Summary of Community Planning Partnerships' (CPPs) Early Years Change Fund returns (2012-2015)

Health/NHS funding

The Health/ NHS Early Years Change Fund monies were allocated for specific programmes:

• Child Healthy Weight Interventions
• Childsmile
• Healthy Start
• Infant Nutrition and Maternity Services
• Family Nurse Partnership

While funding amounts for some of these were agreed and set for the lifetime of the Change Fund, for others there was some level of flexibility. The following table shows the planned investment for the health lines of the change fund, the actual investment as recorded by the Scottish Government and the spend reported by CPPs. As in the previous section, the figures presented in the reported spend for 2012-2015 column in the table above are taken from figures supplied in Annex A in the 2014/15 returns. Again, these figures are approximate as some CPPs were unable to provide precise figures. One particular issue related to some areas where programmes are being managed on an NHS area basis. This makes it challenging for CPPs to identify the proportion relevant to their own particular area.

Specific Programme allocations: Health/ NHS Early Years Change Fund

	Planned investment for 2012-2015	Actual investment for 2012-2015	Spend reported by CPPs in returns for 2012-2015
Child Healthy Weight Interventions (Effective Prevention Bundle)	£6 million	£5,915,000	£6,236,820
Childsmile (Dental Services Bundle)	£35,625 million	£34,996,000	£31,504,328
Healthy Start	£39,323 million*	£30,785,000	£540,556*
Infant Nutrition and Maternity Services	£22,101 million	£19,360,000	£14,107,568
Family Nurse Partnership	£13,850 million	£14,637,000	£15,357,789
Total	£116,899 million**	£108,945,000**	£72,228,006

*Healthy Start is a UK-wide demand led scheme that is administered by the Department of Health. The Scottish Government reimburse the Department of Health for voucher claims in Scotland. Planned investment of £39.3m was based on an estimate of uptake. £30.8m was the spend for actual uptake. The £540k reported by CPPs is therefore spend on additional work associated with improving uptake.

** Annex 1 contains further detail on the planned spend and actual investment reported here.

** GIRFEC: an additional £3,252,000 was provided to:

• £2 million investment allocated to NHS Scotland for Health Visitors to support GIRFEC and the Early Years agenda.
• £1 million investment to support prevention and early intervention in the early years driven through a range of approaches including: the early years collaborative; support for family centres; family support and parenting; early learning and childcare; and play. All designed to build on measures which deliver positive outcomes for children and families.
• £252,000 to supplement the investment allocated to NHS Scotland to support the delivery of the National Delivery Plan for Children and Young People's Specialist Services.

Child Healthy Weight Interventions

In years 1 and 2 of the Change Fund, many of the CPP returns for Child Healthy Weight Interventions focussed on achieving the Scottish Government´s HEAT (Health Efficiency Access and Treatment) target of achieving agreed completion rates for child healthy weight intervention programmes in the years 2011-14. Indeed, in the year 2 returns, nine of the CPPs reported that the HEAT target for their NHS area had been met or exceeded.

One example of NHS area interventions being delivered across CPPs was NHS Grampian Grow Well Choices Programme. Aberdeen, Aberdeenshire and Moray reported that training for this school-based programme has been delivered both in programme delivery and in other aspects of health including nutrition and health behaviour. Other work around this programme has included development of the Grow Well Choices Early Years Programme and toolkits. CPPs reported an increase in children's understanding of healthy weight.

Other NHS-area programmes included: Fun Fit Tayside, a school and community-based programme; NHS Ayrshire & Arran's two child healthy weight programmes JumpStart evening programme and JumpStart Choices; NHS Lothian's school-based Healthy Families Healthy Children and Health 4 U; NHS Greater Glasgow and Clyde's ACES (Active Children Eating Smart); and Max in the Middle for primary 6 and 7 children in NHS Forth Valley.

There was no HEAT target for 2014/15 and in year 3 returns, CPPs reported more on their own targets and interventions or reported on the ongoing successes of the existing programmes mentioned above.

Other work around child healthy weight has involved:

• School and nursery based interventions as well as one to one interventions; and ongoing joint delivery with education and health partners.
• Record keeping to show numbers referred to and accessing interventions, both one to one and as part of school or other programmes (including information such as ages and changes to BMI).
• Translation services enabling engagement with non-English speaking parents.
• Community-based interventions, for example Three community weight management groups have been delivered by Mytime (Angus).
• Workforce development and staffing.
• Awareness raising.
• Supporting healthy weight interventions with children known to children's specialist services.
• Health and wellbeing programmes in early learning and childcare settings.
• Whole-family / family health lifestyle interventions.
• Work has been carried out in mums and toddler settings to raise the issue of portion size, healthy snacks and hidden sugars in particular (Orkney).
• Over the three year period the Early Years Change Fund has supported us to maintain and develop a range of statutory and third sector services to deliver supports to our youngest children in targeted areas of need (Dumfries and Galloway).

Case Study: Clackmannanshire, Falkirk and Stirling

The Max in the Middle and Max in the Class Programmes were delivered to 80 classes per year (46 Max in the Middle and 34 Max in the Class) through the years 2012 to 2015. The breakdown is 50% Falkirk, 23% Clackmannanshire and 27% Stirling. Over 40% of interventions have been with schools from areas with a high index of deprivation.

Impact has been evaluated on three main levels: impact on the children themselves, impact on learning and teaching, and impact within the home.
Max in the Middle summary findings from the most recent report by Louise Hammill 2015.

On child - impact on food/drink/activity and sleep e.g.

• 'I have started to eat my five a day'
  
• 'I have started to drink more water'
  
• 'I never miss breakfast now'
  
• 'I am more confident around children my own age'
  
• 'I have started to go to a gymnastics club and I love it'
  
• 'I have changed what time I go to bed so I can get my 10hrs sleep
  

On teaching and learning:

• Greater class cohesion and confidence
  
• Pupils are more likely to try new foods and activities
  
• Springboard for new learning a teaching linked to CfE
  
• Highlight of a school career
  
• Effective staff development of over 60 teachers and 120 school volunteers
  

At home - Impact on eating, cooking, play and interests e.g.

• 'Conscious about having their five a day'
  
• 'Started having breakfast before school'
  
• 'Wanted to cook and make at home what they had learnt on 'Tasty Tuesdays'
  
• 'It was easier to get him to go outside and play instead of constantly being in the house'
  
• 'More interested in walking the dog on a daily basis'
  
• 'Child keen to join new club which they had previously not been interested in'

Childsmile

Childsmile is a national programme to improve the oral health of children in Scotland and reduce inequalities in dental health and access to dental services.

As was the case in relation to Child Healthy Weight, Childsmile is also key to a Scottish Government´s HEAT target: 'At least 60% of 3 and 4 year old children in each Scottish Index of Multiple Deprivation ( SIMD) quintile to receive at least two applications of fluoride varnish per year by March 2014'.

The planned investment towards Childsmile was to implement the programme in all NHS Boards and to fund the costs associated with training of staff and provision of toothbrushes and toothpaste for the toothbrushing programme. Many of the CPPs reported progress in relation to this target while others included information on delivery of the Childsmile programme elements:

• Childsmile Core
• Childsmile Practice
• Childsmile Nursery
• Childsmile School

Across the 3 years of the Change Fund returns, CPPs reported on the delivery of Childsmile including: the numbers participating; the number of children registered with dental practices; the percentage of children now free from dental decay; decreases in number of missing or filled teeth; and staffing and monitoring procedures.

Examples of outcomes include:

East Dunbartonshire: Childsmile Practice is delivered in all 49 early years establishments. Training delivered annually to all new and identified nursery staff champions. Dental Health Support Workers have been recruited and trained to work with families and Early Years staff to improve oral health and increase dental registrations. Health Informatics Centre ( HIC) monitoring systems established to determine tooth brushing uptake in early years establishments.

Inverclyde: 100% Nurseries & P1/2 have a tooth brushing programme in place.

Orkney: The annual funding allocation supports the delivery of the Childsmile programme in Orkney and funds staffing including co-ordinator, Extended duties dental nurses, Oral Health support worker, and school based toothbrushing supervisors supporting the Childsmile Core Toothbrushing Programmes. The benefits of the Childsmile programme in improving oral health are clear. National Dental Inspection Programme ( NDIP) figures show that oral health has continued to show an improving trend over the past few years. Most recent information (2014) shows that 72% of P1 show no obvious signs of tooth decay (Scottish average 68%). The Childsmile Nursery and Schools Programme offers fluoride varnish for all children from nursery to all P5, and to P7 in smaller schools. The HEAT target of 60% of all 3-4 years old having at least 2 fluoride varnish applications across all SIMD quintiles was met at end March 2014 and continues to be maintained. Local data indicated this as at least 71% at end March 2015.

Healthy Start

The Healthy Start Scheme is a UK-wide scheme providing vouchers for food and vitamins for low income families and pregnant women under 18, up to the child's fourth birthday. The Healthy Start food vouchers can be used to purchase fresh and frozen fruit, vegetables and milk (including infant formula milk) as well as being exchanged for Healthy Start Vitamins.

Healthy Start is administered by the UK Department of Health and the Scottish Government reimburses them directly for Scottish voucher claims. CPPs are reporting on additional work associated with improving uptake and not on the voucher spend, which is why the reported spend is significantly lower than the planned investment.

CPPs included a variety of activities in their returns, including work taking place through the EYC to maintain and increase the uptake of Healthy Start; several CPPs reported increased levels of uptake. Examples included:

• Promotion and information provision, to increase the uptake of vouchers.
• Monitoring awareness of scheme amongst parents and professionals and amongst shops. For example: Survey of local access e.g. shops willing to accept vouchers / experience of process (Orkney).
• Community Pharmacy vitamin schemes to increase the uptake of vitamins.
• Discussion and information on scheme at first visit (booking) with maternity services. Provision of maternal vitamins at antenatal booking.
• Provision of vitamins to all pregnant women.

Case study: Fife approach to Health Start Vitamins

The Fife approach to Healthy Start Vitamins, which is achieving the highest uptake rates in Scotland. A 'Test of Change' between NHS Health Improvement and Fife Council Education and Children's Services, which is a pioneer site for the national collaborative has seen a 50% increase in the uptake of vitamins through distribution in nurseries (for more details see "Cameo 3: Early Years Collaborative"). Practitioners across a range of services ( e.g. acute orthopaedics, dietetics) have been testing how they can build on their contacts to promote uptake of HSVs. Fife's approach has been singled out as being an exemplar for Scotland (communication to 12th June 2015 NHS Boards Health Start boards on 12th June 2015).

Infant Nutrition and Maternity Services

The Early Years Change Fund included allocation of funds to support the implementation of Improving Maternal and Infant Nutrition: A Framework for Action which aims to improve the nutrition of pregnant women, babies and young children.

Main activities within CPP areas included supporting the UNICEF Baby Friendly Initiative including training on and promotion of UNICEF standards and Baby Friendly accreditation or reaccreditation.

Many areas have developed breastfeeding peer support groups and/or were promoting 'Welcome to Breastfeed Here' Schemes. Funding also contributed to monitoring and reporting on breast feeding rates.

There was a focus on healthy eating initiatives and improving eating habits.

CPPs reported training parents in food skills and providing cooking skills programmes and healthy weaning initiatives. There was also nutrition and food skills training for early years staff.

Several CPPs funded additional staff or staff training including infant feed coordinators and infant feeding advisers.

Weight management for pregnant women and babies featured in several returns.

One to one interventions were delivered where identified and required.

Funding was used to provide resources such as breast pumps, learning materials and publicity materials.

Some CPPs delivered specialist services such as: donor breast milk banks; pre-conceptual care service to support obese women; support for programmes specifically for vulnerable young parents; and the following example from North Lanarkshire: Cow's Milk Allergy. Development of first line management of suspected cow's milk allergy for health visitors and supportive parents leaflet. This ensured appropriate early intervention whilst preventing inappropriate referrals to specialist dietetic services.

Other support included a programme aimed at increasing activity: Maternity staff have been trained to lead buggy walks for families with young children to increase activity and support healthy weight (Orkney).

Family Nurse Partnership

This is an intensive, preventative home visiting programme delivered to young, first time mothers which is currently being delivered in ten NHS Board areas. The programme aims to improve maternal health and birth outcomes; to improve child health and development; and to improve economic self-sufficiency of the family. The programme is delivered by specially trained nurses from early pregnancy until the child reaches two.

Most CPPs included information on Family Nurse Partnership ( FNP) spend in their returns, although in a small number of instances CPPs reported no spend, for example, Dumfries and Galloway commented: NHS D&G does not have sufficient numbers of the young women this initiative is aimed at to implement FNP. Similarly, FNP is not offered in Orkney; however they reported that they are using the shared learning from FNP.

In several other cases CPPs reported that the programme has not yet been implemented or that implementation is in the early stages including Aberdeen, Aberdeenshire and Moray where: The FNP programme in Grampian commenced actively recruiting first time pregnant teenage clients on 18th May 2015. The first four FNP "babies" were born in August 2015.

Returns from those CPPs with established FNPs showed developing services with teams being expanded to ensure the programme can be offered to all eligible young women.

CPPs report good uptake and engagement. For example, in East Dunbartonshire: During the first phase of the programme in East Dunbartonshire 13 young first time mothers participated in the programme and are receiving intensive support to develop their confidence in parenting and improve their health outcomes.

Other returns include the following examples:

Engaging service users in developing the service: We are currently undergoing client events, with 2 events planned for December 2015. This will include the opportunity for clients to give feedback in a safe environment. A report will be collated and an action plan developed in response to the findings. (Clackmannanshire, Falkirk, Stirling: NHS Forth Valley)

Co-ordinating service provision: In West Lothian the FNP ( NHS Lothian) and Young Mothers' Service (West Lothian Council) are designed to work together to provide intensive key working support to young and vulnerable mothers up to age 25. West Lothian now ensures that 100% of its pregnant and parenting women under the age of 20 are offered an intensive keyworking service to support families at their earliest stage.

Support for mothers in deprived areas: Local health intelligence suggests that around 80% of our caseload have multiple deprivation, with many families residing in SIMD areas 1 and 2. (Clackmannanshire, Falkirk, Stirling: NHS Forth Valley)

Returns indicate that FNPs are contributing to a range of outcomes including:

• Reducing smoking in pregnancy
• Improvements in breast feeding and immunisation rates
• Child protection
• Reducing A & E attendances
• Parenting skills
• Reducing repeat teenage pregnancies
• Positive impacts for young people not in education or employment.
• Better engagement of fathers.

Case study: NHS Lothian FNP (From Edinburgh CPP return)

Currently, service expansion has enabled service provision in Edinburgh City, West Lothian and Midlothian geographical areas of NHS Lothian. Annual review data and outcomes submitted to National FNP unit on 16/11/15.
There is strong 'buy-in' at a senior and multi-agency level. The planned process of expansion has been carefully paced with recognition of the need to maintain the quality of programme delivery. The aim toward expansion of the service is on a sustained basis across NHS Lothian, with a full concurrent service delivery model in place by 2016.

NHS Lothian were formally recognised in March 2015 when it was announced by the First Minister of Scotland, Nicola Sturgeon that Edinburgh had become the first city in the world who had achieved delivery of a concurrent service to all eligible clients. This was achieved against the backdrop of progressing with our vision of a fully expanded service across NHS Lothian with a concurrent service delivered in West Lothian from March 2013, and within Midlothian from April 2014. Our final expansion will involve introduction of a service in East Lothian which we are progressing towards by August 2016.

Health/ NHS change fund related activity: additional funding

CPPs were asked to report on 'Health/ NHS change fund related activity over and above the original NHS commitment i.e. examples could include 27 - 30 month review, Health visitors, Speech and language therapy'. While not all CPPs reported additional Health/ NHS change fund related activity in every year of returns, all did report on some activity in at least one of the years.

One main area of additional spend related to the introduction of the 27-30 month review. For example, Edinburgh reported: Between April 2013 to March 2014 the target of 80% of all eligible children having a 27 month review was exceeded. Achievement was 87.3%. Almost 80% of children reviewed are reaching their developmental milestones. This compares well with the EYC stretch aim of 85% by the end of 2016.

There was also a focus on developing improvement methodology and testing changes. This included general mentions such as the Western Isles: A wide range of staff are fully engaged in the EYC with several Plan-Do-Study-Acts ( PDSAs) in place. There were also specific examples, including South Ayrshire: Specialist Midwife Substance Misuse (Alcohol), SMSM(A), has commenced a PDSA examining more in depth support with women who continue to drink alcohol when pregnant. There is a referral pathway in place formulated by the SMSM(A) which refers women to appropriate addiction services.

CPPs reported additional funding on a range of other activities including:

• Angus reported additional funding from NHS Tayside for Family Nurse Partnership development.
• Refreshed Midwifery Framework: Organisational development support and IT provision e.g. for staff engaged in Tayside Maternity pathway (Dundee).
• Development and embedding partnership and multi-agency working, particularly to deliver parenting programmes.
• The provision of parenting programmes, for example: Parents As First Teachers ( PAFT) 1-2-1 parenting support from pre-birth to 3 for vulnerable first time mums (Dumfries and Galloway).
• Staffing and staff training and support, including: Investment in skill mix of health visitors - Support in place to further develop areas of work delivered by children and families health staff (East Renfrewshire).
• Health initiatives, including: Since 2008/9 NHS Lothian has been working with Mid Lothian Council and leisure trusts to provide a balanced programme of prevention and treatment. The prevention programmes (Healthy Families Healthy Children and Health 4 U are run in primary and secondary schools respectively). The treatment options for very obese children and young people include the Get Going programme, delivered by local authority/ leisure trust colleagues, and a specialist dietetics clinic (Midlothian).
• Provision of a number of specific services:
  • Oral health.
  • Nutrition.
  • Speech and language development.
  • CEL 16 (Health Assessment for LAC).
  • Parental engagement.
  • Support for parents with learning disabilities.
  • Support for children with disabilities.
  • Vulnerable pregnancy support.
  • Support for breastfeeding.
• Provision of resources, including web-based resources.
• IT developments and electronic record keeping.