Lesley Riddoch: Under-fives care key to future ability

Holyrood must reinstate routine face-to-face contact between families and health visitors. Picture: Getty

John Major – of all people –has forced social mobility back into the headlines. After his outburst about the “shocking” dominance of a privately educated middle-class, David Cameron entered the fray, declaring: “I want to see a Britain where no matter where you come from, what god you worship, the colour of your skin, what community you belong to, you can get to the top in television, the judiciary, armed services, politics, newspapers.”

In one exchange, two Tory prime ministers managed to capture almost everything that’s wrong with Upstairs, Downstairs Britain. Cameron defines mobility as the ability of the best to reach the very top. Fairer societies are less concerned about the composition of the numerically tiny “top” than the numerically huge average. And Unicef’s child wellbeing index shows that countries which focus on average, not elite, performance reap huge rewards in social cohesion and health outcomes. In short, we micro-manage only the “top” at our peril.

John Major too has missed the mark. There are indeed rigid and predictable life outcomes for children according to social class, but private schools come late in the food chain of cause and effect. As the “Growing Up in Scotland and Scandinavia” conference in Edinburgh heard this week, all the evidence suggests the fundamentals of inequality are laid far earlier and can only usefully be tackled at that crucial pre-school stage.

According to a 2011 report by ScotCen Social Research: “By age five, children with a degree-educated parent are, on average, 18 months ahead in their vocabulary ability compared with children whose parents have no qualifications. They are also 13 months ahead in problem-solving abilities.”

And that huge, measurable disparity in verbal ability is often the easiest way to predict more serious but correlated difficulties like anxiety, depression, behavioural problems and attention deficit disorder which tend to emerge slightly later in a child’s life.

According to American childcare specialist Dr Jonathan Koch: “Child neglect in the first two years of life may be a more important precursor of childhood aggression than later neglect or physical abuse at any age.” And if addressed quickly, problems detected early can be tackled.

Research by the American child welfare expert David Olds demonstrates that 30 hours of support for the children of first time, low income mothers between mid-pregnancy and the age of two years can halve criminal behaviour, substance use, smoking, running away and high-risk sexual behaviour by the age of 15 – and improve the life chances and wellbeing of parents. His study also suggests nurses are most effective in this work and continuity of care is crucial.

So how are we doing in Scotland where outcomes for the most vulnerable children are notoriously and rigidly poor?

The Scottish Government is passing a Children and Young People Bill with a named (non-parental) professional responsible for each Scottish child and already has an enlightened policy – Getting It Right For Every Child. And yet they haven’t reversed a damaging change by the previous Scottish Executive which effectively axed regular checks by health visitors to detect early warning signs of problem behaviour.

Before 2003 health visitors used to make universal checks at six weeks, three months, eight months, 18 months, two years, 3.3 years and just before school. But then a review suggested the system was ineffective and expensive – favouring pushy over needy parents. Universal health checks were reduced to just one at six weeks which triaged children according to predicted vulnerability because of social factors like lone parent status, teenage pregnancy and economic adversity rather than actual vulnerability through measurable individual factors like speech or linguistic ability.

Since 2006 the majority of children in the “core” group get no further checks. Those in the “additional” group might get some further contact. And those in the “intensive” group are generally passed to child protection. So health checks for the majority of children have effectively stopped after six weeks. After protests, a 27-30 month language and behaviour check was reintroduced. That’s still not good enough.

Some 60,000 children in Scotland are living with problem drug or alcohol use in the family, yet only 2,000 are subject to child protection procedures. What happens to the rest?

Work done by Dr Phil Wilson, PProfessor of Primary Care at Aberdeen University, suggests most kids with speech and behavioural problems are actually in the “no further checks needed” core category because, “no more than half of vulnerable families can be reliably identified by [six weeks] even in the context of an intensive home visiting programme.”

Health visitors aren’t psychic. They can’t easily predict which child is most at risk. They find out through proactive contact and well-crafted linguistic tests. Health visitors gain access to the home (unlike teachers) and are not threatening to families in crisis (unlike social workers). This creates a “routine” relationship with parents. Without such precious trust, families don’t come forward when problems actually arise.

So there was near-universal professional backing for the Children’s Bill suggestion that health visitors should be the “named persons” for children in the 0-5 age group. But how can health visitors assume that weighty responsibility when universal heath checks are woefully inadequate and staff numbers are crashing?

The Royal College of Nursing say half the health visiting workforce is 50 or over with few new entrants, and Unite observes England aims to recruit 4,200 more health visitors by 2015 while Scotland will not commit to raise workforce numbers by the necessary 20 per cent.

Most European countries have six to ten development checks between birth and school – we effectively have only two. Elsewhere, parents who don’t come forward for checks are pursued by a health visitor or social worker because children have the right to these developmental checks. In Scotland it’s the parents’ right to decide.

Put simply, the Scottish Government must reinstate routine face-to-face contacts between parents and health visitors and recruit now to meet this urgent need. According to John Carnochan, who founded the Violence Reduction Unit in Strathclyde Police: “It would be better to invest in extra health visitors even at the expense of other public services, including police.”

In these straitened times it’s worth remembering two things: Crises services cost far more than preventative services; and social mobility is a crisis over which we can exercise control – not just wring our hands.