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Draft Budget 2012-13 - Call for Evidence

Published: 
01 March 2012

Scrutiny of the Forthcoming Spending Review and Draft Budget 2012-13: Preventative Spending

Detail: 

General Call for Evidence - Response of WAVE Trust

The Committee has invited responses to the following questions:

Question

The previous Scottish Government said that: “Preventative action is integral to the approach to government in Scotland and delivering the outcomes set out in the National Performance Framework”. What spending commitments and priorities  would you like to see in the 2012-13 draft budget and spending review in order to ensure that progress is being made on preventative spending and, in particular, Early Years intervention?

WAVE Trust Response

Issues

Before recommending commitments and priorities, it makes sense to identify the known key issues which a prevention approach could transform. In listing these we also identify specific interventions which would address them, though we stress that it is more important to adopt a sound overall strategy than to cherry pick particular programmes.

The following issues are of particular relevance.

Empathy: a major causal factor underlying violence and anti-social behaviour – and the recent mindless riots in England from which Scotland was mercifully spared – is a lack of empathy with the victims. Empathy is largely instilled in children by their experiences of how they were cared for in the first year or two of life.

  • Empathy can be improved through programmes such as Roots of Empathy in schools.

Emotional regulation: a further factor in the recent riots, and which is seen in outbursts of anger, bullying in schools, domestic violence and some forms of criminal violence, is lack of emotional regulation. This is basically learned at home in the earliest years of life.

  • Emotional regulation can be improved through promoting good quality attunement between parents and babies via programmes such as Video Interaction Guidance (VIG), and improved secure attachment of babies through programmes such as Circle of Security.

Aggression: Professor Richard Tremblay of the University of Montreal has identified that the most aggressive children at age 2½ to 3 (those who will become the future violent offenders) are already ten times more aggressive than the most peaceable one third in that age group. This reflects their different family experience in the first 3 years of life. It is much easier to tackle this aggression at age 3 than to wait until it becomes a set behaviour pattern at ages 5 to 15.

  • The prime way to reduce aggression in children is through changing their parents’ behaviour via parent training programmes. We commend the national parenting programmes of Sweden, the Netherlands and New Zealand (SKIP). Domestic violence reduction would also play a valuable part. For those three year olds who are showing elevated levels of aggression, such programmes as Incredible Years and Triple P can greatly help.

Poor physical health: The recent BBC programme ‘The Nine Months that made you’ shows that lifelong physical health is significantly determined by the quality of nutrition of the mother during pregnancy – especially during the first few months of pregnancy. Smoking in pregnancy also has a significant effect. The Adverse Childhood Experience (ACE) studies of Dr Vincent Felitti in California show that the one sixth of children who suffered the highest levels of ACEs (e.g. abuse, neglect, exposure to domestic violence, parental alcoholism) had strikingly higher levels of liver, lung and heart disease and lower life expectancy. Many other physical health problems are also influenced by ACEs. The peak age for child abuse in the UK is 0-1.

  • Poor physical health can be prevented by improved diet before and during pregnancy, significantly reduced smoking in pregnancy, raising levels of breastfeeding and sharply reducing ACEs in the early years.

Poor mental health: The ACE studies also show that high levels of ACEs are correlated with high levels of mental illness, depression and suicide. The single greatest cause of mental illness in the western world is foetal alcohol spectrum disorder (FASD). As the CMO Harry Burns has pointed out there has never been a single case of FASD to a mother who remained teetotal in pregnancy.

  • The key to a prevention strategy is for Scotland to have a high quality, perinatal and infant mental health service. In addition poor mental health can be improved by reducing, or ideally eliminating, alcohol consumption in pregnancy, improved attunement and secure attachment as noted above, and sharply reducing ACEs in the early years.

Poor educational performance: which in turn leads to later poor social and financial outcomes for the individual and creates a long-term tax drain on society. Numerous international research studies, including those by James Heckman, show that such key skills as perseverance, conscientiousness, motivation and self-regulation are learned in the home long before children reach school. The quality of interaction within the family determines these, and these soft skills, in turn, have a major impact on children’s ability to learn.

  • Poor educational performance can be tackled by both universal parenting programmes (e.g. SKIP) and targeted programmes such as Video Interaction Guidance (VIG), which raise the quality of parenting in the first two years of a child’s life and deliver the soft skills which underpin later successful school performance.

All of these solutions would sit well within a preventive approach focusing in particular on the period between onset of pregnancy and age 2. There are also early years prevention programmes whose benefits straddle several of the issues above. We recommend the intensive health visiting programme for teenage mothers, Family Nurse Partnership, and the Dutch approach to supporting parents and babies from birth to school age, achieved through their Kraamzorg and mother and well-baby clinic systems.

Strategy

For optimum effectiveness, any decisions about 2012-13 preventive spending would benefit from being set within an overall, longer-term prevention strategy.

The essence of the strategy should be to transform the quality of early childhood in Scotland and in particular, the period from onset of pregnancy to age 2. The strategy would distinguish between national initiatives – e.g. a national campaign to make Scotland one of the world’s best places for babies – and policies which must be implemented at local level – e.g. a radical reduction in levels of abuse and neglect of babies in our target age group.

Where local action is key, we recommend national leadership to inspire local authorities to act preventively – e.g. a seminar drawing together all CPPs in Scotland, led by Ministers and leading opposition politicians, at which national and international experts present the case for prevention, finishing with a call for specific action proposals to be submitted by each individual CPP.

For a national approach of prevention to work, local authorities would need to adopt and follow strategies for children based on prevention. WAVE has already been involved in the development of such strategies for two English local authorities. We commend the Croydon Total Place approach though we believe this could be improved by the introduction of additional elements including the specific programmes (e.g. Roots of Empathy, VIG) recommended in this submission and the best elements of the Highland Region streamlined rapid reaction system (which addresses the silo issue).

Spending commitments and priotities in the 2012-13 draft budget

Our first recommendation for a specific priority relates to an activity we believe should be carried out before 2012-13: the development of a detailed prevention strategy, with specific action plans, timelines, accountabilities, budgets covering at least the period to 2015 (but ideally to 2020). This would allow priorities for 2012-13 to be set within the context of an overall strategy. Because it could draw on a great deal of thinking which has already gone into the issue, producing a draft strategy need not take more than a month to six weeks.

In the absence of such a formulated and agreed strategy, we propose the following spending commitments and priorities.

  • A national parenting campaign
  • National seminar(s) for CPPs, to inspire prevention strategies at local level
  • Setting up the very early years components of the strategy – pre-natal, breastfeeding, risk assessment in pregnancy
  • Planning for the activities post 2012-13, such as an improved national perinatal and infant mental health service, and family support after birth
  • Running such key programmes as Roots of Empathy, Video Interaction Guidance and Family Nurse Partnership in selected areas
  • Agreeing and adopting measurement systems to underpin the prevention strategy, including establishing base line measures e.g. maternal sensitivity at 4 weeks and 10 months, secure attachment at 12 months, aggression at 30 months, universal assessment of developmental progress at 18 months and 3 to 4 years, school readiness at entry to reception class

Other suggestions

We would like to offer two further suggestions for discussion:

  • Consider a Scottish Prevention Agency which mirrors the Scottish Violence Reduction Unit, with responsibility for physical and mental health, social and emotional development, school readiness, educational performance, child protection and child well-being. This need not involve a large budget.
  • Consider setting up a Scottish Exiles Prevention Fund, whereby the Scottish diaspora could donate money to fund preventive spending initiatives in Scotland

Question

The Scottish Government has emphasised an outcomes based approach through both the National Performance Framework and Single Outcome Agreements.  What, if any, additional national and local indicators would you like to see as a means of supporting the shift towards a greater focus on preventative spending?  

WAVE Trust Response

Ideally we would prefer to propose outcome measures within the context of an agreed prevention strategy. However, in advance of the creation of such a strategy, we identify the following as important indicators of the progress of a prevention approach:

  • Levels of alcohol consumption in pregnancy
  • Levels of smoking in pregnancy
  • Levels of stress at 32 weeks in pregnancy
  • Levels of breastfeeding (partial and exclusive) at various points
  • Maternal sensitivity at 4 weeks and 10 months
  • Secure attachment at 12 months
  • Aggression at 30 months
  • Developmental progress at 18 months and 3 to 4 years
  • School readiness at entry to reception class

We have further thoughts which we would prefer to offer within an agreed strategic approach.

Question

The Scottish Government’s response to the Committee’s Report on preventative spending stated that: “The Spending Review that will follow the Scottish elections in May will provide another opportunity for the Scottish Government to support delivery agencies in their efforts to increase the proportion of their budget dedicated to preventative activity.” What support should the Scottish Government provide in its spending review to support delivery agencies in increasing preventative activity?

WAVE Trust Response

The key delivery agencies in the implementation of a prevention strategy will be local authorities and NHS boards. The two prime forms of support which the Scottish Government can provide are leadership and finance.

We have suggested above that the Scottish Government could lead and inspire local CPPs (and this extends to local authorities and NHS boards) to adopt preventive strategies and local action plans. The Croydon Total Place Study suggests that the limiting factor in adopting locally preventive strategies is less likely to be finance than lack of political will and local leadership. The Croydon study calculated that adoption of a preventive strategy in that borough would yield significant net savings to the public purse within three years. (Its actual estimates, perhaps a touch optimistic, were that an upfront investment of £2.5 million over two years would produce net savings of £8 million in three years and £25 million in six years.)

We believe clear and strong national leadership, with cross party backing, and supported (as it would be) by international expert opinion, could create a fundamental shift in local area policies.

Any ring-fenced money which could be allocated to local areas for preventive work would be not only a boon but a long-term investment by the Scottish Government. The work of Professor James Heckman, together with John McLaren at Glasgow University, has identified the catastrophic consequences for the public purse if we do not shift to a prevention strategy, because of the changing national demographics.

Question

What long term planning [should be] carried out to fully deliver on preventative spending strategies and how [might agencies] plan for this within short term budget periods?

WAVE Trust Response

We recommend the creation of an overall long-term prevention strategy for Scotland with the goal to transform the quality of early childhood and in particular, the period from onset of pregnancy to age 2.

Long-term planning by individual agencies would take place once the strategy is formulated and would support those specific elements of the strategy which fall within their remit.

Within the short-term budget periods we recommend agencies be given guidance on the preventive activities for short-term focus. As recommended above, the short-term priorities might include:

  • Setting up the very early years components of the strategy – pre-natal, breastfeeding, risk assessment in pregnancy
  • Planning for the activities post 2012-13, such as an improved national perinatal and infant mental health service, and family support after birth
  • Running such key programmes as Roots of Empathy, Video Interaction Guidance and Family Nurse Partnership in selected areas
  • Implementing the agreed measurement systems to underpin the prevention strategy

Question

What baseline evidence [could be] used to measure preventative outcomes?

WAVE Trust Response

  • Levels of alcohol consumption in pregnancy
  • Levels of smoking in pregnancy
  • Levels of stress at 32 weeks in pregnancy
  • Levels of breastfeeding (partial and exclusive) at various points
  • Maternal sensitivity at 4 weeks and 10 months
  • Secure attachment at 12 months
  • Aggression at 30 months
  • Developmental progress at 18 months and 3 to 4 years
  • School readiness at entry to reception class