, then for 38 weeks of the year they see a qualified teacher. That is minimal. At the very least we should get this right for all children. The reason why it is not happening is the enormous caseloads that I have told you about already and the lack of funding which is driving that. Health visitors want to visit every family and to see those children. We are seeing frontline skills redistribution and health visitors replaced with practitioners who are not health visitors. That is an untested model. We are trying to do a holistic assessment of families’ needs: that is physical and mental health for the adult and the child, child development, social needs and safeguarding. That takes a practitioner with a breadth of skills who is experienced at working with families. We see hundreds of children, so we can spot nuance and deviation from the norm quickly. Your flags are up. As soon as you walk into a family home, you can see it because you have seen so many children. A parent might be unaware that their child has a need, but because you see some mannerism, you spot red flags quite quickly. We need to get it right for children. In terms of the additional context that has been asked, it is really important that we expand our offer in England. The Institute for Health Visiting’s “Health Visiting in England: A Vision for the Future” has eight contacts in it. We have taken a very pragmatic view.

Sorry, did you say eight contacts?

Yes, eight. We have taken a pragmatic view. I know that Scotland has 11. We are saying that it should be proportionate to need; if families need more, they should get more, like they do in Scotland. Scotland has recently just extended its health visiting plan to include further enhancements for families with additional needs, which I would fully support. As a basic benchmark, I think eight is right. The three-and-a-half-year review, which was mentioned in the last Health and Social Care Committee, is fundamental for that good level of development target that we are aiming at. If you have a child who is falling behind at two, at the very least you need to follow that child up at three and a half, so that you have still got a window of a year to do something about it before they start school.

That is enormously helpful. As you say, the last Health Committee recommended one further contact, and that would have been far too modest as far as you are concerned. That was to have been a follow-up question. It was interesting that in answer to the question from the Chair earlier, in terms of two big asks, you did not say—

I could have had about a hundred extra asks.

Moving on from that and reflecting on the workforce challenges within the sector, particularly workload challenges, it is quite clear that if the Government are pursuing their three shifts—two of which are highly relevant to your area of work—one is prevention, and the other is the shift from hospital to community. What conversations are going on between your profession and further up the food chain regarding how they are going to deliver those shifts by enhancing the resource going into your sector? Surely some conversations are going on now?

We are involved in numerous Government groups. The commissioning framework for children and young people with cerebral palsy pathway has just been published. The postnatal care pathway is sitting waiting to be published. Looking at child development, we have been involved in immunisations. There are no announcements at the moment, so I cannot really comment, but those conversations are 100% going on to deliver them. As you mentioned, health visitors are in a really strong position to support those shifts, plus the third one: the shift to digital. There is some great work going on in that space too, which we need to maximise. It will not happen unless we invest in the workforce. We have been very clear with the Government about that. A day does not go by when people don’t come to me and say, “A health visitor could do this, they could do that, they could do the other” and I totally and utterly agree. It is a very flexible workforce, but only when it has the capacity. It takes time, and health visitors’ time translates directly into health visitors’ salary costs. There are only so many hours in a day to meet a family’s needs.

On the back of that, I have a final question. To what extent is retention of the workforce an issue? Given the workloads that you are talking about, one might conclude that they create pressure that would further result in people leaving the profession earlier than we would like.

I cannot lie; some health visitors feel very burnt out at the moment. At the other end of the spectrum, I am overwhelmed every day by the tenacity of health visitors and the brilliant work that they are doing, despite the pressures that they are under. We had our conference recently in Manchester, and the room was full of health visitors doing amazing things using the minimal resources that they have, so I think that it is there. We have three asks. First, train more health visitors. Secondly, retain the ones that we have. They are a precious resource and we need to make health visiting an attractive career. Thirdly, we need reform. We need support to reform our services to bolster them, so that we can address the needs that you have spoken about so clearly, which we know are fundamental to the Healthy Child programme. We have a workforce that is ripe and ready—they would love to do that. What they want is a Government to stand up and say, “We back our health visitors and we support them. We show you this by putting our words into action and we are going to invest in you.” I am hoping that might be the outcome of the spending review.

Alison, in your response to Andrew’s question you touched upon vaccination. I want to ask specifically about the role of health visitors in vaccination and immunisation. NHS England has launched a number of demonstrator sites and made commitments to increasing vaccinations, and increasing vaccinations as part of health visits was in the last Labour party manifesto. Where are we with vaccination rates and the involvement of health visitors, from your perspective?

England has the worst uptake of immunisations compared with the other UK nations, but the pathfinder project is well under way. I sit on the project board for that, alongside local government representatives, as an adviser. It is being led by NHS England, as you said, but in partnership with UKHSA. What I can say is that all the design criteria for the project have been finalised, and they are going out for expressions of interest from these pathfinder sites. We need to learn and understand how to deliver this in practice. The aim of the programme is to increase uptake. It is trying not to replace the service offered by GPs but to reach the families that have fallen out of the system for whatever reason, and to target them to try to increase uptake. We believe that health visitors have a crucial role to play because they have that trusted relationship with families reaching them. No. 1 is to try to be there to answer their questions. People talk about vaccination hesitancy, and often that is because they lack the information to make an informed choice. Part of the role is not only to promote vaccination uptake but to administer vaccines for those families that, for whatever reason, find it difficult to reach the normal services. There has been some great learning, particularly during the pandemic. I live in Wiltshire, and when we tried to reach the boat people of Wiltshire, people said, “They will never get vaccinated,” but they did. If you take the service to them, you can do it, and I think there should be a similar model for health visiting. There are three options that might be feasible but need to be tested. One is for the health visitor to administer the vaccine directly on the home visit. The second is to take a member of a vaccination team with you on the visit, broker that introduction and do it there with them. The third is to set up the satellite services, maybe in asylum-seeking hotels or Gypsy Traveller sites, where you go and see all the families are there and deliver them all in one go. It is a test-and-learn implementation science. The evaluation arm is not just asking, “Did the children get vaccinated?”, but, “What are the key ingredients that support implementation of this kind of approach?” Obviously, immunisation is a key public health initiative, alongside clean water—there cannot be a more important one. Health visitors are behind it. We did a survey of our members to ask whether they feel ready and support this, and overwhelmingly they supported the concept. Four in 10 said that they were ready to go and they were interested in becoming pathfinder sites now, which means that six in 10 were not. As you would guess, the key driver would be a lack of workforce. Give us the workforce and people are ready to do it.

The strategy from NHS England was launched in January 2024—well over a year ago. I understand from your comments that we are still at the expressions-of-interest stage for demonstrator sites. Presumably the test-and-learn phase will be at least 12 months if not longer—

Yes, the timescale did shift. It was an ambitious—I think that is the right word to use—timescale for a big project like that.

As for the impact on the issue of the uptake of vaccines, this sounds like it will be a couple of years away from anything at scale. What do we need to accelerate the programme?

We need to take the learning from colleagues who do this kind of work. To do this thorough implementation science approach, to understand how things work, is really important. Otherwise, we could fritter money away on a good idea that might not be feasible in reality. We need to test it. We are hoping for a mix of urban and rural sites to test the model and the different versions of that model—people might also come up with their own model. Then comes the point at which we accelerate at scale.

You made the point that we learnt a lot of lessons in the vaccination programmes during covid. Are we seeking to learn lessons that we largely already know?

Some key lessons we already know—TB outreach—and some fundamental truths we have tried to weave into the programme, in terms of intelligence, to help to design it.

Finally, because of time—the Chair is keen for me to be brief—what is your sense of when we are likely to have a national roll-out of vaccination of children via health visiting?

I do not have the finalised programme in front of me, but I imagine this goes out for expressions of interest, then people have to build their team and have a delivery arm, and it has to be delivered for a certain period of time before it can be evaluated. It will take a while—a year, I would have thought, but I am guessing.

Until the demonstrator sites. My question was, do you have a rough timeline for when a national programme will be rolled out?

No, I cannot answer that question. I do not lead the programme; we just advise it from the edges.

Basically, we are tapping into all the possible funding models. Some of our services are local authority-funded, some by the family hubs and Start for Life programmes, and some through the joint commissioning of pooled funding between health and social care in Essex and Birmingham. We have found that, certainly with the central Government funding, where there was a delay in the extension of that funding—the family hub funding extension was announced in November 2024, and Start for Life in January 2025—a lot of our services were tapping into both those programmes, so that created a lot of uncertainty for the families that we were supporting and for the workforce. That prevents long-term planning with funding. Given all those different funding sources that we tapped into, we found that, by and large, the local authority-funded programmes tend to be more targeted in their approach. They tend to be programmes for families and children who qualify for the section 17 funding, whereas central Government funding allows much more breadth and innovation around what we can actually do and how we do it. That is where we see a lot of the examples that we have heard about today. With that real, holistic and wraparound support for families right up to the age of 19, or 25 for special educational needs and disabilities, we are able to do some of the deep work that will then be very long-lasting. We have found that integrated funding has led to much better integration of health and social care and the co-location of health visitors, midwives, speech and language therapists and clinical psychologists, alongside social care professionals, and housing and welfare benefits advisers. But what sometimes tends to happen is that outcomes can get a bit blurred, and that is where that national outcomes framework would be incredibly helpful.

At one level, money is money, right? Nobody ever says no to money coming through the door. I think the first key point to make is about the scale of funding here. The funding for Sure Start at its peak in 2010 was a little over £2 billion a year in current prices, whereas for family hubs, even if you take the maximalist approach of counting everything that local authorities are doing, and potentially double counting some spend, you are looking at something less than £600 million a year, so there is a massive difference in the scale of resource going into these services right now. To put that in context, if you look at something like the Government’s new childcare entitlements—just the working families’ under two entitlements—that is over £4 billion a year by the time those are fully rolled out. So in the early years sector there has been a real shift from integrated early years support towards much more targeted childcare support. With regard to the integrated early years services, I think Rukshana made some very strong points. There is a case for getting different bodies involved and, particularly at a time when funding is constrained, trying to be creative about where you are going to get resources in. We have talked a lot already today about core accountability frameworks, core data support and core services. The risk, if you have more centres of funding, is that you are going to dilute that single brand or single backbone of the programme. That becomes particularly important in a world with the opportunity mission, if we are looking towards family hubs and similar as being one of the major tools to achieve what is in fact a national, overarching mission.

In Hull, we have a very mixed model of funding. Sitting where I am in children’s services, I spend most of my time juggling external funding, juggling grant funding, against the core funding provided by the local authority. We are very fortunate in Hull: we do receive a high level and proportion of grant funding. The Family Hubs and Start for Life programme is a relatively small proportion of the overall funding that we have for our family hubs programme in Hull. I have been very fortunate since I have been working at Hull city council: irrespective of which administration has been in power, there has been a real understanding of the impact and value of early intervention services and the role of children’s centres, as they were, or family hubs as they are now. So despite the squeeze on local government budgets, we have retained a core of eight family hubs, with four spokes, across the city and retained a core amount of services. As Rukshana has already said, things are much more—possibly very much more—targeted than in the old Sure Start days, as funding dictates. In the council, we have a mix of core funding, which comes from children’s services and the public health grant, and then that is linked with the Family Hubs and Start for Life programme. The programme—we are now in our fourth year of delivery—enables us to do that bit more. It does not fund our core delivery. That would always be there because that is a core council commitment to families in Hull, recognising the importance and the needs of families in Hull. What the Family Hubs and Start for Life programme has done is take us further and faster. It has taken us to different places. It has enabled us to strengthen our parent-infant relationship, our parenting support. It has enabled us to have more people on the ground, building those relationships and supporting those parents in a specific way, around those particular elements of the programme. As Rukshana has said, the uncertainty, in terms of the short-term nature of the funding, does not help. I would really support, as I have said previously today, longer-term funding in terms of Government grants and Government funding.

I think we will always be juggling a mixed model of funding, and I think we are good at it. From a local government perspective, I know that if my director of finance was sitting in this seat, he would say, “Please give us a much longer-term local government settlement—have some longevity to that so we can plan ahead.” If my director of children’s services was sitting here, I think she would say, “And make sure that there are some ringfences in there around children’s services and that there are some recommendations, and”—as we have all said as a panel—“have some key outcomes that have to be delivered in terms of children and families.” We are always going to be juggling some of that funding, and I think our voluntary sector do that extremely well. We have a mixed model in Hull, where five of our core hubs are delivered by ourselves in local government, and the other three are delivered by our voluntary sector partners, who own the buildings and deliver the services. They bring such added value to the city; they are able to tap into other charitable things—that local government offer is not able to bring such added value to the city—and they are uniquely placed in terms of delivering some of those wider services as well. So, operate collectively as one team, but, yes, I think we will always be in that position. And in terms of broader health services and how the NHS is now, redeveloping itself and so on, working closely with ICB colleagues on those more specialist services—midwifery, mental health services—is critical as well.

The way I would want to see it changed is that we have to bring it back to the children and the families at the end of the day: what is the best thing for them, and what do they need? They need both universal and targeted support in each and every local place. I would want to see a statutory footing for this funding, to make it a legal requirement for every single local authority and local partners to have a family hub within their local community, so that we have that network across the country. That should be linked to that outcomes framework as well, so that, in addition to having that funding, you are really able to demonstrate that impact.

I would go even bigger than you, Rukshana. I think we could be learning from places like Australia. They were asked this question in Australia: should it be the voluntary sector that delivers, or should it be the state? Actually, the answer was very hardline: that in a civilised society the state should fund healthcare for children. The role of charities and the philanthropists is to augment it—to do the extra nice bits that make it even better. So we need to have high bars. We are creating the human infrastructure for our nation for the future. We invest in buildings, bridges and roads; no one bats an eyelid. The bar is set incredibly high for investment in babies and children, and I want that to change. I would like to see us view spending on children as a capital investment, not as a cost, and actually fully cost the delivery of the Healthy Child programme in full, which is sitting on a shelf, gathering dust. How much does it cost to deliver that in reality and to actually put the money behind it to turn words into actions? Our babies, young children and families deserve better, and the metrics are telling us we have an imperative to act now.

For me, the question is less, does the current model work, and more, what is the realistic alternative to the current model? If the realistic alternative is that we think there is an opportunities mission, we think there is a spending review and we think there is an opportunity here to free up more central Government funding, more state funding, for family hubs, there are some advantages there, and we have talked through many of those. If the realistic alternative is that the public finances are very constrained, spending settlements are very tight and anything that we put towards family hubs we are really taking away from something else, then we need to think much more carefully about exactly what those trade-offs are. There is then more of a world of, how do we think about partners, and how can we think about crowding in funding from other sources, recognising that it is not perhaps the absolute ideal of where the Government would want to be, but maybe that is the best we can do in a constrained world? So that counterfactual really matters.

Excellent questions, Alex; and thank you to the panel. Last but by no means least is my colleague Ben.

Christine, may I just check something with you? You said that Sure Start used to get about £2 billion, and by using every imaginative approach—I think you talked about taking a maximalist approach and double counting—family hubs get £600 million, which is about a quarter of what they used to get. I have also read that the IFS has estimated that family hubs actually get less than 5% of what Sure Start used to get. If you can pay £2.5 billion in 2010, which Sure Start used to get, but £69 million in 2025-26 for family hubs, it is a huge collapse in funding. That is correct, isn’t it?

The trend in funding has actually been quite remarkable. The differences in the figures that you are pointing out come down to whether you look specifically at funding for family hubs, or whether you also count the wider local authority spend on similar integrated early years services. The accounting returns basically make it quite difficult to get a very confident number on that.

I have been listening to this discussion with rising fury. The situation we are in now, with the collapse in health visitor numbers and in the funding to help parents at the start of their children’s lives, is—I have to say it—an absolute disgrace. We are letting our communities down. We are letting our families down. We are creating huge problems in our communities. I just wanted to get that off my chest. However, alongside that, I want to say well done for what you are doing in an absolutely stinking situation—it is a bloody disgrace where we are now. Forgive my language, but it is a bloody disgrace. We have to put it right now. I understand the challenge you are facing, and I really say well done again to you for the work you are doing to try to do the best for children and families in this impossible situation. I hope that, over time, we can and will put it right, but well done for what you are doing now. I want to explore a particular aspect of the invidious funding situation that we are facing. In the spending review, some people are calling for all English local authorities to get more funding to support families, through family hubs. Some people are saying that, because we are in the financial straits that we have been left with, we should expand provision only in the areas of greatest need. What are your views on that?

Like everyone, we would advocate that everybody receives something within their local authority area. All families deserve access to services and support, and, as Alison very eloquently said, you sometimes do not know where that need is until it is found or exposes itself. Sir Michael Marmot talks about universal proportionalism, and that is what we have to come back to. When you are talking about levels of need, we have an index of deprivation for a reason. We look at that index of deprivation and know where our levels of need are higher and greater.

So you would go with something for everybody.

I would say something for everybody, but it must be proportionate to need, and definitely based on need and deprivation.

I agree. We need to have a core family hub offer right across the board. In areas of deprivation, you need to increase that funding because of the level of need. Also, we need to really think about those families that then go into crises and what we can do with that upstream. We know the evidence shows that, when you provide that preventive early support, you prevent more families from going into crisis and requiring more funding from the state in the longer term.

In our research, we looked at where Sure Start centres were most effective and we found that, for health outcomes specifically, the benefits were stronger in about the 30% most disadvantaged LSOAs, or lower layer super output areas. These are neighbourhoods of about 1,500—

Sorry—you are unpacking jargon with more jargon. Lower layer super output areas?

This is a statistical measure of geography, and it is a neighbourhood of about 1,500 people. If you look at that neighbourhood level, the 30% most disadvantaged neighbourhoods in the country were where the health benefits were strongest. When you look at wider outcomes such as education, you saw a much more mixed picture with benefits across the piece. The first thing that tells me is that thinking about this in terms of disadvantaged neighbourhoods, wards or smaller communities is probably more helpful than thinking about this in terms of doing everything at the local authority level.

You would not say, “Give everybody something”; you would say, “Focus on the most disadvantaged areas”.

You can focus your provision within the most disadvantaged neighbourhoods, but that is quite a different question from saying, “These local authorities are in, and those local authorities are out”.

The Families First partnership reforms are significant things happening in the children’s reforms area. The Department for Education is looking at reviewing our approach to targeted support and our multi-agency child protection teams; when you look at the diagram, our early support on family hubs is a little bit on that left-hand side. Are we having those holistic conversations about how we join up all that funding?

You are saying we are not having those holistic conversations.

Yes, from a local government and children’s partnership across each area point of view, I think that would be a very sensible place to start. We should be thinking about how something called a social care prevention grant, which has been given to each local authority to support the Families First partnership reforms across the country, can be linked. That is obviously means tested and linked to some sort of funding formula within Government. We should also be thinking about that, and how it links in with that early support and help offer at the family hub level.

I would like to come on to Alison, but if you do not mind I will stay with you for a minute, Rachel. There is a dearth of financing compared to the way it used to be, but are you saying that we are still not spending it as cleverly as we could if we joined things up better?

Absolutely. We certainly have networks across our region where we are very much discussing family hubs as part of that integrated Families First partnership response, because we do not want to start separating things for families and creating another transition point. So joining up the funding for that makes ultimate sense as well.

I agree with my colleagues. Vulnerable families—coming back to the point I made earlier—live in every postcode, so I do not think it is right that, as a country, we say that if you are vulnerable and live in one half of the country then you do not get any help and if you are in the other half you do—if you are vulnerable you are vulnerable. It is the number of vulnerable children living in each postcode that matters, so funding should be proportionate to need. The index of multiple deprivation would be a good model to use. Just as a reminder that the Healthy Child programme is quite different to the family hub model, so there is a pooling of budgets for vulnerable families, but let us also remind ourselves about routine post-natal care, antenatal care and all of the health priorities we also need to address in terms of funding mechanisms.

That is very helpful. Throughout this, you have been talking about how we need long-term and ringfenced funding, and we need it to be obligatory—we need the funding to be ringfenced and required by law. This is about what you think should be in place to ensure that this happens. Should we be insisting in some way that people integrate things effectively? How could we do that best?

We used to do it under an inspection framework for children’s centres, which was quite effective in terms of placing responsibilities on local authorities and their partners to work together and collaborate. But again, where we are taking the Families First partnership guidance, as it is at the moment, through “Working together to safeguard children”, it all needs to be linked into all of that. The Healthy Child programme has got some statutory guidance around that. It is about that part of that Families First partnership, and the wider work that the Department for Education and the DHSC do together.

Taking that point, Alison, when something is as ripped to pieces as Sure Start was, and when there are cuts across the board for everything, you cut knowledge within central Government and lose civil service expertise. Do we have the expertise, at the moment, in central Government, to drive this effectively and improve what happens locally to improve outcomes for families and children? Do we actually have the people we need, or have too many of them been lost? Will we have to rebuild that expertise in Government?

I am going to sit on the fence for that answer. There are some really great people working in Government with good knowledge and expertise, but we have lost a lot of intelligence. I used to work at Public Health England as a civil servant, and we used to have clinical expertise within the civil service, whereas now, it is very much fast-track career civil servants, who lack that kind of clinical background. I think there is a wealth of benefit in having clinical expertise driving policy. They very much lean on organisations like ours to help write national policy, which is challenging because we do not receive any funding to offset that. For health visiting particularly, we need strengthening of the commissioning guidance, because there are very loose levers—or even none—to hold the local authorities that are failing children to account. They just turn spreadsheets green, red and orange, and actually, nobody really does anything about the ones that are red, which I think is a travesty. They should be held to account for letting children down. We need strong levers to drive change.

Thank you. Christine, would you like to come in on that?

It is half-past 11, so we are nearly finished. Your answer has to be succinct.

I do not think that what has been lost is the skills and experience of individuals. I think there are a lot of very talented civil servants working to drive this forward. What has been lost is the institutional levers around partnership, working across Departments and doing that in a serious, actually integrated way, where people take into account what other Departments are experiencing, rather than trying to build that up when everyone is still fighting their own corner. It is that institutional framework rather than individuals.

That is really helpful—thank you all very much.

Thank you Ben and thank you all for coming today. It has been an absolutely excellent session.