Best Start Foods - evaluation: annex B - qualitative research

3. Findings

The research findings will outline the main themes that emerged from the research and explore any variations in views by respondent categories or demographics. The findings are presented thematically, beginning with participants' experiences of the Best Start Foods (BSFs) application process. Next, participants' knowledge and understanding of BSFs are considered. Following this, participants' use of BSFs and impact of BSFs on clients and their families are examined. Finally, an exploration of ways in which participants think BSFs could be improved is outlined.

3.1. Experience of Best Start Foods application process

This section explores clients' experience of theBSFs application process including how they heard about it, reasons for applying, as well as what hindered and/or helped when they applied. It will also include healthcare professionals' own views and experiences with their clients applying for BSFs.

Participants awareness of Best Start Foods

Clients reported becoming aware of BSFs from a range of sources, with some finding out about BSFs from a number of sources. These included:

• healthcare professionals (e.g. midwives, family nurses, health visitors)
• other professionals (e.g. benefits advisors, case workers)
• word-of-mouth (family and friends)
• advertisements (online, posters, TV adverts)
• directly from Social Security Scotland if they had previously received Healthy Start Vouchers (HSVs).

Clients most commonly became aware of BSFs from healthcare professionals they were in regular contact with. Midwives, family nurses and health visitors had informed them that they were eligible and encouraged them to apply. In cases where clients had received HSVs, either healthcare professionals or Social Security Scotland had informed them of the change to BSFs. However, there were participants who said they did not receive notice regarding the switch. Some clients also became aware of BSFs through other family members and friends that had received it. They were told about the benefits and purpose of BSFs, which then led to clients searching for additional information.

Healthcare professionals became aware of BSFs through colleagues and previous healthcare roles. All healthcare professionals knew that it was formerly HSVs, and that it had switched to BSFs in Scotland. Information regarding BSFs was shared verbally, via email or through leaflets, though not all received leaflets. There were healthcare professionals that expressed that they did not use any materials in discussions with clients and simply told them about BSFs.

The amount of information that clients received regarding BSFs varied. There were clients that had conducted their own research to find out more about BSFs once they were informed about it via other channels. Others applied with little knowledge of eligibility criteria or the purpose of BSFs. Some clients reported receiving information from healthcare professionals who supported them to complete an application. Awareness that BSFs was part of a joint application with Best Start Grant (BSG) and the Scottish Child Payment also varied^[13]. Clients that were unaware of the joint application reported that they only became aware of BSFs when they received a decision letter.

Reasons for applying for Best Start Foods

All BSFs clients highlighted a financial need for the payments, which was the main reason for their BSFs application. Clients were on low incomes and therefore required additional financial support and welcomed the BSFs card. There were clients that were full-time carers for their partner or child with a disability, in education, or were on reduced maternity pay. Single parents felt they needed additional support, as food shopping is one of their biggest expenditures and they depended on only one source of income.

"To be honest, I feel like I need to do everything I can to make sure my boys have got everything they need, and to not to be too proud to accept help." (BSFs client)

Another reason for applying for BSFs was because clients were encouraged by their healthcare professionals or case workers to do so. They shared that they either applied without knowing they were eligible or had to reapply when they knew they were eligible. Clients had applied a second time when they met the BSFs eligibility criteria, such as when the client or their partner became unemployed or went on maternity leave. Maternity pay was not seen as being sufficient to provide for their children, so clients decided to apply for BSFs.

There were participants that had previously received HSVs. In these cases, clients were informed that they would need to reapply for BSFs. There were clients that reported being automatically switched over from HSVs to BSFs. However, the Scottish Government confirmed that there was no automatic registration from HSVs to BSFs^[14].

Application process

Overall, BSFs clients found the application process straightforward and quick to complete. Clients that completed an online application form said this format was convenient, and the questions were appropriate and easy to answer. Those who completed a paper application form or completed their application over the phone appreciated being able to make use of different formats.

"So it was mostly just tick boxes, really. Apart from filling in your actual details, it was mostly just tick boxes. From what I can remember, you had to tick what income support you got, and what age your child was and things. It wasn't a long process at all. It wasn't that you were filling in a lot of information that they needed and things." (BSFs client)

As has been mentioned, not all BSFs clients were aware that applying for BSFs involved a joint application along with Best Start Grant and the Scottish Child Payment. Clients saw this as beneficial as there may be people that are unaware of their eligibility and would not have received other grants along with BSFs. The joint application process also saved them time filling out multiple application forms. However, there were clients that felt the applications should be separate as they may be eligible for the payments at different time points.

BSFs clients reported mixed views regarding communication during the application process. The speed of receiving a decision regarding their application varied, ranging from 2 to 12 weeks. There were clients that were pleased with the perceived, prompt response time. Other clients shared that they had to wait longer than advertised which made them concerned and anxious that they would not receive the benefit. There were some cases where clients had forgotten about applying and were simply happy when they heard back, regardless of the length of the response time.

Overall, clients viewed the content of the decision letter positively. They were pleased that they were going to receive BSFs and found the letter informative and easy to understand. However, there was some confusion amongst clients regarding how they received communication from Social Security Scotland. Some clients reported receiving progress updates via text or email, whilst others only received a letter.

What helped the application process

Multiple advantages regarding the application process for BSFs were reported by participants. BSFs clients thought the questions were clear and not too personal and viewed the online formatting of the application form positively. Overall, participants reported a preference for the online application form. They liked that they did not have to deal with the issue of phoning and chasing staff up or the slow process of posting their application form.

"Online definitely helps. It just means you're getting the information in right away. You're not having to go to the Post Office, post box and then all that process. It cuts all that out." (BSFs client)

There were clients that also appreciated the option of applying via phone or post. However, some clients did not know that paper applications were available. Experiences with applying over the phone were positive, as clients generally thought it was easy to get in touch with staff. Some clients commented that they have struggled with answering questions online due to poor internet literacy. They also suggested that other clients may struggle if they don't have access to the internet.

"…sometimes, I get so mixed up with everything that's got to be done online and I get so confused that sometimes, I fill out the wrong forms for the wrong son. I've done it quite a few times, so I prefer just calling people and speaking about things that's got to be sorted or arranged, because if it was through the internet, I think it would take longer." (BSFs client)

Both healthcare professionals and clients discussed the various ways clients have received support when applying for BSFs. Support came from Social Security Scotland, family nurses, case workers or family and friends, and clients found it made the process easier and quicker. In the online application, there is an option to use the webchat or to phone a staff member. Overall, staff were viewed as helpful and knowledgeable.

Reasons for the need for support in applying included language barriers and lack of confidence. Clients that didn't speak English at all, or as a second language, found it difficult to understand certain words or phrases. They were therefore supported by friends and professionals that spoke English and guided them through the process. Clients that struggled with speaking English also highlighted the benefit of applying online, because they could answer at their own pace and use their phone to translate questions.

Confidence in applying for BSFs varied across participants. Healthcare professionals that discussed supporting their clients highlighted issues with literacy skills and access to technology. In these cases, they would provide support with filling out the form online or by working alongside other organisations to provide internet access and laptops for clients.

"It's more the girls own vulnerabilities that make it difficult to access, some of them don't have internet access, some of them don't have a phone or a computer that they can do it on. Some of them have got [low] educational attainment and that makes it really challenging for them to even think about going online onto a form and try filling that in. Also evidence, sometimes they're quite poor at keeping the important information to hand, some of them have been looked after, a lot of them have been in abusive situations and they don't always have all the information they need and that can be a barrier. That can be difficult for them, if they don't have a National Insurance number and they have to go through that whole process and get them a new one that can be quite difficult." (Healthcare professional)

What hindered the application process

Whilst the BSFs application process was generally viewed positively by participants, some clients reported experiencing challenges. The main challenges experienced during the application process were related to communication. Response times from application completion to communication of a decision varied between 2 and 12 weeks. Clients that received later responses regarding their application felt anxious not knowing whether they would receive the additional financial support from BSFs. Clients that received communication explaining the delays in receiving a decision or the BSFs card felt reassured that their application was not forgotten and were more understanding of the longer waiting times.

"Well, obviously at the time when I applied, I had a 1 year old, so I'd sort of got myself to the point that I thought I was eligible and that that this would help and things, so it was quite… When you didn't really hear anything, you just sort of expected that you weren't, but then you were expecting a letter to come through to say that you weren't eligible, so I still held out hope, but it was just quite anxious waiting to hear anything." (BSFs client)

Communication with relevant staff was also reported by participants as somewhat challenging. Both BSFs clients and healthcare professionals commented that they struggled to get hold of Social Security Scotland by phone to enquire about their application. Some participants reported receiving multiple requests from Social Security Scotland for the same information which led to delays in receiving BSFs and was stressful for applicants.

"I think the only thing that made it difficult was like contacting them because I got told all different things…I had to be phoning them about stuff, there was never sort of a straightforward answer. So like depending on who I spoke to like I was told all sorts of different stuff." (BSFs client)

"I have sat with women in their family home trying to assist. Now I can't make the phone call for that client, it has to come from them but you could be sitting beside them in the house as a prompt to boost their confidence to have the conversation. You could phone that helpline, you could be phoning that number and it could be ringing out for the duration of your visit and I have done that sitting waiting for the phone to be answered for 45 minutes or longer… Most people will just give up…the response as well is inconsistent so why does one client get an automatic response and payment comes, they get their card in the post quite quickly…there doesn't seem to be any rhyme or reason to this. So that's a frustration." (Healthcare professional)

3.2. Knowledge and understanding of Best Start Foods

This section explores clients', retailers' and healthcare professionals' knowledge and understanding of BSFs. This includes their awareness and views on what can be purchased with the BSFs card, as well as their understanding and thoughts on the different payments.

Awareness of the range of foods to be bought with BSFs

Clients' knowledge of and views on the range of foods that can be purchased with the BSFs card varied. Overall, participants were aware that the purpose of the BSFs card was to purchase healthy foods for their children. Clients were informed of what items could be purchased using BSFs in the guidance letter that they received with the BSFs card. The list of what could be purchased was also stated on the card, which participants found to be a helpful reminder when shopping.

Despite receiving this information, not all clients were aware of the full range of items that could be purchased with the BSFs card. Clients commonly knew that the BSFs card could be used to buy cow's milk, formula milk and fresh fruit and vegetables; the same items which could be bought with HSVs. However, it was less common for clients to be aware that frozen or tinned fruit and vegetables, pulses and eggs could also be bought with the BSFs card. Clients that thought BSFs is meant to be used to buy healthy foods also listed other foods that they perceived as healthy that were not on the recommended list that they believed they could purchase, such as fish, poultry, meat and bread. There was some uncertainty as to whether food items, such as spices and non-dairy milk alternatives, could be bought using the card. There were BSFs clients that understood the purpose of the card differently, which was to buy any items that their children need. This included purchasing some of the foods on the recommended list, but also using the card to help cover the cost of other essential items, such as nappies and clothes.

Retailers' knowledge of BSFs ranged from no awareness of the payment card to a fuller understanding of its purpose and intended use. All retailers had heard of the previous payment system, HSVs, but not all had heard that BSFs had replaced it in Scotland. They instead assumed that HSVs had stopped altogether. Retailers that had been aware of BSFs prior to the interview, tended to be those with a national promotional remit, and therefore had a general sense of its purpose. It was understood by these retailers that BSFs is intended to help families with young children afford healthy food and drink and that they could buy fruit, vegetables, formula milk, and cow's milk. There were retailers that only became aware of BSFs when invited to take part in the interview. Other retailers with little awareness had a vague understanding that the purpose of BSFs was to buy healthy foods and made assumptions that it was similar to HSVs or "milk tokens".

Similarly to BSFs clients and retailers, healthcare professionals understood that the purpose of BSFs was to purchase healthy foods. However, not all were aware of the complete list of items that could be bought. As some healthcare professionals' knowledge was based on what was previously recommended with HSVs, they knew clients could buy fruit, vegetables, formula milk, and cow's milk. They were not aware of the additional items included on the recommended list for BSFs, such as eggs and pulses.

Healthcare professionals were aware that the items that could be purchased with the card are not monitored and therefore the BSFs recommended list is not necessarily adhered to. Some shared that they would encourage their clients to consider using the card to buy other essential baby supplies, such as nappies and wipes. Other healthcare professionals also suggested to families they could buy other food items, such as pasta, rice and bread, despite not being on the recommended list of foods.

Views on the range of foods to be bought with BSFs

There were BSFs clients that thought the range of foods that could be bought with the BSFs card was appropriate and reasonable. This range allowed clients to buy essential foods for their children and also enabled them to prepare healthy meals. Clients also felt that it encouraged them to eat a healthier diet and reflected that others might not buy as much or any fruit and vegetables if it wasn't for the BSFs card.

"Like I totally agree with it, like sort of…to buy fruit and vegetables and that, like my little one is crazy with fruit and veg, she absolutely loves it and I think it's more beneficial because I think some people wouldn't buy like fruit and vegetables without having it." (BSFs client)

Clients expressed contrasting views on the recommended range of food items which could be bought using BSFs. One view was that the range of recommended foods was too limited and that clients should be allowed to buy a wider range of healthy food items. Some went further and said they thought essential non-food items should be allowed to be bought using BSFs as long as it was for the purpose of providing for their children. There were multiple suggestions as to what items should be added to the list of foods that can be purchased with the BSFs card. Non-dairy alternatives and foods that are high in fibre were suggested, as there were clients with children that had dietary restrictions and digestive problems. Other suggested items included nappies, wipes, foods high in carbohydrates, kefir, and various protein sources. There were also clients that felt that the card should not only help in covering the cost of shopping expenses but also allow them to afford to pay their bills. Comments around using the card to help pay for electricity and heating bills were shared.

"I think what they have is very restrictive…I think they need to add other things, as well, because what they have, like fruit and veg, then they have peas and lentils. I didn't really see a lot of carbs in there." (BSFs client)

"I thought the card you should be able to just use it for what you need to use it for because like you've got nappies and that as well that you need to buy, like I think you should be able to just use it for what you need at the time." (BSFs client)

Despite suggestions of unrestricted use of the BSFs card, there were clients that felt that because of the payment amounts, it would be more cost effective to use the card to only buy healthy foods.

"The credit, the amount we have is not so much, so I think it's best to limit them to items that can create more impact on the baby's lifetime… because the amount is not so big, it's better to just limit them to those items that will nourish the baby." (BSFs client)

An alternative view was that the items which could be bought with the BSFs card were not restrictive enough. There were a small number of clients that shared concerns that people could potentially use the card for inappropriate items, such as alcohol, and felt that by restricting it more (or applying the actual guidelines) it would prevent people from exploiting the scheme. Similarly, when retailers were informed that BSFs is a prepaid payment card and its intended use is to help low income families to afford healthy foods, they reported mixed feelings. Whilst it was understood that the use of a card would benefit clients in terms of reducing stigma, there were retailers that felt that it limited their ability to monitor what is being purchased in store and how often, which would enable them to make informed choices on stock and in store promotions. Retailers also questioned whether there were restrictions in place to prevent clients using the card on other items, such as cigarettes and alcohol. It is important to note that there was no evidence from any of the interviews that clients, healthcare professionals or retailers knew of instances where the BSFs card had been used to buy items such as alcohol or cigarettes. Furthermore, retailers are not expected or encouraged to police what the BSFs card is being used to purchase.

There were retailers that viewed what could be bought with BSFs positively. They thought the range of foods were the right choice, well thought out and would help in terms of preparing healthy meals. Retailers also commented on how the financial support from BSFs encourages families to adopt more healthy eating practices.

"It helps people that are struggling, and if it's the healthy things like milk, fruit and veg, that's the stuff that sometimes is quite expensive. Therefore if they're getting help to buy that, that means they're giving their kids a healthier start in life. They're getting healthier meals because they've been able to buy that stuff because they're getting that help." (Retailer)

"It's all staples. You can make an awful lot out of that, can't you? That's the basis for a lot of meals, pulses and everything." (Retailer)

There were retailers that proposed broadening the scope in terms of what could be bought with the card. They felt that there was a greater range of healthy foods that could be included with BSFs.

"I would say that I think it's quite a narrow scope of what healthy food means. I do understand there are challenges in widening it out and making it just a general food thing, I wouldn't want to do that, but a healthy diet is not just vegetables and fruit…I think giving people the option for particularly things like tinned fish which are really high in nutrients, really really relatively cheap, a source of protein and could really encourage varied diets and varied cooking." (Retailer)

Overall, healthcare professionals' views on the range of foods were positive. The recommended list was considered appropriate and they felt that it would encourage healthy eating. When informed of the additional foods that clients could buy with BSFs that were not included with HSVs, healthcare professionals were pleased that foods such as pulses were included, because they provide protein which is important for children's healthy development. However, there was a view that clients may not know what some pulses are and may lack knowledge of how to cook with them.

However, there were healthcare professionals that raised concerns that the range of foods clients could purchase was restrictive and did not reflect the eating habits and cooking skills of their clients. There was a view that young clients in particular do not have the skills or confidence to cook healthy meals from scratch, so they opt for pre-made baby food or meals. It was therefore a concern that limiting what can be purchased with the BSFs card would lead to greater difficulties with promoting healthy eating habits. This perceived issue was also raised by retailers, who suggested that ready meals should be included in what could be bought with BSFs.

"…it takes a lot of support for some of them to be able to put healthy eating into practice and I think if it was restricted it would restrict choice for them and the ability to feed themselves. So sometimes they make unhealthy choices because that's what they know how to cook and what will feed their family." (Healthcare professional)

Awareness of the different BSFs payment values

The value of BSFs payments varied. The value of the payments were: £18 every 4 weeks (£4.50 per week) during pregnancy, £36 every 4 weeks (£9 per week) from the client's child being born up until 1 year, and £18 every 4 weeks (£4.50 per week) when the client's child is between the ages of 1 and 3 years. Increases to payment values were made in August 2021, in which values changed from £4.25 to £4.50 a week, and £8.50 to £9 a week for the first year of the child's life. An increase to income thresholds was also made in August 2021 to ensure that families on the lowest incomes continued to be eligible for BSFs.

Clients' knowledge of the BSFs payments varied greatly. There were clients who knew the exact payment they received, others who knew roughly how much they received and also those who had no idea of the amount they received each month. Clients who were aware of the value of the payment they received had gained this information from the BSFs website, the guidance letter which arrived with the BSFs card, through phone calls with staff, or from checking the balance on their card regularly.

Clients that had a better awareness of the amount they received each month were also more informed about the changes in payments. Their understanding was that the payment was higher for children under one year to accommodate the price of formula milk^[15]. This reasoning was also supported by healthcare professionals. However, there were other clients that were not aware of the change in payments or the amount they were receiving. An explanation for this was that some clients only received BSFs when their child had already turned one year and therefore did not experience a change in payment. Other clients did not recall receiving any information regarding the changes in payments or the amount they would receive so would just check their balance before they went to the shops.

Views on the different BSFs payment values

Views on the different BSFs payment values were varied. Clients that felt the different payment values were suitable understood that payments were higher when a child is born to help compensate for the cost of formula milk though they did not know it was higher to also support breastfeeding mothers. The payments were viewed as being helpful and sufficient to add on to their budget to afford what they needed.

"I think they're good payments, because they help massively, especially with me being on a carer's allowance and benefits. It does help the budget a wee bit, because if you didn't have that I think I would have struggled a wee bit more." (BSFs client)

There were BSFs clients that did not think the range of BSFs payment values was suitable. Although there was an acknowledgement and understanding of why the payment was higher during a child's first year of life, participants highlighted that their food expenses did not change as their child aged. It was argued that children eat more and try a wider variety of foods as they get older. Clients therefore highlighted that cutting the payment amounts in half when a child turns one would sacrifice the quality and the amount of fruit and vegetables that are bought.

"It's just that obviously whenever your kids are eating proper foods and solids, you technically should be spending more on them because you should be trying to buy them a decent quality. So I worry about them buying substandard foods and the kids not getting the nutrients that they need, or not getting as much as milk as they should be getting because the parents are buying less of it to try and top up on the veggies and the fruits." (BSFs client)

Healthcare professionals shared similar views. Although the BSFs payments were seen as helpful, they perceived that clients would benefit more if the higher payment remained the same from when their child is born until the age of 3. This would better enable families to provide their children with healthy meals and snacks and would take some of the financial pressure off the parents.

"I know formula is more expensive but then on the other side of that they're eating more food probably so it then means that perhaps the parents are making less healthy choices because the less healthy things are more affordable. So things like fruit and vegetables are expensive and I mean everything is going up isn't it for everybody. So yeah I think my thoughts are that when its cut at 1 I think people really do feel that and I think it would be better if they maybe had the same amount until nursery because obviously at nursery they'll go there and they'll get a snack and things and that will take the pressure off parents a bit." (Healthcare professional)

3.3. Participant experience of using Best Start Foods

This section will examine BSFs clients' experiences of using the BSFs card, including how often it was used, where it was used, what it was used to buy, and ease of card administration. This section will also explore what has worked well and what challenges have been experienced while using the card.

Shopping behaviour

Overall, the BSFs card was being used as intended. Clients reported using it to mainly buy cow's milk, baby formula, fresh fruit and vegetables. There were clients who used BSFs to buy the other recommended items (e.g. eggs, pulses, and frozen or tinned fruit and vegetables) but there was generally less awareness that these items could be purchased using the card. In addition, clients mentioned using the BSFs card to buy a range of items not included on the recommended list. Items included other food items such as bread, pasta, fish, poultry and meat which clients thought qualified as healthy foods. They also used the BSFs card to buy some non-food items which clients thought were essential and they had to buy regularly, such as nappies, baby toiletries and clothes.

The BSFs card was used in a wide range of shops, including large and small supermarket chains as well as smaller franchises and local independent shops^[16]. Clients predominantly mentioned using the card in shops, though they seemed less aware that the card could be used online or they were uncertain how shopping online would work. For example, they did not know how they would go about splitting the payment for recommended items and other items and there was uncertainty as to whether the BSFs card could be used to pay for delivery. Clients were anxious about accidentally using BSFs to buy items not on the recommended list. Overall, clients were unaware that the BSFs card does not restrict the items which can be purchased.

How often clients used the BSFs card varied. There were clients who used the card weekly or several times a week to buy essential items such as milk, fruit and vegetables. Others used the card less frequently, choosing to use it for larger shops where they would split their shopping, using the BSFs card to pay for the recommended items and another debit card to pay for the remaining items. There were also clients who used the BSFs card only very occassionly, preferring to save it for times, particularly at the end of the month, when money was tight. In these circumstances the BSFs card was described as a "safety net" or "lifesaver".

"It's definitely positive and like I say when I have that one week in the month where things are really tight with bills and less money that week it's like a lifesaver to be honest. The fact that it works in most shops as well I can even go to my local shop and use it which is really handy." (BSFs client)

What worked well

General quality of the guidance

Overall, BSFs clients were positive about the guidance they received along with the BSFs card. On the whole, they thought it was clear, easy to understand and covered key information on: activating the card; checking the balance; replacing a lost card; what items the card can be used to buy and where it can be used. However, clients who could not read English reported having to rely on others to read and explain guidance as it was not offered in other languages.

Through the use of the card clients identified gaps in their knowledge which, if addressed, could improve the ease of use for all clients (see improvements section).

Card format and ease of use

The card format of BSFs was viewed postively by clients, retailers and healthcare professionals and was favoured over the previous voucher system. Clients who had previously received HSVs experienced a number of challenges using them, including: vouchers being lost or damaged; vouchers expiring before they could be used; and losing money if the items they bought did not add up to the exact value of the voucher. Clients also reported that they felt uncomfortable using vouchers because other people could see them which led to feelings of embarrassment.

In contrast, clients found using the BSFs card to be straightforward and experienced fewer issues. It was viewed as being easier to use because there was no expiry date on the monthly payments; anything that was not used stayed on the card. They also found checking the card balance by phone or using an ATM to be straightforward and relatively quick to do. However, not all clients appeared to be aware that they could check their balance using an ATM. Furthermore, clients thought that the card was harder to lose than vouchers because they kept it in their purse or wallet alongside other payment cards.

On the whole, clients also preferred the card format because it was more discreet. Previously clients would have had to hand over vouchers for retail staff to check and scan but with BSFs, clients either used contactless payment or chip and PIN, which also enabled them to use self-checkout, something that was not possible with HSVs. Clients liked the card format because it meant everyone else, including retail staff, saw it like any other payment card and clients felt less embarrassed and exposed using it. The card format was also preferred by clients who did not speak English as it was familiar to them and did not require them to be able to speak or read English to use it. Overall, the card format meant that clients could have minimal interaction with retail staff when using the BSFs card, either because they used self-checkouts, or because the payment card required far less interaction with retail staff than HSVs.

"I don't even think they [staff in shop] knew the difference, which was great because previously when it used to be the vouchers I used to use, sometimes they didn't know how to put them through, or they would tell you you were only allowed to use like one at a time. It was a lot more discreet with it just being a wee card you can just use, and they don't really know, so it's good." (BSFs client)

Finally, there was also the perception that the BSFs card could be used in a greater variety of shops to buy a wider range of foods than the previous HSVs. This enabled clients to choose to shop at different retailers to find the lowest prices.

Retailers also thought the card format was an improvement and easier for them to implement than vouchers. With HSVs, retailers had to scan and keep the vouchers and then submit them to receive payment. None of that was required with BSFs card because retailers received payment automatically.

What was challenging

In general, clients found using the BSFs card to be straightforward. However, there were clients who experienced some challenges, particularly when using the card for the first time. The majority of these challenges were caused by a lack of knowledge about the card, either by the client or the retailer. Clients reported instances of having the card rejected the first time they tried to use it, which caused embarrassment. The card was rejected for a number of reasons, including:

• The card had not been activated (either because the client had not read, or was unable to read, the guidance)
• The client tried to use contactless for the first transaction (the PIN needs to be used for the first transaction)
• The client tried to use the card in a Payzone shop and it did not work^[17]
• Some shops were not verified to accept BSFs (e.g. because they are not classified as food shops)
• Insufficient funds were available on the BSFs card for the value of the shop
• Retailers refused to accept the BSFs card because they did not recognise it.

Having their payment rejected was embarrassing for clients, even when retailers responded in a supportive manner. It also caused confusion as clients did not always know why the card was not accepted, particularly when they had previously been able to use HSVs in the same shop. There were occasions when card rejection resulted in a client being unable to buy culturally specific foods for their child because they could not buy it elsewhere. Having their card refused often resulted in a client sticking to shops they had successfully used the card in previously, even if it was inconvenient or more expensive.

"I didn't even know what to do. I kind of just told, I asked the lady at the shop if she minded just putting everything back for me, because I was embarrassed. I explained my situation and obviously, it was just, it was her that actually said, 'Oh, well do you know that it actually needs registered?' I was like, 'Well, no, I didn't actually know that', and then she was like, 'Oh, yes.'..She just said there was a few people that had been into the store and had done the same, so she just said obviously, the best thing to do was go home and register it. That's basically what I did." (BSFs Client)

Apart from challenges caused by the BSFs card being refused, clients mentioned minor inconveniences with using BSFs card. For example: finding it time-consuming calling allpay to check the card balance; not always being able to use contactless payment (because the card machine requested a PIN); and not understanding which shops did not accept the BSFs card.

An aspect retailers found challenging about BSFs was their lack of knowledge about the scheme. There was an assumption that the payment value and items that could be bought with it would be the same as HSVs but they did not know if this was correct. Retailers also found it challenging not having any information on the use of BSFs in their shop(s). Retailers said that data on the items being bought and how often would enable them to make informed choices on stock and in store promotions.

3.4. Impact of Best Start Foods

This section explores what impact, if any, BSFs has had on clients and their families, as well as the perceived impact from the perspective of healthcare professionals. This includes exploring any impact BSFs has had on healthy eating, health and wellbeing, and household finances.

Healthy eating

Both healthcare professionals and BSFs clients reported mixed experiences in terms of the impact BSFs has had on clients' healthy eating behaviour. There were participants that perceived that receiving BSFs had made no difference to the type of foods they purchased, their meal planning, or shopping habits. These clients were already purchasing fruit, vegetables and milk prior to BSFs and felt they were already eating healthily as a family. However, for clients that had experienced an impact, the extent and ways in which the BSFs card had made a difference to their food habits varied.

Buying and eating more healthy foods

Overall, since receiving BSFs, clients have been able to buy and eat more healthy foods than they could afford previously. However, shopping habits varied across BSFs clients. While participants regularly bought milk, fruit and vegetables as part of their shopping, BSFs enabled them to buy these healthy items in greater quantities.

"I've been able to get more fruit and veg into her, like, rather than just the little bit that I could afford without the card." (BSFs client)

BSFs clients' motivations for purchasing and eating more healthy foods varied. There were participants that purchased more fruit and vegetables because their children enjoyed them and receiving BSFs meant they did not need to limit the amount of healthy foods their children could eat. For participants that felt they were already eating healthily as a family, BSFs enabled them to purchase a greater amount of healthy foods that could then be incorporated into their meals on a more regular basis. Additionally, there were healthcare professionals that reported that BSFs clients were likely to buy more healthy foods because the recommended list of what can be purchased with the card was limited.

"We're quite a healthy family as it is, but we always have veg every night now. We used to have it three, four times a week, but we have it every night now." (BSFs client)

"Limiting them to certain amounts of fruit, we could give them extra, so it was like, 'Help yourself', as opposed to, 'No, you can't get that because we need to keep that all week.'…I felt better because I knew my kids were getting more than what they normally would have had." (BSFs client)

In addition to being able to buy a greater quantity of healthy foods, BSFs allowed participants the financial capacity to buy a wider range of fruits and vegetables for their children to try. Prior to receiving BSFs this would not have been considered, as participants would not purchase foods that they were uncertain their children would enjoy or that they did not enjoy themselves. Their reasoning was that they could not afford to waste food or money if their children decided they did not want to eat it. BSFs has therefore given clients the financial freedom to ensure their own and their children's diets are varied as well as giving their children enjoyable experiences when trying new foods. Being able to afford a wider variety of foods was particularly beneficial for participants whose children had food intolerances, digestive problems or were fussy eaters as catering for them could be expensive.

"It's like, for example, they like dragon fruit, which I'd never tried that before, but they knew that from school, dragon fruit, and they're always asking, 'Mum, can I have it?' Because normally I would be saying, 'No, because I don't know this fruit and I don't like to waste the money on something which I don't know.' With the Healthy Start I feel more open, actually able to let the kids experiment with the fruit and veg if they want to try something new, because I don't feel that would too much affect our pocket, if you know what I mean" (BSFs client)

BSFs also allowed clients to reconsider their own attitudes towards healthy eating. This was particularly the case for participants who did not eat a lot of fruit and vegetables when they were younger. Watching their children's excitement in trying new fruits and vegetables made clients realise the importance of providing their children with a variety of healthy foods. This impact was also reflected by healthcare professionals, who reported having more discussions with families about their attitudes towards healthy eating. BSFs had helped change their mindset and clients were excited to share their own and their children's experiences of trying new fruit and vegetables with the healthcare professionals.

"Like I said before I wouldn't buy fruit and veg, I never was a big person to be liking fruit and veg. But I suppose now that I've got my little one it's made me rethink about eating this sort of stuff." (BSFs client)

"I'm not a fan of melon and my kids love melon, that kind of thing, maybe without it [BSFs] I might not have bought it because if they didn't like it, it would have been thrown out. Whereas it's maybe been bought and tried and they've loved it so I'll continue buying it, although it's something I'm not keen on myself…it's kind of broadened my horizons on the foods that are available and encouraging them." (BSFs client)

Improving healthy eating habits

In addition to buying more and a wider range of healthy foods, BSFs also enabled clients to purchase better quality and fresher fruit and vegetables. Clients felt BSFs enabled them to have more choice in terms of the items they bought and they felt happy knowing they no longer had to pick the cheapest options if they did not want to. Since receiving BSFs, these participants could afford to buy less frozen and processed foods and replace it with fresh fruit and vegetables.

"I would say we definitely eat a lot more fresh food now. When I first had my son, everything was, it was more than likely frozen. I didn't cook properly. Even though I had the ability, it was just too expensive. But once I had my daughter, it meant I could buy fresh meat and things like that, because I had a section that I didn't have to worry about in my shop, because the allpay card would take care of it. So, I would say that it's been beneficial to the whole household, really, in terms of healthier eating." (BSFs client)

Healthcare professionals and clients reported that BSFs has enabled families to make healthier food choices. Being able to afford to buy more and a wider variety of fruit and vegetables has encouraged participants to purchase healthier snacks, such as different types of fruit, for their children instead of processed and unhealthy foods like crisps. It has therefore lowered their consumption of processed food and encouraged heathier eating for their children as well as themselves. Healthcare professionals reported that fruit as a healthy snack was particularly popular amongst younger parents because it did not require any cooking.

"…I've noticed with my wife for the last three or four months, she's reduced her buying of snacks, as in chocolates, biscuits and crisps and she's upped everything else, as in fruits and veg and milk, etc. That's a conscious decision I think she's made because of the kids' health." (BSFs client)

"I think meals are healthier with like the vegetables and stuff and like my little one would snack on fruit all day if I allowed her. So like things have become healthier." (BSFs client)

BSFs also had an impact on clients' healthy eating in terms of trying new recipes. There were clients who said that receiving BSFs enabled them to experiment with preparing new types of meals in order to incorporate more fruit and vegetables into their children's diets. Healthcare professionals reported that families that had not previously eaten a lot of fruit and vegetables were excited about trying different healthy foods and new recipes as a result of receiving BSFs. BSFs allowed clients to experiment with different healthy foods and take an interest in their own health. Healthcare professionals also shared anecdotes about their clients making their own baby food, such as purees, and trying fruits they had not eaten before.

"I think as a family it's improved our eating habits. It's definitely improved mine because there is more fresh fruit and veg in the house and there's more healthier foods and as I say I'm learning to cook my own pasta sauces and trying to be quite sneaky and creative." (BSFs client)

"I think it [BSFs] lets people experiment a bit more and try things that they might not have then had and take a real kind of interest in their own health and I see a big rise in people using not the baby jars but wanting to make their own mash and purees for their babies, like with sweet potato for example, rather than buying the jars. So again it's cheaper for them and it's better for baby, jars often have lots of water and things put into them. So I think just being more experimental with weaning and also trying new things for themselves." (Healthcare professional)

The impact BSFs (and HSVs previously) had on diets of families had also filtered through to some retailers. Understanding the impact that schemes like HSVs and BSFs could have on families inspired retailers and strengthened their support for the scheme.

"There was one story that always sticks in my mind, when I went to a conference on it, about a woman who had budgeted her meal plan down to the penny as you have to when you're low on resource and she actually had slightly more money one week than she realised she had…having the Healthy Start voucher meant that she could get a mango for her kids that they'd never had before and they got to try a mango and that is just incredible. To be able to use food as a treat, it's a healthy treat but it's also a new experience and it's something that every child deserves and it was afforded by that because a mango is probably not an essential item that you're going to buy if you need to buy peas for a recipe. But the fact that she had a few more quid that meant that she could buy…that is priceless." (Retailer)

Health and wellbeing

The reported impact of BSFs on health and wellbeing from both healthcare professionals and BSFs clients consisted of both neutral and positive experiences. There were participants who reported that BSFs had no impact on families' health and wellbeing and healthcare professionals who felt they could not comment on the impact because families had not shared this with them. However, other participants found that BSFs had impacted on the health and wellbeing of families to varying extents.

Impact on parental health and wellbeing

Overall, clients experienced reduced levels of stress and anxiety in relation to finances as a result of receiving the BSFs card. BSFs had given participants a sense of relief knowing they could use it to buy healthy foods for their families. This freed up their own money to pay for other household bills or purchase essential non-food items. They also expressed relief as BSFs enabled clients to be financially independent, whereas they previously had to ask for support from other family members. This was reiterated by healthcare professionals who observed that their clients were less burdened by financial worries. Healthcare professionals were pleased to see the positive impact BSFs was having on the health and wellbeing of families as a preoccupation with finances could impact the relationship they had with their children.

"We know that if parents are focused on worrying about things like finances, housing then their ability to be there for their children can be impacted and the attachment. So it's amazing isn't it how it all ties in just from the food but it does make a huge difference." (Healthcare professional)

BSFs also had a positive impact on how clients felt about providing for their family. The additional income made participants feel happier knowing they could afford to purchase more fruits and vegetables for their families and spend additional money on better quality and fresher food. Participants reflected on a desire to provide their children with the nutrients they needed and were pleased that they could accomplish this with the BSFs card. The improvement in healthy eating habits and the benefit of BSFs in providing the appropriate nutrition for children was also highlighted by healthcare professionals.

"I think the majority of the time if they're encouraged to eat well it's good for them, it's good for their development, it's good for their brain function and that makes me happy as a parent that I know they're getting some healthy foods." (BSFs client)

"I think it's pretty much guaranteeing that a baby that's maybe living in poverty is going to have regular access to food and nutrition, whether that's pre-packaged baby stuff or not. It's ringfenced money to ensure that they've got access to food and nutrition." (Healthcare professional)

Clients also felt happier knowing they did not have to limit the amount of fruit and vegetables their child could have. Knowing they could go to a shop and buy their children what they liked increased clients' self-esteem and offered an element of comfort as a parent. Participants also added that they, alongside their children, have been eating healthier and have been inspired to try new recipes. With BSFs, they were able to incorporate more fruit and vegetables into their diet. In addition, healthcare professionals reported that BSFs provided them with more opportunities to talk to families about diet and nutrition during pregnancy and noted that their clients were more motivated to keep themselves and their children healthy. Knowing that they can afford to provide nutritious foods for their own bodies and help their children grow gave clients a sense of pride and achievement.

"I think they find that its more accessible for them because if they've got the card that can help them to get things that they know are going to help their baby to grow as well. It also gives them a sense of pride and like they're achieving something if they're able to fuel their own body well to feed their baby." (Healthcare professional)

The practical use of a prepaid card was also discussed as having an impact on the mental wellbeing of BSFs clients. Participants who had previously received HSVs reported a positive impact on how they felt when it was replaced with BSFs. They shared that they felt less anxious or self-conscious going into shops compared to when they received HSVs. Additionally, participants that experienced mental health problems appreciate the option to use the card online, which for some was seen as more convenient and comfortable.

"I would say it's definitely been beneficial. I suffer from depression and anxiety. I also have ADD, so having that card to be able to use it online, as well, which I do love, because you have days where you just, you don't want to go out! It is good. It is good to have, and it certainly makes me feel a lot less anxious about making sure that the kids have got enough, because being the ages that they are, they eat all the time." (BSFs client)

Impact on children's health and wellbeing

Overall, participants highlighted that BSFs had a positive impact on their children's health and wellbeing. This impact was observed in terms of their children eating more and a greater variety of fruits and vegetables. This was viewed positively as fruit and vegetables are good for them nutritionally and support their development. Clients' children had positive experiences where they were allowed to choose which fruits and vegetables they would like to try. They also reported that their children were particularly excited to expand their knowledge and their curiosity around different types of fruit and vegetables.

Household finances

Although there were some participants that felt BSFs had no impact on their household finances, clients and healthcare professionals overall found that the payments had made a difference to varying extents and in different ways.

Reduces food expenses

Overall, BSFs helped families with the expense of healthy foods. The extent to which the payments helped meet household food costs varied. There were clients who initially thought that the weekly BSFs payments were fairly low but found that in practice it had helped greatly in providing healthy food essentials for themselves and their family. This was especially the case for participants that had been experiencing financial struggles, due to redundancy, lower maternity pay, and difficulties receiving benefits. Participants described that when they were dealing with particularly difficult financial circumstances, they worried about not being able to buy food. The BSFs card provided reassurance to clients that if they were dealing with highly-constrained finances, they knew that the card was available for use to buy essential foods for their children. There were participants that emphasised that they would use the BSFs card at the end of the month when money was particularly tight, and they needed to purchase food to tide them over until pay day. In cases where participants did not need to use the card, they felt that the card was a backup in case their financial situation deteriorated.

"Yes, it was just sort of a safety net for us. If I didn't need it every month, I knew it was there if I needed to use it, so there was always a safety net that if my wages weren't as much one month, we would still eat the last week of the month, kind of thing." (BSFs client)

"It's had a massive difference on our family, just enabling us to buy fresh fruit and milk and veg every week. Again, that's something that we weren't really able to do before, because we didn't have the money to buy fresh all the time, and kids should have it." (BSFs client)

There were healthcare professionals that felt that BSFs made a particular difference to their clients' ability to afford formula milk as it is more expensive in comparison to fruit and vegetables.

"I would say that probably the biggest benefit is going to be how…if they're formula feeding in the postnatal period I think that's where we see perhaps the biggest benefit because the cost of formula makes a big dent in their income. There's no doubt about that." (Healthcare professional)

The reported impact was not limited to BSFs clients and their eligible children. BSFs also helped some clients cover the cost of heathy foods for their older children as well as non-immediate family members that they support or care for. However, it is important to note that this was not true for all families. For clients with larger families, BSFs did not always fully cover the expenses of fruit and vegetables for the entire family. However, it did ease some of the strain of paying the full cost of their food shopping themselves.

"Yeah of course it's a good impact, in general it's helpful even though it's not enough when you've got a family and kids you know there isn't enough a month and there isn't enough for all the needs in the month but in general it's helpful." (BSFs client)

Relieves burden on overall household expenses

For clients, the fact that BSFs helped in meeting the cost of their food shopping in turn offered some relief in terms of other household expenses. It meant that families could focus on using their other income to pay for utilities and other family or household expenditure. For some clients, BSFs was considered a massive help in meeting the costs of their household expenses. There were instances where clients had heavily relied on the BSFs payments and considered the benefit to be a kind of financial lifeline. Healthcare professionals recalled clients telling them that BSFs had been their only source of income between receiving Universal Credit payments. Having BSFs as their only means of accessing food highlighted the importance of the payments and that clients relied on them to provide for their families. For others, BSFs was relied on to a lesser extent; they used the BSFs card only when they were running particularly low financially. In these instances, healthcare professionals believed that BSFs was useful in providing families with additional income but that it was not necessarily life altering.

"Like I said, we're just barely paying bills, or everything's broken into monthly instalments because we can't afford to pay everything in one go, so it really helps with taking the pressure off for food supplies, etc. It helps with managing bills, then, because it takes a weight off the bill money getting spent on foods." (BSFs client)

For some households, BSFs enabled them to set aside money, in some cases for the first time, that would have previously been spent on food and used it to buy other items for their children, such as clothes, art supplies, or activities for their children.

"It's more of a case of it's given me extra funds for other things for the kids because I would have always got the fruit and vegetables and things like that anyway. It just frees up money for other things, like we do quite a lot of arts and crafts and things like that, so it gives extra money towards that and towards days out and things. So it's money that you wouldn't have had. You just make sure that you spend it wisely and make sure you spend it on your kids." (BSFs client)

Saving money was only possible for clients when their child was aged under 1 as this was when they were receiving the highest payment for BSFs. When the payment dropped after their child turned one, clients reported finding it harder to redirect funds in the same way.

In addition to saving money, there were participants that reported that BSFs had also helped them with budgeting and increasing their own financial capability. As they were limited to a certain amount of money that they receive on the card, clients would keep track of the money they have coming in each month. Participants would keep a record of what they had spent on the card to ensure they did not overspend as they knew the card would be rejected.

"It helped me budget a little because you only get a certain amount in the card, which means if you go, if you spend over that, you need to put the money to it yourself." (BSFs client)

"It makes me feel really, really positive. I do a spreadsheet each month of everything we've got coming in and everything that we've got coming out, so we've reached a point we've now been relying on that to make sure that we're doing the things that we want to do." (BSFs client)

Healthcare professionals also spoke with BSFs clients about the cost of different foods and where the best places were to use the card. They felt the impact BSFs had on their client's household finances could also vary depending on the budgeting skills and knowledge of an individual. When clients were more educated in terms of budgeting, they were more likely to be able to use the BSFs payments flexibility and make it last longer.

Other impacts

Both healthcare professionals and clients shared the various ways in which BSFs had impacted on families' household finances, healthy eating, and health and wellbeing. However, other impacts which did not apply to these three categories were also discussed in interviews with both healthcare professionals and BSFs clients.

BSFs clients reported experiencing less stigma when using the BSFs card compared to using the HSVs. Clients that had previously received the HSVs had reported feeling embarrassed and judged by others when using them in shops. They felt that using paper vouchers in shops drew attention to the fact that they were receiving financial support. The BSFs card was therefore more discreet and was generally preferred over the vouchers.

BSFs also had the unintended impact of raising children's awareness and interest in money and budgeting. There were clients that had told their children that the BSFs card could only be used to buy fruit and vegetables as a way of explaining why they could not buy them sweets when they went shopping. This sparked an interest in their children who wanted to be involved in choosing healthy food and clients used this interest as an opportunity to introduce the concept of budgeting with their children.

"I couldn't buy him sweeties because I didn't have money, but I used to tell him the card was magic and it could, the card could buy him fruit. So, whenever he wanted fruit, just to buy it…he used to go to the checkout hisself [sic] with the card and obviously, not by hisself but basically without me, and just buy his actual fruit and he was happy with that." (BSFs client)

3.5. Views on improving Best Start Foods

While participants were overwhelmingly positive about BSFs, healthcare professionals, clients and retailers all made suggestions on how BSFs could be improved.

Application process

Clients were very postive about the BSFs application process, and on the whole found it straightforward. However, clients, healthcare professionals and retailers raised concerns that awareness of BSFs was low and therefore eligible families may not be applying. There were clients who thought the best way to ensure that those eligible for BSFs apply for it, was for the government to make direct contact with those who meet the eligibility criteria. Others went further and suggested that data from other sources (e.g. Universal Credit, Child Benefit) could be used to automatically register people for BSFs. One of the retailers expressed support for automatic registration due to awareness that Healthy Start in England was in the process of moving from vouchers to a prepaid card and without automatic registration, a significant drop in applications resulted. It was not clear if these participants realised that automatic application for BSFs does occur for those who apply for Best Start Grant or the Scottish Child Payment; if they are eligible for BSFs too, they do not need to apply separately.

"I think it should be automatic, to be honest, like any family that have a child, rather than people applying for it, maybe with the hospitals, if there is a way they can collect this stuff." (BSFs client)

Communication

Promotion of BSFs

All participant groups agreed that the promotion of BSFs could be improved. There was a sense that there were families, healthcare professionals and retailers who had little or no awareness of BSFs. For example, public facing retailers were aware that customers were no longer using HSVs in their shops but they did not know that BSFs had replaced the vouchers. Retailers said that if they knew more about BSFs, they could promote it to their customers. Clients also reported knowing families who were not aware of the change from HSVs to BSFs. They had assumed their vouchers had stopped because they were no longer eligible and therefore had not applied for BSFs. To address the lack of awareness of BSFs, participants suggested both a wider public marketing campaign and targeted advertisement and promotion to retailers and healthcare professionals.

"Possibly maybe just the lack of knowledge at population level that perhaps families are relying on people like myself and midwives to prompt them to apply for these things…I think the Best Start cards and grants as well are quite low key in the sense that people don't really know about them so that would be a nice advertising campaign." (Healthcare professional)

"To be quite honest I mean nobody is really aware of it apart from when a customer comes in store with the card…I think what they really need to do is have some kind of campaign to say that basically you know this is the situation, or this is what's available out there and basically go around the shops and see if they want to basically be part of it. A lot of store owners I've talked to did'nae even know…I know they knew that the Healthy Start Vouchers were finishing but nobody really knows about the replacement for them." (Retailer)

Healthcare professionals appeared to have the greatest awareness of BSFs. They reported they had received communication about BSFs through the NHS as it was part of their role to promote the benefit to families. Some received information electronically while others were given leaflets. However, there were healthcare professionals who said they had not received any written information, and everything they knew about BSFs was passed on verbally from their colleagues. Both healthcare professionals and clients saw the role of midwives, health visitors and family nurses as a key route to informing families about BSFs. Therefore, in addition to a public campaign, they thought it was important that relevant healthcare professionals were all consistently provided with literature about BSFs so they were well informed and able to share this information with families.

Retailers drew on their experience of other schemes being promoted to them and made a number of suggestions on how to improve awareness of BSFs amongst retailers and their customers. Overall, retailers stated that they would like to be better informed about BSFs including how the card works, what items can be purchased with it and any responsiblities retailers have as part of the scheme. A number of ways to achieve this were suggested, including direct communication from Social Security Scotland to retailers. This communication could be through the provision of materials to retailers or a representative visiting stores to speak to retailers in person. A retailer also suggested the development of an online training module to raise their awareness and understanding. It was proposed that promoting BSFs to retailers would also benefit families, as retailers could then pass information onto their customers. Materials such as posters, window stickers and leaflets were all put foward as ways to inform customers about the availability of BSFs and in which shops the BSFs card would be accepted.

"I think maybe some posters at point of sale so we can explain to the customer what the scheme is all about, or some kind of like advertisement, so we have an understanding of it or have a rep coming in and selecting what stores are going to be involved in it and explaining to us what's going to happen…I have an advertising screen on the window so it's very easy and stuff like that because people don't really look at posters and stuff anymore, it's all social media and digital now." (Retailer)

"I would maybe have thought when they brought out the card they could probably let supermarkets know, maybe write an email to them and just let the bosses know so that the staff would be aware…I don't think that happened when they brought out the card, so people didn't know what to look out for. I don't know whether that was on purpose, but I think letting the supermarkets know would be one thing I would like for them to improve on." (BSFs client)

Retailers were very supportive of BSFs and what it aimed to achieve. They expressed an interest in helping to promote BSFs and felt more communication between the government and retailers, perhaps in the form of a designated contact at Social Security Scotland for retailers, would foster opportunities to work together on campaigns and promotions. For example, if retailers had a greater awareness of what items could be bought with BSFs, they could consider in-store promotions of these items. In addition, retailers thought it would be beneficial to receive feedback from Social Security Scotland regarding any barriers or challenges clients faced using BSFs cards in shops so they could work together to try and find innovative solutions.

"The only big challenge is lack of data because if I'd had data I might have been able to persuade the buyers to give me more products to give away, to continue the promotion for longer but it's extremely difficult when you're kind of working in the dark…not just hard data on usage but people's impressions, maybe barriers for users that could be shared with us. We might be able to find more innovative solutions to them." (Retailer)

"Maybe just more communication in general…I don't really have any data on how Best Start [Foods] is performing, what uptake is like, reaction to the card move. I had a very general update that it had gone well but nothing specific. The less detail we have on a scheme the less able we are to support it and Best Start and Healthy Start are schemes in particular that are very well received within the business. We're a food retailer that would like, well we're actively promoting schemes at the moment that support people to tackle food hunger. These are schemes that do that, if we don't have detail on it, it's really hard to do anything. So it's not so much support as it is updates, communications." (Retailer)

Social Security Scotland communication with clients

While there were clients who were very postive about the communication and support they received from Social Security Scotland, there were others who experienced challenges and saw room for improvement. For example, clients reported being turned down for BSFs when they first applied, but the decision letter they received did not explain why. This caused distress to the client and required them to invest time contacting Social Security Scotland to find out more information. To prevent a similar situation occurring again, clients would like to see application decision letters setting out clearly any reasons for a declined application, particularly if a client may be eligible to apply at a later date.

"Basically they don't word them [decision letters] particularly great. It just basically said you aren't eligible. It doesn't explain why you aren't eligible, so if you're getting that letter on a Friday afternoon and you're having to wait until the Monday, and obviously you're not on a great income if you're getting it to begin with, and if you've got young kids and you're on your own, that's a stressful weekend. You're worried sick about how you're going to feed your kids. So if they gave a bit of explanation and broke it down for you…everybody's not got a bachelor's degree, so we need it broken down into layman's terms." (BSFs client)

Clients would also like to see improvements made to the communication at the end of BSFs. There were clients who reported being caught off guard when their BSFs payments stopped, as they received no prior warning. While there is information online that indicates that BSFs will stop when a child turns 3, some clients were unaware of this, or had forgotten. To ensure that clients are not surprised by their payments coming to an end, it was suggested that Social Security Scotland could send a letter/email to clients in advance of their final payment to inform them of this payment date so they can prepare financially.

"I didn't really get any warning or any notice that it was finishing. Just every month I would check it, and one month I noticed that it didn't come in…obviously whenever I applied, it said that it was only up to the age of 3, but that was two years ago, so you become quite used to something. Just because there was no letters or no warning really, no emails that it was coming to an end…I think even like three or four months before it comes to an end would be useful, just to let you know that it is coming to an end, this is when your last payment will be, just so that people can prepare and stop becoming reliant on it." (BSFs client)

Finally, while some were very complimentary of the helpline staff, there were clients who would like the knowledge of helpline staff improved. A client encountered significant delays to their application as a result of lack of knowledge amongst staff concerning Universal Credit. Training staff to ensure they are kept up to date with any changes to UK or Scottish social security benefits was proposed as a way to resolve this issue.

Accessibility of support and communication

As noted previously, some clients experienced challenges applying for BSFs, seeking support or using BSFs, because support and communication was not accessible to them. Clients that did not speak English at all, or as a second language, experienced language barriers and stated that they would like the option of choosing to receive communication (e.g. application form, decision letter, guidance) in other languages. Where this was not possible, access to an interpreter or translator would help clients with the application process and any queries they may have^[18]. It was noted that those with visual or hearing impairments and those with poor literacy may also face challenges with the accessibility of communication and suitable solutions should be found.

"If you need to call them the waiting times are quite long and once we try to speak to someone eventually, then there is the barrier of the language, we cannot communicate and cannot give them the details that they need, or we don't understand what they want…The only thing that could be done better is if someone is speaking to them to apply for the card…if someone is phoning and they don't speak English at least they can provide an interpreter to help." (BSFs client)

Healthcare professionals commented that some of the young parents they worked with lacked the confidence to pursue support for themselves. With long waiting times for the helpline it was not always possible for healthcare professionals to sit with parents while they made the call. If call waiting times cannot be reduced, one suggestion was to enable clients to nominate a proxy to make contact on their behalf.

"If they've [families] got an issue with it, Best Start won't speak to us unless we are with them, which is fine, but currently when you phone up, the waiting time's an hour-and-a-half, and none of us have that time in our diaries to be able to spend that sitting waiting on a phone. So the system around that is flawed. I don't know how it could be fixed. I don't know if they could contact in to say, 'I give my consent for my family nurse to speak on my behalf,' or that kind of a thing, but it's really, really tricky to try and contact them." (Healthcare professional)

Guidance

Overall clients felt that the guidance leaflet received with the BSFs card was useful and comprehensive. However, once clients started using the card, gaps in their knowledge were identified. To address these gaps, clients called for information in the guidance to cover a fuller list of retailers where the BSFs card can, and cannot, be used, and information on how to use the BSFs card online (clients were concerned they could not use it to pay for delivery). It is worth noting that some clients found the information overwhelming and would like the guidance in a more succint format that was easier to digest.

"A lot of shops didn't even recognise what it was. They do make it sound like you can use it in a lot more shops than you can use it. They could have gave you a better…a more concise list of shops that you could actually use it at or the shops that have already started to recognise it…I had difficulties at smaller shops, well smaller shops and bigger shops like newsagents, places that I would have used my milk token paper vouchers and been absolutely fine with, as soon as you showed a card they were like we don't recognise this. I can't remember if it was Tesco's or Aldi's but there was at least one big shop that refused to take it at all. So it wasn't just the little shops it was the big shops as well that wouldn't recognise it." (BSFs client)

As mentioned previously, there were clients who lacked confidence and skills in cooking healthy meals and may have held preconceived ideas that cooking healthily is expensive. To help families, it was suggested that healthy recipes that can be made on a budget could be provided alongside the guidance document.

"Maybe some ideas for a bunch of recipes along with it would maybe give people a bit of encouragement to go out and make something healthy on a budget. I don't think there's anything associated with it that would encourage people or show them what they could make on a budget with it. That might be worth a try. I was always looking online for recipes, or budget ways to make things go that little bit further. Maybe something like that could be included, even just a little pamphlet with a few recipes or things they could try." (BSFs client)

Improving speed of applications

Participants would like to see the length of time between completing an application and receiving the BSFs card shortened or at least the consistency of response time

improved. The reasons for delays varied, therefore healthcare professionals and clients proposed a range of ways that could help solve the issue.

Allowing applicants to submit evidence at the time of application was suggested as a way to reduce the time taken to receive a decision on an application. Waiting for Social Security Scotland to get in touch to request information and then finding and submitting evidence was time consuming, particulary if a client needed to request evidence from another organisation or service. Clarification in advance of the type of evidence that was required could also improve the speed of the application process. Furthermore, offering clients the option to receive notification of their application decision by email was another way that Social Security Scotland could reduce the time from application to decision notification.

"They're not asked to upload any documents for, like, proof of pregnancy. So that doesn't come until somebody's reviewed the application, which, to me, I just think could they not massively reduce the waiting times in decision-making if they just asked for those documents on application so that they're not then waiting 30 days to contact them to say, 'Could you upload documents so we can make a decision?' If they'd just done it with the application, they'd be able to then make a decision on that. I know they wouldn't have their MAT B1, but they could upload proof of address and Universal Credit and things like that." (Healthcare professional)

"It was a bit of a lengthy wait, to be fair, but because obviously, you're waiting for letters. If it was all done electronically, it would be a lot quicker and obviously, receive your card in the post, but yes. I think if it was all done email-wise, it probably would be a lot quicker and better for the environment, as well!" (BSFs client)

Clients who encountered delays due to receiving repeated requests for the same information, or as a result of another error, thought response times could be improved by resolving issues within the application system. It was unclear if errors occurred as a result of a technical or a staff issue, or both. Therefore, in addition to the technical system being checked for errors, clients thought it was important that staff reviewing applications and working on the helpline were well trained and informed on the Scottish and UK benefits system. A client reported significant delays to their application because a lack of understanding of the implementation of Universal Credit.

"I mentioned that bit of confusion with them asking for proof sort of multiple times. I think I guess from an administrative point of view just making sure that the process is as simple as possible and once people have done that…I mean these things happen but yeah I think just from the admin side of things maybe just trying to make sure it's smooth." (Healthcare professional)

Participants reported experiencing long wait times when calling the Social Security Scotland helpline and when waiting for responses to their application. At the time of application there were participants who were informed of delays due to a high number of applications. Employing more staff to work for the helpline and review applications during busy times was another way in which clients perceived the application response time could be improved. It was suggested that Social Security Scotland could also promote additional ways for clients to seek support, for example, via webchat, to relieve pressure on the helpline.

"I didn't know there was a webchat until I googled it myself. They need to tell you that because you're just stuck there and you're no' able to get through on the phone." (BSFs client)

Use of the BSFs card

Overall clients' experiences of using the BSFs card were positive. On the whole clients found the card easy to use and said it enabled them to buy healthy food for their family. However, when asked, BSFs clients, retailers and healthcare professionals gave their views of how BSFs could be further improved.

Scope of BSFs

While clients reported that BSFs allowed them to buy a wider range of healthy items than HSVs, they felt that expanding the range further would be beneficial. Items which are good sources of protein (e.g. meat, poultry), fibre (e.g. wholegrains) and other nutrients (e.g. fish) were seen to be essential for a healthy diet for their children. Clients also mentioned that catering for children with special dietary needs (allergies and intolerances) was expensive and they were uncertain whether BSFs could be used to purchase items such as milk alternatives (e.g. oat milk). There were retailers that supported this view, and proposed adding healthy ready meals to the list of items that could be bought using BSFs to support those who do not have cooking skills. However, others were concerned that expanding the list of foods would mean that BSFs would not cover the cost of the range of items. Furthermore, clients found it challenging having to split their shopping to pay for some items with the BSFs card and others with another source of payment. Expanding the range of healthy foods eligible under BSFs would simplify this process for families.

"Things like pasta or rice that would probably be a good thing to include and possibly bread as well, especially with rising food costs coming, there's been a lot of talk about that in the news this week certainly about rising food costs and how we measure that, so that would be probably a good thing for families to have access to." (Healthcare professional)

"One of the issues we have, especially with younger families, they don't cook themselves, so they're more inclined to buy ready meals…that might be an idea to add those things as well so that they can buy them straightaway and have something to feed their kids. However, in the first instance I do agree cooking yourself is the best way." (Retailer)

In addition to expanding the range of healthy foods, there were clients who would like to use BSFs to pay for a small number of essential non-food items such as nappies and toiletries for their children. These are items that clients buy regularly, are essential and have a significant cost. While non-food items do not come under the remit of BSFs, clients expressed a need for financial support to be able to afford these items.

Eligibility and payment

Clients were appreciative of the financial support offered by BSFs but they felt the impact would be even greater if eligibility for BSFs was extended until their child starts school. Participants shared that their personal circumstances meant that they would find it difficult to cover the costs of nutritious food after BSFs came to an end. For example, a single parent said that until their child went to school they could not pick up more work shifts because they could not afford to pay for childcare. For others, their caring responsibilities impacted on their capacity to work.

For some clients, changing the BSFs payment to a single value from when a child is born until a child turns 3 would be an improvement. Where BSFs had impacted on the amount and variety of healthy food families bought, the reduced payment was disruptive to healthy eating habits. Children became used to, for example, having fruit as a healthy snack and clients found it difficult to adjust their shopping once their payment dropped. Clients reported not being able to afford the amount and variety of fruit and vegetables they had bought with the higher payment which they felt impacted on their families' nutritional intake. Not only would a fixed rate of payment be less confusing for clients, there was a sense that it would be less disruptive to building healthy eating habits with their child.

"It would be brilliant if it would be possible to extend the payments up to the moment when the kids get into school, because then you know they still receive some veggies and fruits there, and they get the promotion of their daily portion of fruit and veggies. I know so many families which, to be honest, when they don't have access to extra support with the Healthy Start, they don't buy the fruits and veggies. The kids hardly get them in their diet. They're hardly drinking milk, and that's affecting them basically in their bodies later on, because you have to have strong bones, you have to get the vitamins to grow, so yes, it's very good to have support of that." (BSFs client)

Healthcare professionals agreed that implementing the higher payment for those aged 1 to 3 would encourage and enable children to eat more fruit and vegetables which would have a long-term impact on their health. They shared the concern that reducing the payment may result in fruit and vegetables being cut from children's diets because families could no longer afford to pay for it.

"I would have said instead of them to bring the amount from £37 a month after a year to £17, why they just divide that so have the £37 and the £17, divide it and just, instead of to be paid £37 a month, just make it the flat rate of let's say £30 or £28 for the first two years. You know what I mean?! It would have been better, yes, so that when you know you are getting a certain amount of credit, they should just pay it throughout the period of, the period that you are eligible to get that." (BSFs client)

Card management

On the whole clients found card management for BSFs straightforward. However, there were clients that faced barriers, for example, calling to check their balance because they did not speak English, had hearing impairments or struggled with phone calls. To address these barriers clients suggested introducing an app for card management. There was a view that an app could also be quicker and easier for some who are used to using apps for other card management. Receiving monthly texts or emails to inform clients when payments had been made would also make card administration and budgeting easier.

"The rigmarole of phoning up [to check balance]…I had to go and store the number in my phone and then you put your big long card number in, then you had to put your telephone code in, then you had to put another code in. So it would have just been easier if they had an app that I could quickly go in and it would go, sort of, ping! Here's your balance." (BSFs client)

"If they had an app, an app would be amazing because obviously I can check it that way, but obviously there's members of the deaf community that have got kids that can't check their balance like that, whereas an app's universal." (BSFs client)

There were also clients who reported experiencing challenges using contactless payment in stores. Instead they were always asked to enter their PIN. This caused further problems for clients if that had forgotten their PIN as they would need to call allpay to retrieve it or resort to using another card. It was thought that an app would go some way to reduce the effort of retrieving a PIN, though clients would like the option to use contactless payment too.