Skip navigation

No child left behind


23 Apr 2015

The imminent transfer of the 0-5 year elements of the Healthy Child Programme to Local Authorities later this year presents a huge opportunity to improve the health and well-being of children and families.

The government recently announced it had met its target to increase the number of health visitors by 4,200 by the end of this Parliament. This resource represents a vital investment in, and increase in capacity to deliver, early intervention and prevention.

One of health visiting’s strengths is that it is a universally accessible service, is non-stigmatising and able to cross the thresholds of most homes. The service is the backbone of the core universal offer outlined in the Healthy Child Programme 0 to 4 years old. It is this offer that allows health visitors to identify vulnerability and additional need at key points in a child’s early life. This enables more effective targeting of families who require additional early help. Without this universal component, it becomes so much harder to effectively target early help and so many opportunities to intervene earlier will be lost.

So, whilst I would be the first to celebrate this investment in such a critical service, as with all opportunities, there are challenges too which are timely to consider at this critical moment in time.

Firstly, what happens now? What difference will this additional resource make? And, perhaps most crucial of all, how do we make sure the outcomes for 0 to 5 years olds improve?

The challenge now is for commissioners, providers and practitioners to ensure that there is maximum impact as a result of this additional resource.

Whilst there are some grounds for optimism, some recent history is less reassuring. In the past, some of our practice has been guilty of either overtly or covertly reinforcing inequalities and in doing so perpetuating the inverse care law. And in so doing, we are (whether intentionally or otherwise) socially constructing and reinforcing inequalities. We do not always organise or design services in ways that involve clients’ views from the outset, or that enable them to service those most in need. As a consequence, people don’t get the help they need or get side lined.

These socially constructed inequalities manifest themselves in a number of ways, through service specifications, policy and practice.


In my view, there has been too much focus on transactional analysis and process in health visiting and other children’s services and too little emphasis on transforming services and commissioning for meaningful outcomes.

Service specifications have focused on measuring activity, e.g. the percentage of children who attend for their 9–12 month check. Whilst this matters, on its own, it is insufficient as a measure of whether services are doing their best to narrow the gap in the extent to which children from different socio economic groups achieve school readiness. Commissioners need to think beyond how many children have been assessed at 9–12 months, and also consider what happened as a result of those assessments: How many children did we identify with additional need? More importantly, if the uptake met an agreed target of 90%, what happened to the 10% who didn’t attend and what are providers doing to ensure that these children are followed up appropriately?

The challenge to commissioners is to see beyond the transactional and mandated elements of the service specification to something that is much broader in ambition and scope: commissioning early years integrated models that deliver clear outcomes including for those who need extra help the most.

Joint commissioning of early years services can support more integrated delivery through identifying and commissioning against agreed shared priorities and outcomes.

There are many local authorities and clinical commissioning groups who are attracted to the notion of doing this efficiently and effectively for outcomes and have moved to or, are moving to integrated commissioning hubs for children (and adults), thus enabling an alignment of commissioning across the life course of the child and young person that would cover universal services, such as health visiting and school nursing, as well as more targeted and specialist services, such as Troubled Families, Family Nurse Partnership (FNP), drugs, alcohol and mental health, and so on.


There are many public sector organisations that use ‘do not attend’ (DNA) policies (including GPs, hospitals, and community services). They are used to justify efficiencies and the effective management of waiting times and lists. In practice, they can become an insidious vehicle allowing public services to exclude many vulnerable families, particularly those who may lead chaotic lifestyles, or who might be new to the country and/or do not read or speak good English. (What is the point in sending people reminder letters if they can’t read them?!).

We need more sophisticated ways of tracking and following up families, that involves improved sharing of information and communication.


At practitioner level these problems manifests in the ‘report and record’ culture: for example, phoning a client and leaving messages, or visiting a home and leaving a note each time I visit to say ‘I have called and to get in touch’ or ‘If I don’t hear from you I will assume you no longer require my service’. If this happens three times with no response, I can justify my attempts to engage by duly reporting what I did and recording it in my practitioner notes.

The consequences of these types of actions are that far too many children slip through the net. Many of them are the very children who we need to be seeing and with whose parents we need to be working much earlier – who, if left alone, will turn up at school on their first day with a nappy on, unable to hold a pen and with a dummy in their mouth.

This should not sit comfortably with any of us, but it is happening up and down the country.

What needs to change?

It has been my privilege over many years to have worked with and be inspired by a number of health visitors and early year’s practitioners who are the exception to these patterns. These teams and individuals had what I call ‘stickability’. They knew their most vulnerable clients, refused to give up on them, and worked hard at building a relationship – and eventually gaining their trust.

It means being resilient, sometimes in the face of outright hostility. It also means a shift in emphasis away from the deficits model of needs – of wanting to fix clients’ problems for them, because we know what is best for them – and towards one that starts with the client’s agenda, not ours, is strength-based and which promotes self-efficacy. (FNP is an excellent example of this approach in practice.)

In practice this translates to a commitment to never giving up on any family. It also means a change in culture, values and behaviour.

In order for practitioners to work in this way, organisations need to ensure staff are well supported and empowered through regular good-quality supervision, provided with opportunities to update their knowledge and skills, and a culture that commits to never leaving any child behind.

The Marmot vision of giving every child the best start in life still holds true, but what we also need is a commitment by commissioners, providers and practitioners not to leave one single child behind.

I see the additional investment as a fantastic opportunity to transform the lives of children and families. So, from a commissioning perspective I am going to commit to doing everything I can in my role to relentlessly pursue better outcomes for children, challenging certain behaviours and practices to ensure that no child gets left behind. Will you?