Cofnod y Trafodion
The Record of Proceedings

Y Pwyllgor Plant, Pobl Ifanc ac Addysg

The Children, Young People and Education Committee

26/10/2017

Agenda’r Cyfarfod
Meeting Agenda

Trawsgrifiadau’r Pwyllgor
Committee Transcripts

Cynnwys
Contents

5        Cyflwyniad, Ymddiheuriadau, Dirprwyon a Datgan Buddiannau      

Introductions, Apologies, Substitutions and Declarations of Interest

5        Ymchwiliad i Dechrau’n Deg: Allgymorth—Sesiwn Dystiolaeth 1

Inquiry into Flying Start: Outreach—Evidence Session 1

34      Ymchwiliad i Dechrau’n Deg: Allgymorth—Sesiwn Dystiolaeth 2

Inquiry into Flying Start: Outreach—Evidence Session 2

55      Ymchwiliad i Dechrau’n Deg: Allgymorth—Sesiwn Dystiolaeth 3

Inquiry into Flying Start: Outreach—Evidence Session 3

85      Papurau i’w Nodi

Papers to Note

85      Cynnig o dan Reol Sefydlog 17.42(ix) i Benderfynu Gwahardd y Cyhoedd o Weddill y Cyfarfod

Motion under Standing Order 17.42(ix) to Resolve to Exclude the Public from the Remainder of the Meeting

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle y mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Aelodau’r pwyllgor yn bresennol Committee members in attendance
Michelle Brown Bywgraffiad|Biography	UKIP Cymru UKIP Wales
Hefin David Bywgraffiad|Biography	Llafur Labour
John Griffiths Bywgraffiad|Biography	Llafur Labour
Llyr Gruffydd Bywgraffiad|Biography	Plaid Cymru The Party of Wales
Darren Millar Bywgraffiad|Biography	Ceidwadwyr Cymreig Welsh Conservatives
Lynne Neagle Bywgraffiad|Biography	Llafur (Cadeirydd y Pwyllgor) Labour (Committee Chair)
Mark Reckless Bywgraffiad|Biography	Aelod Grŵp y Ceidwadwyr Cymreig Member of Welsh Conservative Group
Eraill yn bresennol Others in attendance
Alison Cowell	Cyfarwyddwr Clinigol, Gwasanaethau Cymunedol Plant, Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr Clinical Director, Children’s Community Services, Betsi Cadwaladr University Local Health Board
Alison Davies	Cyfarwyddwr Cyswllt Arfer Proffesiynol, Coleg Brenhinol y Nyrsys Cymru Associate Director Professional Practice, the Royal College of Nursing Wales
Sandra Dredge	Uwch Nyrs ar gyfer Iechyd Plant Cymunedol, Bwrdd Iechyd Lleol Prifysgol Caerdydd a'r Fro ac yn cynrychioli Fforwm Penaethiaid Gwasanaethau Ymwelwyr Iechyd a Nyrsio Ysgolion Cymru Senior Nurse for Community Child Health, Cardiff and Vale University Local Health Board, and representing the Welsh Heads of Health Visiting and School Nursing Forum
Hannah Fleck	Rheolwr Gwasanaeth Llesiant y Gymuned, Cyngor Bwrdeistref Sirol Conwy Service Manager Community Wellbeing, Conwy County Borough Council
Helen James	Pennaeth Nyrsio Iechyd y Cyhoedd i Blant a Gwasanaethau Paediatreg, Bwrdd Iechyd Lleol Addysgu Powys Head of Children’s Public Health Nursing and Paediatric Services, Powys Teaching Local Health Board
Lesley Lewis	Pennaeth Gofal Sylfaenol a Lleoliadau Nyrsio, Bwrdd Iechyd Lleol Cwm Taf Head of Nursing Primary Care and Localities, Cwm Taf Local Health Board
Claire Lister	Pennaeth Gwasanaethau Integredig Oedolion a Chymunedol, Cyngor Bwrdeistref Sirol Conwy Head of Integrated Adult and Community Services, Conwy County Borough Council
Amy McNaughton	Ymgynghorydd Iechyd y Cyhoedd, Iechyd Cyhoeddus Cymru Consultant in Public Health, Public Health Wales
Nicola Milligan	Aelod Bwrdd Cymru Coleg Brenhinol y Nyrsys, Ymwelydd Iechyd Arbenigol, Bwrdd Iechyd Lleol Cwm Taf Royal College of Nursing Welsh Board Member, Specialist Health Visitor, Cwm Taf Local Health Board
Sarah Mutch	Rheolwr Dechrau'n Deg, Cyngor Bwrdeistref Sirol Caerffili, a Chadeirydd Rhwydwaith Rheolwyr Dechrau'n Deg Cymru gyfan Flying Start Manager, Caerphilly County Borough Council, and Chair of all-Wales Flying Start Managers’ network
Sarah Ostler	Cydlynydd Dechrau'n Deg, Cyngor Bwrdeistref Sirol Merthyr Tudful Flying Start Co-ordinator, Merthyr Tydfil County Borough Council
Liz Wilson	Rheolwr Iechyd a Gofal Cymdeithasol Dechrau'n Deg, Cyngor Sir Caerfyrddin Flying Start Health and Social Care Manager, Carmarthenshire County Council
Swyddogion Cynulliad Cenedlaethol Cymru yn bresennol National Assembly for Wales officials in attendance
Sarah Bartlett	Dirprwy Glerc Deputy Clerk
Llinos Madeley	Clerc Clerk
Siân Thomas	Y Gwasanaeth Ymchwil Research Service

Dechreuodd y cyfarfod am 09:32.

The meeting began at 09:32.

Cyflwyniad, Ymddiheuriadau, Dirprwyon a Datgan Buddiannau

Introductions, Apologies, Substitutions and Declarations of Interest

[1] Lynne Neagle: Good morning, everyone. Can I welcome you all to the Children, Young People and Education Committee? We’ve received apologies for absence from Julie Morgan. Can I ask whether there are any declarations of interest? No. Okay.

Ymchwiliad i Dechrau’n Deg: Allgymorth—Sesiwn Dystiolaeth 1
Inquiry into Flying Start: Outreach—Evidence Session 1

[2] Lynne Neagle: We’ll move on then to item 2 this morning, which is our first evidence session into the outreach element of Flying Start. Our first session is a panel of witnesses from the Welsh NHS Confederation and Public Health Wales. I’m very pleased to welcome Lesley Lewis, who is head of nursing, primary care and localities at Cwm Taf university health board, Alison Cowell, who is assistant area director central from children’s services at Betsi Cadwaladr university health board, Helen James, head of children’s public health nursing and paediatric services at Powys teaching health board, and Amy McNaughton, consultant in public health at Public Health Wales. Thank you all very much for attending this morning. We’re very pleased to have you here. If you’re happy, we’ll go straight into questions. The first question is from Hefin David.

[3] Hefin David: From Public Health Wales and the health boards’ point of view, what is your involvement in the programme? And can you also concentrate on the role of outreach beyond the lower super-output areas, and how that can be supported and extended?

[4] Lynne Neagle: Who would like to start?

[5] Ms Cowell: Do you want me to kick off in terms of a health board perspective? Flying Start is obviously part of our service. So, the health board manages the health leads and the health delivery elements of Flying Start. So, it’s integrated as part of our managerial structure. In terms of outreach across, we have six local authorities in north Wales. So, there are some variances in terms of how that outreach pans out, but, in the main, it is about looking at the peripheral area of the core Flying Start area and then determining those families that actually have additional needs, that perhaps have already been in Flying Start at one point and have moved out, and it’s about having that continuity of care. So, we’ve kind of used it flexibly, but we’re talking very small numbers in terms of the outreach.

[6] Hefin David: Right. So, outreach is not extended enough.

[7] Ms Cowell: It’s very small. So, in some counties, you’re talking five children that will be in receipt of the outreach elements.

[8] Hefin David: So, would you say, therefore, that there’s a significant number, a small number of people, who, were they living in a lower super-output area, would have this access, but, because they don’t, they aren’t getting access to it? What are the kinds of numbers you’re talking about?

[9] Ms Cowell: Well, yours is quite small as well, in Powys, isn’t it, Helen? So, certainly in north Wales—you go to Wrexham and there are 40 children who are in the outreach area, and then you come across to—I’ve got Conwy, Denbighshire. We’re talking threes and fives, and that’s because of the cap and how that works. 

[10] Hefin David: Okay. What can be done to improve access to it?

[11] Ms Cowell: In terms of the outreach, that’s the financial cap, so that’s prescribed to us.

[12] Hefin David: Okay—

[13] Ms James: I think, within the guidance, it stated it should be 2.5 per cent of the uplift, which is a really, really very small amount, and I think, within Powys, it amounts to about two children. But we are trying to be more flexible in how we manage that, and we have aligned ours with our team around the family process, so that we’re looking at need and where there is identified need, and, like Alison said, if families move out of the Flying Start area and would then continue with the Flying Start scheme, we are really trying to prioritise those children and provide the service.

[14] Lynne Neagle: Lesley, did you want to come in for Cwm Taf?

[15] Ms Lewis: Yes, please. From the point of view, I think, of local authorities, they apply them differently, the outreach criteria, and I think for health boards across, then that is a challenge. I think it’s a challenge for our populations. I know that public health have provided some evidence around the population need, and, obviously, within Cwm Taf, we have high areas of deprivation, and the numbers are small, as my colleagues have said. So, to give you an example of that, within RCT, which is Rhondda Cynon Taf, we have 20 places for outreach, and that is for developmental delay, in the main, to assist children to go in then to nursery education. Now, our need is greater than that, so it’s about managing that need and managing that expectation. I think, for me, it’s about ensuring that we don’t add to inequality, and that is key. So, it’s something we need to look at. I think we have demonstrated that outreach does work and does help the families it’s supposed to help, but I do think there is an issue around resource with outreach.

[16] Hefin David: And, with that limited resource, some local authorities are better at utilising limited resource than others.

[17] Ms Lewis: I’m not saying they’re better.

[18] Hefin David: Do it differently—

[19] Ms Lewis: I think they’ve got different challenges, and I think they work together, with health, to try and resolve that. So I’m not saying some are better.

[20] Hefin David: So, there’s no model of best practice, then.

[21] Ms Lewis: I think most are using a similar system, really, around developmental delay to assist children to go into schools. So, for Merthyr, for example, which is a smaller local authority, we do usually support 16 children. So, it is about resource.

[22] Hefin David: So, what about moving to a regional approach, rather than a local authority-based approach? Would that make any difference to outreach?

[23] Ms Lewis: A regional approach to outreach.

[24] Hefin David: Yes. So, if you imagine—. The Cabinet Secretary for local government is encouraging regional working. Would this regional approach, which is the trend, at the moment, enable better outreach or would that cause a less likely outcome?

[25] Ms Lewis: I think you’d have to look at the models. I think you’d have to look at the benefits and risks of the model. My concern around going to a regional approach for outreach is, from a funding perspective, that might be quite helpful, but we mustn’t lose sight of the fact that we want to build communities, and we want communities to be part of that. So, again, if you look at adverse childhood experiences and looking at how a community actually develops children in their first 1,000 days, we mustn’t lose sight of that from a regional basis.

[26] Hefin David: So, you could lose that.

[27] Ms Lewis: Well, I’m just saying you could mitigate that, but that would be a potential risk, I would suggest.

[28] Lynne Neagle: Darren, you’ve got a supplementary on this.

[29] Darren Millar: I just wanted to ask a very brief question. You mentioned that the outreach numbers are capped because of the finance, and that the numbers in Powys, for example, Helen, are very, very small, and that you prioritise those who move out of area to give some continuity of service. What if you’ve got more than two people moving out of an area?

[30] Ms James: I think within Powys we are quite creative. We are looking at using our Families First and our Flying Start programmes in an integrated way more, and we’re looking at providing services based on need. So, we’re using our common assessment framework process, the assessment process, and the team around the family principles as well to support those families more. So, we are trying to be more creative in how we are providing the support.

[31] Darren Millar: But what happens if you’ve got half a dozen kids moving outside an area?

[32] Ms McNaughton: I think that’s one of the fundamental challenges with the geographical model, because what we know is we’ve got the 2.5 per cent cap, but, as part of the evidence we submitted in advance, some of the analysis Public Health Wales has done has shown that, when you actually look at levels of income deprivation, around two thirds of people who are living in income deprivation live outside of areas that are geographically defined as deprived. So, we know that there’s a significant population that could benefit from the sorts of things that Flying Start is able to offer, but, with a 2.5 per cent cap, you’re not going to be able to reach all of those families.

[33] Darren Millar: Would you like to see the cap abolished, then, in order that you can follow kids who’ve been starting to receive a package of support and service and the families that’ve been receiving that support and service?

[34] Ms Cowell: I think what we know is that Flying Start works in terms of that model of intensive health visiting and building up that consistent relationship with families on a community basis. We know that that’s beneficial to families. So, how it’s resourced is an issue, and how we flex the whole—what other initiatives there are within that community. So, as you say, Families First, particularly. Because, in health visiting, this is what we do—this model of support to families, this is what we do. We just want to do more of it.

[35] Hefin David: Are the families who aren’t having access to the programme because they’re outside those areas but would otherwise have it—are they vocal in saying to you, ‘We need access’?

[36] Ms Lewis: Yes. Certainly within the Cwm Taf area, yes, families do request additional support around Flying Start—they do. They see the benefit of it from a family perspective, and we do have queries.

[37] Hefin David: Okay. And they’re upset that they can’t access it.

[38] Ms Lewis: Yes.

[39] Hefin David: Alison, you look a little bit more sceptical.

[40] Ms Cowell: I think it varies, because some families will want to push you away as well, because they don’t want that input and they don’t want that support. So, you get mixed responses.

[41] Hefin David: Right. Why don’t they want that support?

[42] Ms Cowell: Because, when you’re working with families, it’s about building up that relationship, isn’t it, and some families won’t want to have that support and for you to be involved. Usually, they will engage, but it takes time for some families to engage. And I think some families will be more vocal about that in terms of thinking that they’re missing out on things. The free childcare will often be the thing that they will vocalise that they’re missing out on, rather than that intensive support.

[43] Hefin David: And the intensive support is what brings the health benefits. Is that—?

[44] Ms Cowell: Yes.

[45] Hefin David: And how would you conceptualise the health benefits? What, specifically, were the long-term benefits? Public Health Wales, perhaps; I should give you a chance to—.

[46] Ms McNaughton: I think the thing that’s important to note is that the whole package that makes up Flying Start—so, that access to childcare, the intensive health visiting contact and also the wider parenting support and speech and language—are all elements that’ve been shown to have longer term physical, mental and social outcome improvements. So, it’s quite a holistic approach and it’s one that brings a range of benefits, but, certainly, in terms of things like speech and language development and moving on to being school-ready and all those important indicators of well-being, and also your potential to benefit in the future from other wider opportunities, we know that those are the core evidence-based things that we need to be doing. I think the focus is on how we get that to more people.

[47] Hefin David: Yes. And the last question: from an outreach point of view, you would be able to measure that, I assume, by looking at the benefits within those Flying Start areas and the ones without. Is that possible to understand?

[48] Ms McNaughton: It’s challenging at the moment. It’s about what data’s collected and how routinely that’s collected. We’ve got a real opportunity, I think, with the Healthy Child Wales programme, because obviously there’s going to be much more routine data collection as a result of that being collated centrally. And that will give more of an opportunity, I think, to do some of the comparing between Flying Start and non-Flying Start areas, which has been difficult to date.

[49] Hefin David: Okay, thank you.

[50] Lynne Neagle: Thanks. John.

[51] John Griffiths: Yes, I just wanted to say that my experience of talking to some families who’d benefit from Flying Start is that there is that tendency amongst some not to want to be part of the programme. And you hear a lot of things like, ‘Well, my mother says that, actually, that’s all a lot of nonsense’, and, you know, ‘That’s not the best way to bring up your children’, and so on. So, I guess you get something of a culture clash at times, and sometimes you even hear stories that the health visitor has said, ‘Yes, actually, I don’t do that with my children, but this is what the programme is supposed to involve’. Is that familiar to you—that sort of experience, when, as you say, you have to build a relationship and, I guess, sometimes, it’s quite difficult?

[52] Ms Cowell: I think you will always hear all sorts of anecdotal comments and it’s important, really important, that health visitors are working to the evidence base, and that that relationship building is continual and consistent. And that’s where we will get the big outcomes that we’re looking for.

[53] Ms James: I think the intensive health visiting allows health visitors the time to really reinforce some of those health promotion messages and support changing behaviours as well. So, I think that's a really important part of Flying Start.

09:45

[54] Ms Lewis: And, just to add to that, I also think that I don’t think that is the norm; I think from a health visiting perspective, it is a universal service, which is non-stigmatising, and I do think it’s very much valued by our communities and by parents, in particular, and the additional work the health visitors do around different things like baby massage, baby swim, and all those additional things the health visitors participate in from a community perspective are also valued. So, I think, you know, it’s a combination of things, really.

[55] Lynne Neagle: Okay. Do you want to go on and ask your questions, John?

[56] John Griffiths: Yes. If I could go on to some other issues, we’ve touched on the geographical areas and Public Health Wales’s point in terms of those within or without the areas that are covered. If I could use an example—I mean, we know resource is limited. We’ve discussed the cap. In my constituency—I’m sounding a bit parochial, Chair, aren’t I; apologies—I went to the Moorland Park Community Centre where they have Flying Start. Right next to it is Broadmead, so Moorland Park and Broadmead are both social housing estates. Moorland Park is within the Flying Start area, Broadmead is without. I spoke to the staff there and the person running the Flying Start facility, and she said, ‘Oh, we’ve got spare capacity here. We could take several more children and provide the childcare, and we could easily take them from Broadmead where there’s such great need, but, because of the postcode criteria, we’re unable to do so.’ So, there’s an example of actual resource being in place, funding not being a problem, spare capacity, and, because of the postcode issue, people missing out.

[57] Ms James: I think within Powys we actually would take those children. I think if we have spare places in our nursery settings, where those places are paid for, through the CAF and the TAF process, we will accommodate those children in those nurseries where we can. So, again, I think that shows the differences in the models, how the model is applied across—

[58] John Griffiths: But does outreach allow for that, in terms of the criteria?

[59] Ms James: It certainly would with us. Yes.

[60] Ms Lewis: It would.

[61] Ms James: Yes.

[62] John Griffiths: And that’s quite clear, is it? Because I think we have three strands to the criteria and that doesn’t seem to fit any of them.

[63] Ms James: It’s probably not clear in the evidence, but it has been applied locally, I think.

[64] Ms Lewis: I think it’s the interpretation locally, around the local authority interpretation and the flexibility that the health and the partnership teams are allowed to apply in those circumstances.

[65] Ms McNaughton: Certainly, part of the work we’ve been doing through the First 1000 Days programme has been offering what we’re calling systems engagement events to public services board areas, and these events are designed to bring together everyone in that local area who work with families during pregnancy up to the second birthday, and they work through a number of scenarios over the course of the day to try and map the best understanding of the system as it stands at the moment and also identify some of the strengths and weaknesses of that system. And one of the things from the four we’ve done so far that does come back time and time again is that there is a real difference between what’s available if you’re in a Flying Start area and if you’re not in a Flying Start area, and that there is a feeling that, if the flexibility was there, that there might be more that health visiting and midwifery services could do to help families that were outside of Flying Start areas. But I think the different interpretations of the flexibility within the current guidance means that areas are saying they would appreciate more clarity or more flexibility, certainly around the geographical elements of that approach to grant funding. I know that limits people in terms of service development sometimes—or is felt to limit it.

[66] Lynne Neagle: Thanks.

[67] John Griffiths: Okay.

[68] Lynne Neagle: I think, Llyr, you wanted to ask about this as well, didn’t you?

[69] Llyr Gruffydd: Well, yes, we’re straying into the area that I was going to explore a little bit, because, in your paper, Public Health Wales talks about the mixed model where there’s a greater or a different balance in terms of targeting individuals and targeting a geographical area, but isn’t that what the outreach element is supposed to give us? 

[70] Ms McNaughton: I think there’s an argument that the outreach element is potentially, yes, meant to be able to give some of that, but I think the issue comes back to whether it’s sufficient to meet the needs that are out there. And I think there is an opportunity with the work that’s going on around the Healthy Child Wales programme now that there are those set, prescribed contact points for support going into all families, that we could look at ways of broadening out the way in which need is assessed, because all the best evidence tells us that, if you want to reduce inequalities, what you need to do is have a universal service offer that can ramp up the level of support that families or individuals need, as their levels of need and vulnerability change. So, something that’s a bit more responsive to individual needs, rather than something that assumes that everyone in a geographical area has the same level of need and that it’s higher than the people outside of that area.

[71] Llyr Gruffydd: And that message is coming through clearly, but of course the whole basis of this programme is geographical, so what you’re saying is that that isn’t really the best way of doing it.

[72] Ms James: There are real benefits to having a geographical model. I think, for me, in Flying Start areas we’ve built some really strong communities and I think that’s been a real benefit of Flying Start. I think, for me, though, we just need the extra flexibility to be able to offer it to those living just outside the Flying Start areas, or even wherever that poverty or need may be within an area. We need a mixed model, I think. The Flying Start model has been great, but we need more flexibility to be able to offer it to more.

[73] Llyr Gruffydd: So, is the flexibility as simple as changing the cap?

[74] Ms Lewis: I think it’s a bit more complex than that, from the perspective of Cwm Taf. I would agree the geographical model is very good in some areas and it does work very well. Where you have communities side by side, I think that is more challenging, and having that flexibility about having a universal service with an assessed need with that additional support for that family is the key. How we deliver that is a different question. The fundamental issue is that we have families with an assessed need that will benefit from Flying Start and, because of the way it is currently configured, are unable to access it because the cap does not meet the full need. It is an issue around resource.

[75] The other thing, I think, that is important to consider around the geographical element, are families that move out of Flying Start. Families don’t have stable housing; we have a lot of families that don’t have stable housing any more with private landlords. That is a particular issue in the Valleys communities, and families move, and they can move quite frequently. So, when they move in and out of Flying Start, although we can support them through the outreach for a period of time, they might then move again. Then they might move back into Flying Start, and I think that is really problematic for the service in developing a relationship, and for the family in having different health professionals involved in their life. I think that element, actually, is counterproductive, then, to what we’re trying to achieve.

[76] Llyr Gruffydd: So, should those people not be counted as outreach, then? Should they have that continuity regardless?

[77] Ms Lewis: That would be my opinion around the flexibility. I think we’re all in agreement around that, but we do need that flexibility, and to enable that to happen, Merthyr is already overcapped. You’ve got a 10 per cent cap on Flying Start, so your case load is 110, and you can go 10 per cent over that cap, and consistently, within our Merthyr team, our cap is over, and if we took that cap away, that is an additional whole-time-equivalent health visitor that would be required to even meet the needs within the Flying Start area. So, I do think we need to look at how we use the resource we have effectively and argue, where we are able to, around resource, as well.

[78] Llyr Gruffydd: So, just finally on this then. So, the message I’m hearing now, then, is everything about the flexibility that we talked about, but really, in the current set-up, we’re not actually maximising the impact that the investment could actually get.

[79] Ms Lewis: I think we’re maximising.

[80] Ms Cowell: We’re maximising what we’ve got.

[81] Ms Lewis: We’re definitely maximising what we’ve got.

[82] Llyr Gruffydd: Would you say you could do more?

[83] Ms James: There’s a need for more.

[84] Ms Lewis: With—

[85] Llyr Gruffydd: More money.

[86] Ms Lewis: —more additional resource. I think, heath visitors—. We are already—. What I’m saying is we are maximising our capacity. We are over capacity consistently, 10 per cent over, if we were managing 110. So, we’re over capacity already. There is no maximisation in the system any more.

[87] Llyr Gruffydd: No. Okay, thanks.

[88] Lynne Neagle: But Public Health Wales have told us that two thirds of families that are income deprived live outside the Flying Start areas. So, how, then, can it just be an issue of using this flexibility? Have you got any comment on that? If two thirds of the people are outside that, that suggests that’s bigger than just a little bit of tweaking and flexibility.

[89] Ms James: I think we’d all agree, probably—. Flying Start is arranged around postcodes, so I think within those postcodes you do have varying levels of deprivation and need, and probably we all have some areas within our Flying Start areas that don’t quite meet that criteria for deprivation, but that’s how the formula’s been calculated, really, for Flying Start. So, again, whether or not we can look at that. I think, geographically, working around an area is really important, it’s whether or not the postcode can sometimes be—

[90] Llyr Gruffydd: Too—[Inaudible.]

[91] Ms James: Yes.

[92] John Griffiths: Just briefly on this, one of the early criticisms—I don’t know if it’s still seen to apply—of Flying Start, in terms of the childcare element, was that disproportionately it was middle-class parents and families who were benefiting from it. Is that the case now, do you think?

[93] Ms James: I think, by and large, we’ve got our areas correct, but I do think there are still some small little areas within those areas that probably don’t have those enhanced levels of need.

[94] Ms Cowell: Because you could have a couple of roads within that geographical area that clearly are not needing that additional intensive support or the free childcare, but they’re eligible for it, aren’t they? But generally speaking, the geographical areas that have Flying Start, we wouldn’t disagree with. In terms of high need and deprivation, the areas are correct.

[95] Ms James: The general areas are correct.

[96] Ms Lewis: We would agree with the areas, but I would go back to the information that Public Health Wales have provided around deprivation and assessed need, and I think that is the key. So, whilst areas are in receipt of Flying Start, I think I would go back to the public health data that’s been provided to the committee to support that argument.

[97] Lynne Neagle: Thank you. Okay. Mark.

[98] Mark Reckless: In your evidence earlier, you referred to the positive impact of Flying Start on speech and language development for children, and Alison, you said ‘What we know is Flying Start works’. And I just wonder what you base those statements on? I was looking at the national evaluation of Flying Start and for instance it says,

[99] ‘no difference between parents in Flying Start areas and parents in comparison areas on parenting selfconfidence, mental health or home environment measures.’

[100] And then for outcomes for children it says,

[101] ‘There was no statistically significant difference between Flying Start and non-Flying Start areas in terms of child cognitive and language skills, their social and emotional development and their independence/self-regulation.’

[102] I just wondered, do you have a different evidence base for the comments you made?

[103] Ms Cowell: I think the problem that we’re in is that we haven’t got hard data, and so when I make that statement, it’s about that anecdotal, empirical knowledge of what the health visitors and families are saying.

[104] Mark Reckless: Anecdotal or empirical?

[105] Ms Cowell: I think we’ve got a mixture in there, okay? So, certainly schools are saying to health visitors that they can actually identify which children have had that Flying Start support, and health visitors themselves are saying that actually, particularly the work with mothers in terms of supporting them emotionally with postnatal depression and that attachment with their children, has been really important. And the case studies that they produce really show that distance travelled. But the way that we’re collating our quantitative and qualitative information at the moment isn’t actually demonstrating the totality of the impact of Flying Start.

[106] Ms McNaughton: I think there are two kind of strands to it, I suppose. One is that there’s a wider evidence base from research about the sorts of things you would want to do if you want to improve outcomes for children and young people. And in the early years, those four things around access to quality childcare, the parenting support and speech and language therapy, and the enhanced health visiting support are the things that we know from the evidence base should work. So if you’re going to invest your money in something, those are the things we should be focusing on.

[107] The challenge, I think, with evaluating Flying Start has been that there might not have been as much attention as we could have placed on how it was going to be evaluated at the very beginning. We know, from experience, that the more thought you put into evaluation processes at the beginning, the more likely you are to have an effective evaluation. And I think there’s been a real challenge for Flying Start in terms of understanding whether or not it’s making an impact for families who have similar levels of deprivation inside and outside of Flying Start areas, which I know is one of the questions you’re particularly interested in looking at.

[108] So, I think the report that has actually tried to look at that is quite an old one, so I think there’s also that issue of, actually, as services have evolved and quality improvement approaches have been taken, and services have adapted to what they see as working more effectively, we haven’t had the opportunity to go back and say, ‘Well, actually, can we repeat that sort of more detailed research process and try to do that evaluation again?’

[109] And I think the other thing is, what we really need to do is possibly put some more thought, if there are going to be changes to the way Flying Start is delivered, into how it gets evaluated in the future, and are we doing things like making sure that, where the Healthy Child Wales programme is going to collect certain pieces of information, equivalent information is being collected for Flying Start areas, so you can compare like with like, and that that becomes easier to do in a more routine way?

[110] Mark Reckless: Thank you. On the Healthy Child Wales programme, I just wanted to ask—I’m not sure which of you is best placed to speak to it—but the degree of overlap with the Flying Start programme and the extent to which that is complementary or in any area problematic.

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[111] Ms James: I think all children will receive the Healthy Child Wales programme. They’ll have all of that programme, but they’ll have additional support and services as well, so it’s not really an overlap; it’s an additionality. So, they’ll have all of the Healthy Child Wales programme, plus the additional, provided from the Flying Start programme.

[112] Ms Lewis: I see that as an assessed need. Everybody will have the Healthy Child Wales programme. Our teams have actually had integrated training around that. So, both Flying Start and generic services work together to deliver that, and then the additional assessed need Flying Start will provide to those families, targeted. That model, I think, would be able to deliver some of the ongoing concerns and issues about the two thirds outside of Flying Start.

[113] Lynne Neagle: John, is it on this?

[114] John Griffiths: Yes, on evaluation, Chair.

[115] Mark Reckless: Can I just ask one further question?

[116] Lynne Neagle: Go on, then.

[117] Mark Reckless: I just wondered how effective, or the extent to which Flying Start is the right mechanism to deliver health promotion messages. For example, on immunisation, as of 2016-17, it was 82 per cent who were immunised within the areas, but 86 per cent outside, although I recognise there would be differences in deprivation and perhaps other relevant factors. Is it a good mechanism, with more intensive health visitors, for instance, for those health promotion messages?

[118] Ms James: Absolutely.

[119] Ms Lewis: Absolutely. You can do outreach immunisation as well. Actually, the rate is 97 per cent in Cwm Taf.

[120] Mark Reckless: Congratulations.

[121] Ms Lewis: Thank you.

[122] Lynne Neagle: Is there any evidence of mothers who are accessing the Healthy Child Wales programme being picked up and then referred into the outreach element of Flying Start? Is that happening?

[123] Ms Cowell: Yes, that is how it happens. So, we’ve got the cap, we know how many children could have that outreach, and we have a system in place where actually, health visitors are identifying children who actually need that additional support, and not ones, necessarily, who have been in Flying Start previously. So, it’s about the discussion around whether or not Flying Start can meet their needs and provide that additionality.

[124] Llyr Gruffydd: Very briefly on that, then, would they more likely be quite close to a Flying Start area, or would they be anywhere, because there is a practical consideration there as well, isn’t there?

[125] Ms James: I think within Powys we have to be realistic. Because of the challenges and the scope of Powys, we tend to provide outreach on the periphery of existing Flying Start areas, because that’s where all of our services are. So, to be realistic, that is actually how it happens in Powys.

[126] Ms Cowell: And that’s generally what happens in north Wales as well.

[127] Llyr Gruffydd: Thanks.

[128] Lynne Neagle: John, you had a question on evaluation.

[129] John Griffiths: Yes, I was just going to ask about evaluation, just a little bit more, Chair. It’s clear that the more evidence there is for a programme, or a particular response—for example, concentrating on the early years in terms of public provision and spending—then the easier it is to make a case and to get resource into the necessary services. So, we do need the evidence, and it doesn’t read as strongly and as convincingly as we would like, I think, at the moment. So, I think what you were saying, Amy, was that evaluation should have been thought about at the outset, and if, for example, you’re comparing Flying Start areas with comparator areas with similar levels of deprivation, we needed baseline information to begin with, which wasn’t there. If that’s correct, do you have the opportunity to work with Welsh Government to make these points? Are you having those opportunities now around evaluation to make sure that we do get to a more robust system?

[130] Ms McNaughton: Yes. On a personal level, I’ve been in post for about eight months now, so I’m starting to build some of those relationships with Welsh Government, and I sit on the Healthy Child Wales implementation group, so I have an opportunity to feed in there. Jean White, who is the chief nursing officer, chairs the programme board for the First 1000 Days programme, so we have links into Welsh Government, and they’re engaged in the agenda, definitely.

[131] John Griffiths: But it obviously has been a real weakness, not having evaluation thought about or built in enough to the programme from the very beginning.

[132] Lynne Neagle: Okay, we’ll move on, then, to talk about—Darren—generic NHS services.

[133] Darren Millar: Yes. So, obviously we know that there are a number of other Government programmes that, potentially, are going to offer even greater benefits than the ones that are being offered by Flying Start—on things like childcare, and we’ve talked about the Healthy Child Wales programme. I’m just struggling to see how everything’s lined up, frankly, to make sure that we’re getting the best bang for our buck in terms of value for money from Flying Start. So, if we know that there are lots of deprived kids outside of these Flying Start areas that are not eligible for the additional package of support that you want to offer—. It seems to me that your message, yes, is to get rid of that geographical boundary, although it’s helpful in terms of being able to concentrate services, if you like, or packages of support, particularly if you have got a childcare provision, for example, or someone’s going out to do something in the community—they can be based in one place. But, really, do you think it would be better, from a value-for-money point of view, to enable you to make the decisions as to who’s eligible and who’s not eligible, so that we can target the money—this is supposed to be about reducing inequality—at those who need it most? So, if we can only afford to target it at a third of those deprived kids, let’s target the most deprived of the deprived kids in order to reduce that level of inequality. Wouldn’t that be a better approach, do you think, from a taxpayers’ point of view, in terms of the money that’s being given—80 million quid this year?

[134] Ms Lewis: I think you have to go back to the public health data and look at the four elements, which are research evidence based, in delivering that element to families that are in need. I do think having a universal service with an assessed need above that, and targeting that, is helpful. I don’t think we can underestimate, though, the health visiting role within that. That is key, to me. The health visiting role, and the midwifery role within that, from a health perspective, is critical. Whilst we have got the Healthy Child Wales programme, the figure for that is capped at 250, and the cap for health visitors in a Flying Start area is 110. So, you can see that intensive health visiting in that area—

[135] Darren Millar: I understand the point that you’re making, Lesley, but you can have that cap if you’ve got more deprived kids on your case load, couldn’t you? Do you see what I mean?

[136] Ms Lewis: Absolutely, yes.

[137] Darren Millar: Whether they are in Flying Start areas or not. So, shouldn’t we trust you more to identify the kids in need, rather than have the system as it is at the moment, which, potentially—as we’ve already discussed—is allowing middle-class families to reap the benefits perhaps of the extra support, when there are kids who are much more, and families who are much more, in need, potentially?

[138] Ms James: I think we are identifying those additional families who are in need, but I think we are probably using our team around the family and common assessment framework processes to tap into Families First funding. So, I think—. There are other funding streams that we are using to support those families living outside Flying Start, where we are identifying increased need. But perhaps there could be more join up of the programmes.

[139] Ms Cowell: Certainly, for us in north Wales, we have got some work in Conwy at the moment with the local authority, looking at, actually, how can we—and this is not just children, this is generational—reorganise ourselves within the county to provide what you are saying there, Darren, in terms of that more intensive support, where, actually, your practitioners and your agencies are a bit more joined up in that community. So, I think it’s not just about the health element saying, ‘Actually, that family needs additional support.’ It’s really, really important that, actually, this is about multi-agency assessment of need, and the flexibility that can be created by that partnership working within a county. But we’re just having those discussions in Conwy at the moment about doing this a bit differently.

[140] Darren Millar: The problem I’ve got at the moment is, based on the only evaluation that’s been done—and I appreciate that perhaps the wrong questions were asked, or that the performance indicators that were looked at may not have been the right ones, but, based on that, it doesn’t look as though Flying Start has made a great deal of difference on those particular measures. Obviously, we’re interested, in a time of austerity, where there is spending restraint, in making sure that the resources are appropriately targeted. Whilst I appreciate, as I say, the beauty of being able to invest in a particular location so that the resources are tightly compacted, where there might be some efficiencies that we can glean from that, the reality is that, if this is a programme about reducing inequality, which is what the stated aim of the programme is, it isn’t doing it, is it?

[141] Ms Cowell: I think, as you started out, we haven’t asked the right questions—

[142] Darren Millar: So, what questions should we have been asking, Alison?

[143] Ms Cowell: —in terms of evaluation. I think that, from our perspective, we would want to see distance travelled being looked at—so, you’ve got the family need and then actually what services are required to meet those needs and what distance travelled has been created, what difference has it actually made. We’re not collecting that qualitative data. So, as you say, the cold, quantitative data is not reflective of the importance of this initiative.

[144] Lynne Neagle: Okay. Darren, you’re done—

[145] Darren Millar: Yes—I mean, there are pretty important questions that were asked by the Public Health Wales information, I think. It’s talking about the development of skills, cognitive development, language skills, social and emotional development, immunisation rates, all of those things. And, frankly, there’s no statistical difference within versus without Flying Start areas, is there?

[146] Ms James: Can I just ask, is that the 2014 report?

[147] Darren Millar: It is. Well, it’s 2013, actually. September 2013. So, it’s a few years back.

[148] Ms James: I think it’s probably timely that we have another evaluation. We alluded to it earlier on. And I think by looking at that and asking for the right information—.

[149] Ms McNaughton: I think one of the other challenges is—you know, we’ve highlighted the immunisation information in there, but immunisation is one of those things that, because it is such an important issue from a public health perspective, there’s a huge amount of endeavour that goes on around immunisations outside of the specific work that Flying Start and the health visiting services inside Flying Start are able to do, which is really vital.

[150] So, what we see is possibly it’s also one of those indicators that maybe it’s not the best one to make a judgment on the difference. But I think the thing that did come through on that report was, as you were talking about, that sort of looking at distance travelled or impact over time. The increase in immunisation coverage has been greater within Flying Start areas than it has been in non-Flying Start areas. I think it’s increased by around six percentage points in Flying Start, compared to about four in non-Flying Start areas. So, there is a suggestion—there are things in there that suggest that we’re having a positive impact with Flying Start; I think it’s just how well we go on to evaluate that once we start to be able to collect some of those developmental indicators through the wider Healthy Child Wales programme as well.

[151] Darren Millar: So, 10 years on, I suppose it’s easier to measure, isn’t it, in terms of from when the programme started.

[152] Lynne Neagle: Okay, Michelle.

[153] Michelle Brown: Thank you. The Welsh NHS Confederation have previously commented that there’s been a shortfall in access to speech and language therapy provision. Do you have any comments on that and does the outreach programme go some way or all of the way to addressing that?

[154] Ms James: Certainly within Powys, we don’t have any particular shortfall of speech and language therapy within Flying Start. Again, our outreach is such a small part of what we do in Powys that they would support the outreach there as well. So, I don’t particularly recognise that statement for Powys, but it might be more of a national picture.

[155] Ms Cowell: I certainly think, in north Wales—a little bit like what Helen has said, I think the only issue for us in north Wales has been some recruitment difficulties, and that’s not just in speech and language, but nothing that stands out for us in north Wales in terms of speech and language.

[156] Ms Lewis: I think it is challenging within Cwm Taf. We do have speech and language therapy interventions to support the team, and they’re part of the team. We’ve also addressed it through nursery nurse support and developing different projects. We do have different ratios for speech and language therapists within Flying Start. So, obviously, the access, then, per the population, is different. So, I think it’s a key area for Flying Start and I think it’s one of the key indicators that we are able to demonstrate improvement through that programme. Actually, I think we do need to look at the resource within that and look at a different skill mix to deliver, which is what we are currently doing.

[157] Lynne Neagle: Okay, Llyr wanted to come in on speech and language as well.

[158] Llyr Gruffydd: I just wanted to say that I’ve seen reference somewhere to the work that’s happening in Bridgend around that, which is particularly being held up as a good example. So, why are they doing so well in Bridgend compared to other places, if there’s not an issue around sufficiency of workforce and—?

[159] Ms Lewis: We’re not saying that it’s not doing well, but we’ve used different things. So, it’s not just about a speech and language therapist, it’s about different interventions. For example, we use WellComm, which many Flying Start areas do, to deliver the speech and language and the play skills with families.

[160] Ms James: It’s about early screening—

[161] Ms Lewis: It is, and it’s very much about the assessment of the health visitor, particularly around that 15-month period, which we know is critical.

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[162] Llyr Gruffydd: Yes, and we know what the outcomes are later in life if children start falling behind. So, is that the central feature, then, of a lot of the work that you do? Because, clearly, the implications of not being where they should be in terms of speech and language development are well evidenced. Is that one of the key aspects that you’re trying to—

[163] Ms Cowell: It’s a really important element, and, as, Lesley, you’ve just described, that language and play experience that the children are having is equally important in terms of building up that speech and language—screening as well as intervention. So, it’s important, and it’s about that school readiness. So, it’s key, because language is about social interactions and not just about speech, isn’t it?

[164] Llyr Gruffydd: Absolutely.

[165] Ms Cowell: So, all the experience of play is much more than just about language development.

[166] Llyr Gruffydd: But you’re comfortable that there are sufficient numbers out there to deliver the services in that respect.

[167] Ms Lewis: For me, it’s differences in the local authority areas. So, you’ve got a 1:1 ratio, I think—I have to look at my notes, sorry. You’ve got a 1:1 for the team in Merthyr, and a 1:3 in RCT. So, it’s just slightly different, but, within that, you can use a different skill mix, and I do think we’ve got the flexibility to do that and deliver it. It’s not about an individual having that expert skill and knowledge; it’s about the team that works with the families having that knowledge, with the support of a specialist.

[168] Llyr Gruffydd: Sorry, just for clarity, one what to one what—1:1 and 1:3?

[169] Ms Lewis: It’s around the population. So, we’ve got one speech and language therapist in Merthyr for one area—

[170] Llyr Gruffydd: Oh, per area.

[171] Ms Lewis: Per area. And then, in Rhondda Cynon Taf, we’ve got—. So, we’ve got three localities, with one speech and language therapist.

[172] Llyr Gruffydd: I see. But others deliver services in different ways as well, which complements that work.

[173] Ms Lewis: But what we do as part of that, then, is you use different programmes, like WellComm, which is supervised by a speech and language therapist, the training and education then of nursery nurses to support and deliver that—

[174] Ms James: And childcare.

[175] Ms Lewis: And childcare, and, particularly, again, in the childcare environment. So, the whole team, which is the concept for the first 1,000 days, there’s the team actually looking at that child and supporting parents as well.

[176] Lynne Neagle: Michelle.

[177] Michelle Brown: Thank you. I just wanted to ask a brief question. Do you collect data on the number of children accessing speech and language therapy? And is there any assessment of the impact that that has had on the child? I suppose the question sort of applies to the other parts of the service that Flying Start offers.

[178] Ms James: I’m sure speech and language colleagues collect that data. I don’t personally collect that data. We’ll see, but I’m sure our speech and language therapists would be doing that.

[179] Ms Cowell: So, the contacts are counted, but, again, it’s back to: are we actually really collecting the outcomes? I think they will be collected by the speech and language therapists, but that’s not then asked for in terms of evaluation of impact.

[180] Ms Lewis: I would agree. I think it goes back to the evaluation criteria that we need to look at going forward for Flying Start.

[181] Ms McNaughton: I think there’s also an issue around the central collation of that information. So, while individual services may collect it, the ability to look at that at an all-Wales level, or to look at variations between areas, is limited.

[182] Lynne Neagle: Okay. Thank you. Hefin, brief questions, please.

[183] Hefin David: Okay. With regard to significant health issues, such as child mortality and stillbirth and hospital admissions, how effectively has Flying Start dealt with those things?

[184] Ms Lewis: Well, we certainly have a midwifery input into Flying Start, and they do pick up cases that are high risk, and they do support the teams. But the midwifery model was not in place originally when Flying Start started; it’s been a development as part of the programme. I don’t know if that’s the experience of my colleagues.

[185] Ms Cowell: And, initially, some local authorities chose to have a midwife as part of the team, and others didn’t. I think the question that you pose is a really important one in terms of actually what are we doing antenatally, what are we doing in terms of smoking cessation, what are we doing around obesity, which, you know, are key influences in terms of stillbirth and low birth-weight.

[186] Hefin David: Alcohol consumption during pregnancy.

[187] Ms Cowell: And alcohol consumption, absolutely. So, what we’re doing antenatally as a multidisciplinary team to that family is really, really important, and what we’re doing as a community. In terms of infant mortality, certainly in north Wales, we did quite a big piece of work around safer sleeping, just to reinforce the messages that we’d had a long time ago around the prevention of cot death, but we extended that out in terms of actually helping the parents to risk-assess those needs themselves, so that they were making informed decisions about their alcohol consumption, their tiredness and where they were positioning their baby. So, infant mortality is really important for us as health professionals to address.

[188] Hefin David: Is it appropriate for Flying Start to be a vehicle for addressing those things?

[189] Ms Cowell: Absolutely it is.

[190] Hefin David: And what about the evidence that the Welsh NHS Confederation gave on the importance of addressing children’s psychological and mental health needs? Can you just expand on the benefits of that?

[191] Ms James: In Flying Start programmes we are promoting attachment and bonding, which in turn supports that strong parent-child relationship. So, that’s a really important thing. I think in all areas, we’re all providing lots of services to support that, whether they be baby massage, baby swim, buggy walking—all of those things just help to nurture that relationship between the child and the parent.

[192] Hefin David: It just seems that these are universal things that you’re talking about and should apply to everyone, but Flying Start gives an extra dimension for people in poverty.

[193] Ms Lewis: I think it’s the one-to-one support as well that the family health visitor is able to provide within the programme. You cannot underestimate, having a 110 case load, the input that you can provide to that family on a one-to-one basis. Because whilst we can support and provide the additional services, you have to get families to those services. In the first instance, they might not be resilient enough to attend a group—they might need more intensive one-to-one support to get them to a position where they feel able to participate in the wider offer that both Flying Start and their community will provide. So, I think, from our perspective, it’s very much about that relationship that the health visitor builds up with the mum in the antenatal period. So, they meet their health visitor and their midwife in the antenatal period, they follow that family through, and it’s not just the support to mum, it’s the support to dad, it’s support to the wider family—the grandparents too—because health visitors are trained to look after the whole of the family and it’s the whole of the family who look after the child. So, I don’t think we can underestimate the benefit of having that smaller case load.

[194] Ms Cowell: And I think that intense relationship, if you like—it’s quite an intimate relationship—that a health visitor will have with the mother and with the dad; less so with the dad, unfortunately, which is something that we’re really, really aware of. If you are interacting with a mother who is low in mood and has got postnatal depression creeping in, the impact on the baby is really quite significant. So, that one-to-one relationship and that intensive work with that mother are so important in terms of that baby’s resilience, as it goes through life into adulthood as well.

[195] Hefin David: With regard to measurements, we’ve touched on this already, but you talked about measuring the outcomes of these things and suggested commissioning further evidence. The evidence has been gathered from those parents who’ve had contact with a health visitor, but Flying Start, from what you’ve said, is a much bigger thing. Is it therefore difficult to capture the data in those terms—are you not capturing everyone who has got access to the programme?

[196] Ms McNaughton: I’m not sure if it quite answers the question, but I think that one of the challenges with something like Flying Start is that when you’ve got multiple different interventions, it’s very difficult to put your finger on which one it is that’s made the difference. It may be the fact that it’s a combination of all of those that have brought a family to a place where they are able to make a change. I think that Lesley’s point about that intensive working is really key, because I think we’d all acknowledge that there are things we know we should do to improve our health and well-being, but we don’t do, and it’s very often not the fact that we don’t know that we should be doing something that’s the limiting factor and us not doing it; it’s about how we motivate ourselves to make those changes and the health visitor—

[197] Lynne Neagle: Yes, but I think what the committee is driving at is that the number of children benefiting is measured by the number of children who’ve had contact with a Flying Start health visitor, but there is no measurement of the number of children who have accessed other aspects of the programme. Do you feel then, given that everybody has a health visitor anyway that that is an appropriate measure by which to measure the effect of the programme?

[198] Ms Cowell: It’s one measure, isn’t it? It’s an important measure, but it shouldn’t be the only one.

[199] Ms McNaughton: And I think the other thing that’s important to think about is when we’re evaluating services, we want to be thinking about the outcomes we want to be achieving for families, and then, sometimes, it’s about looking back at some of the process measures that support a case that you’re moving towards achieving those outcomes. So, what we need to be looking at, actually, for children when they reach school age, is: are we are seeing improvements in school readiness? Are we seeing improvements in speech and language and other developmental milestones when they’re having checks at younger ages? Those are the sorts of things that are really key in terms of actual outcomes, and then, we have other measures along the way, the things that we’re saying, ‘Actually, we think making sure that they have these additional contact with the health visitors is an important part of that process, so let’s make sure that those things are happening, because they’re the things that indicate that we’re more likely to achieve the longer term outcomes we’re after.’

[200] Lynne Neagle: Really briefly, John, because I want to bring Llyr in to ask the last question.

[201] John Griffiths: I’m just wondering if there’s an issue with families refusing to be part of the programme and not wanting to see a health visitor. Does that happen?

[202] Ms Cowell: It can happen, but it’s about not giving up, and that health visitors try to repeatedly re-engage. Or it might actually not be the health visitor. So, that’s the beauty of the Flying Start initiative, that, actually, you’ve got other provision in that team that actually may be better at making those first steps to engagement than the health visitor. So, we never give up.

[203] Ms Lewis: In my experience, that’s rare. Sometimes, it is about perhaps relationships, and sometimes, you might need to change the individual who goes in, for different and a variety of reasons. It’s rare in my experience.

[204] Lynne Neagle: Thank you. Last questions from Llyr.

[205] Llyr Gruffydd: Thank you. Lesley mentioned earlier about health visitor numbers and capacity in Merthyr, for example, where there is basically a demand for one additional member of staff. Does that reflect the situation generally, because I note that the Welsh Government’s annual headline statistics on Flying Start last year said that there are issues of recruiting and retaining health visitors in some local authority areas? And I’m just wondering how much joint working there is between Government, health boards, local authorities and others, to make sure that there is a sufficient workforce out there to deliver the services that you need to deliver.

[206] Ms Cowell: There are difficulties. We are short of health visitors nationally. At one time, the Welsh Government supported an additional cohort of student health visitors whilst the programme was really starting to rank up. So, that was hugely beneficial, not only in total numbers, but also because the cohort was part way through the year. So, if you’ve got a vacancy, you’re not waiting for a year before you’ve got a newly qualified, you’re waiting six months. So, those two cohorts were extremely useful. We haven’t got that now. Because the Health Child Wales programme also requires some health boards to recruit additional health visitors, certainly for us in north Wales, that’s quite a significant issue. So, we haven’t got enough health visitors out there to fill all of the jobs that there are.

[207] Ms James: I think the other issue we have is because Flying Start is a grant-funded scheme, with a three-year cycle of funding, we do have staff on fixed-term contracts. So, that’s not always very attractive if it’s up against a permanent post. So, again, that can create some difficulties for us.

[208] Ms Lewis: I think from a workforce perspective, we work with Welsh Government through the health boards to actually say around [correction: agree] the numbers that we require for training. It is a full-time programme, and obviously, you need a community of practice teacher to support that. And I think, in different health boards, we’ve invested differently within that model. The issue for me is—. We are in a slightly different position within Cwm Taf to other areas. We are fully established currently—and I think that is a challenge for colleagues across the board [correction: Wales]—and that is helpful to meet both the Healthy Wales Child programme and the Flying Start. But our issue going forward is, if you look at our workforce planning, we have very experienced staff, who actually could retire should they choose to, and I think that is going to be a critical issue, not just for health visiting, but for NHS Wales, in the next five to 10 years. And, also, we need new staff to come through, and it’s really losing those staff to train from service. That, for me, is our critical issue. So, we have staff wanting to train, and because of the secondment opportunity and the way that people train as well, that does have an impact on people actually applying for health visiting. And it’s something we work together on. I work certainly with my colleagues across the health board to try and support that secondment opportunity. But we have a deficit within acute and general services as well. So, it’s about us working together for the whole model, I would suggest.

10:30

[209] Llyr Gruffydd: So, the message is that Government needs to do more in order to address the current deficiency, but also the looming deficiencies, the further deficiencies that are on the horizon—

[210] Ms Cowell: We need more—[Inaudible.]

[211] Ms Lewis: We do.

[212] Llyr Gruffydd: Yes, okay. Fine. Just very, very finally then, I note that there is a substantial variation, actually, between local authorities in the number of Flying Start health visitor contacts per child, varying from three and a half contacts in Blaenau Gwent to six or more in some other authorities, Monmouthshire, Gwynedd, Wrexham, et cetera. What’s your view on that? Is that just because of different circumstances or—?

[213] Ms Lewis: No, that’s the vacancy factor. That’s sickness and mat leave.

[214] Llyr Gruffydd: So, it’s having a direct impact on the provision of services now.

[215] Ms Lewis: It’s having an impact on contacts.

[216] Ms James: I think, also, there’s no standardised database for collecting the data. So, I think we’re using different databases to report that information back to Welsh Government, so I think there’s an issue there, as well.

[217] Ms Cowell: And you’ll have differences within your team in terms of deprivation, family need, so there’ll be lots of variables within that. But, I think, as Helen said, fundamentally, our data isn’t particularly robust. But there will always be differences, because family needs will dictate how many contacts are needed.

[218] Ms Lewis: Can I just add to the contact issue? Purely taking it on a number basis is unhelpful. The Welsh community care information system programme, the Healthy Child Wales programme, with the acuity tool—the family resilience assessment instrument tool—will help that. It will help triangulate the data and it will help us explain why there are those differences. I think that is critical, going forward, to supporting the Flying Start evaluation, because we haven’t had a tool across Wales to support that work.

[219] Llyr Gruffydd: But you’re saying that it is workforce issues that are partly contributing to that—

[220] Ms Lewis: Partly. It’s not the whole—

[221] Llyr Gruffydd: No, but it is having an impact.

[222] Ms Lewis: Yes.

[223] Llyr Gruffydd: Thank you.

[224] Lynne Neagle: Thank you. We’ve come to the end of our time, so can I thank you for coming this morning and for answering all our questions? You will be sent a transcript of the session this morning to check for accuracy in due course, but thank you very much for your attendance this morning.

[225] Ms James: Thank you very much.

[226] Ms Lewis: Thank you.

[227] Lynne Neagle: The committee will break until 10:45, but can Members not rush off for one second, please? Thank you.

Gohiriwyd y cyfarfod rhwng 10:32 a 10:47.
The meeting adjourned between 10:32 and 10:47.

Ymchwiliad i Dechrau’n Deg: Allgymorth—Sesiwn Dystiolaeth 2
Inquiry into Flying Start: Outreach—Evidence Session 2

[228] Lynne Neagle: Okay, welcome back everyone. We will go on to our second evidence session and I’m very pleased to welcome Alison Davies, associate director Professional Practice, Royal College of Nursing Wales, Nicola Milligan, RCN Welsh board member and specialist health visitor at Cwm Taf Local Health Board, and Sandra Dredge, who is senior nurse for community child health at Cardiff and Vale University Local Health Board and also a member of the Welsh heads of health visiting and school nursing forum. Thank you very much for attending this morning. If you’re happy, we’ll go straight into questions, and the first questions are from Hefin.

[229] Hefin David: With regard to health visitor case load, in a Flying Start area it’s 110, whereas a regular health visitor would be 350. Are there clear and recognisable benefits from that change in case load, difference in case load?

[230] Ms Davies: Thank you very much for that question, and thank you very much for the opportunity to provide information to the committee today. There are real, clear benefits to a capped case load in the health visiting service for two main reasons, really: (1) to have a limitation on the number of children and families that you provide a service to means that you can manage the quality of that service far better. So, the service that somebody receives from a health visitor who’s got more resource, per se, to give that service, it’s likely to be higher, more bespoke, based on assessment of need. And, from a professional perspective, for that health visitor who’s got a smaller case load, there’s that really excellent opportunity to maximise the service you can give to that child and family. So, there are benefits in having a capped case load.

[231] Hefin David: And does that work into outreach Flying Start areas as well, or outreach Flying Start cases?

[232] Ms Davies: Well, in terms of the numbers of outreach—children and families who receive the service via the outreach—as we’ve heard this morning, those numbers are quite small. So, where you’ve got a case load, health visiting case load, that is a manageable demand, then, yes, there’s still that opportunity to maximise the service given, but, obviously, the lower number of families you’ve got with increased need, the more intensive service you can provide.

[233] Hefin David: Okay.

[234] Lynne Neagle: Anybody want to add anything?

[235] Ms Milligan: Yes. I would just like to say, as a practicing health visitor, the smaller case load allows you to work with your more vulnerable, hard-to-reach families. And, because you work more closely with them, it builds a better relationship, allowing you to deliver the key messages.

[236] Hefin David: And what helps make the decision on the size of the case load? Why 110 compared to 350? What’s the influence on that decision?

[237] Ms Dredge: I don’t think there was a scientific basis behind it. I think, at the time, when Flying Start started in about 2006, 2007, it was—. I think there was no evidence base to draw on. Therefore, the general 250, which has always been the average—

[238] Hefin David: Two hundred and fifty. Right.

[239] Ms Dredge: Yes, 250 for a generic case load. I think they thought that less than half of that would be good for intensive health visiting and would allow, as the girls have said, the time to do that.

[240] Hefin David: And is there scope for change in that? Nicola, would you also feel—but Sandra, first—that there’s scope for changing it to increase the amount of support?

[241] Ms Dredge: I think that, with the new Healthy Child Wales programme, and the family resilience assessment instrument and tool, the new assessment tool, it will give us better evidence as to how many families we’ve got who are at high need within the case loads. So, it may allow us to look a little bit more flexibly, because it may be that some Flying Start, and even generic case loads, should actually be less than the 110. The generic average is anything between 280 and 350. I think Betsi probably have got—. Betsi and Aneurin Bevan have got the highest case loads.

[242] Hefin David: And, Nicola, your experience: would you say that there’s room for changing case loads to—?

[243] Ms Milligan: I think there’s room for flexibility. Using the tools that we have, we may have families of higher need, and we need to spend more time with them. So, I think there can be room for flexibility.

[244] Hefin David: Okay, thank you.

[245] Ms Davies: Can I just add something to that, please? One of the things to think about is the interface between proactive involvement with a family and reactive. So, when we’re looking at something like Flying Start or the generic health visiting service, the preventative agenda there is something that’s really important. The more work that we can do with children and families to enhance health and to enhance those 1,000 days of life, which we know leads into better outcomes all around, then the less need there is for more reactive services along the way. So, that includes our therapy colleagues—for example, speech and language therapy—or local authority interventions that might be needed to support families later.

[246] Hefin David: Okay, thank you.

[247] Lynne Neagle: Okay, thank you. Michelle.

[248] Michelle Brown: Thank you. Do you think there’s any overlap between the services being provided by Flying Start and those being provided by the Healthy Child Wales programme—in particular with reference to outreach services?

[249] Ms Milligan: Sorry, Sandra, do you—?

[250] Ms Dredge: I was just going to say, I can only really speak for Cardiff and Vale, and the outreach in Cardiff is used mainly for our homeless service, but it’s only a proportion of our homeless service because, as you probably know, we’ve got quite a lot of high population, and also one of our Gypsy/Traveller sites. So, it’s used in specifically vulnerable areas, which was thought to be more manageable than having families coming in and out. I’ve forgotten the rest of the question, sorry.

[251] Michelle Brown: I was asking about duplication between the two divisions.

[252] Ms Dredge: I don’t think there’s duplication, no, no.

[253] Michelle Brown: Is there any overlap at all?

[254] Ms Dredge: Well, no, because the services have aligned so that the programmes have aligned. So, the core service, now, for both Flying Start and generic, is the same. It’s the additionality that’s the bit that Flying Start adds, if you like. So, there’s no overlap. The Flying Start children have the same universal service as the generic children, but they benefit by the additional services, like ease of access to speech and language or Stay and Play, psychology—whatever it is in their particular area that they have access to.

[255] Michelle Brown: Right, so they have the basic Healthy Child Wales programme, and then in Flying Start areas—

[256] Ms Dredge: They benefit from the additionality.

[257] Michelle Brown: —they have the addition. What’s the provision like for children who are outside the Flying Start areas but who are covered by your outreach allowance?

[258] Ms Milligan: I think we’ve already heard the outreach is quite small, but it is quite flexible and it is based on need, so it can be based on additional needs, speech and language, or it could be a family that are in the area and move out and need that additional support while they’re outside of the Flying Start area, but the numbers are very small.

[259] Ms Davies: It’s probably worth thinking about—. In children’s services more generally, duplication is avoided wherever possible, because that introduces an element of risk for families. So, in terms of effective management of resource and good practice, duplication would not be something that anybody would be supportive of or enable. Certainly, record keeping and IT systems would identify if there was more than one person involved with the family. That would be unusual. It’s probably worth while appreciating that Flying Start brings more, so it’s the Healthy Child programme and more.

[260] Lynne Neagle: Llyr.

[261] Llyr Gruffydd: You mentioned outreach with Gypsy/Traveller children and homeless. So, what numbers are we talking about there then?

[262] Ms Dredge: I don’t manage Flying Start—

[263] Llyr Gruffydd: No, okay.

[264] Ms Dredge: —whatever 2.5 per cent of the total number is.

[265] Llyr Gruffydd: So, effectively, you’re maxing out on those two groups. Not that that’s right or wrong.

[266] Ms Dredge: Well, they are very vulnerable groups.

[267] Llyr Gruffydd: They are indeed. Yes, absolutely.

[268] Ms Dredge: In terms of the number of hostels we’ve got, they only manage, I think it’s one of the big hostels and maybe one or two of the smaller ones. The rest is still managed by generic services, which means those families don’t benefit from the additionality that the ones in Flying Start benefit from. And they do benefit, in answer to your question. They get the services in the same way.

[269] Llyr Gruffydd: I just found that interesting because the approach to outreach there is focused on specific groups, targeted groups, whereas in other areas it’s a bit more generic.

[270] Lynne Neagle: But you were saying that you haven’t even got enough through the outreach to cover all the homeless families who should benefit.

[271] Ms Dredge: No, it’s a huge problem in Cardiff.

[272] Lynne Neagle: Okay, thank you.

[273] Ms Dredge: We include refuges in that, and Bawso, and all the other—.

[274] Lynne Neagle: Okay, thank you. John.

[275] John Griffiths: Well, I think that leads us nicely into geographical variation, and, from what you say, Sandra, there is quite a considerable variation between different areas across Wales. So, what’s your view on that? I mean, you know, is that inevitable? Is it appropriate? Or do we need a little bit more consistency? Do you think the balance is right across Wales?

[276] Ms Dredge: Do you mean in terms of the specifics of the programme or—?

[277] John Griffiths: The way that the outreach programme is used.

[278] Ms Dredge: Well, I think if you’re going to use a cap of 2.5 per cent, it’s only going to be 2.5 per cent of the Flying Start population, so it’s going to be different, because each area has got different numbers of children who come into the Flying Start arena. So, it’s difficult to—you know, looking at Aneurin Bevan for example, the needs of children in Monmouthshire will probably be different to the needs of children in Blaenau Gwent, will be different to the needs of children in Newport. You’ve got five local authority areas there, and each one will have different specific problems, I would imagine.

[279] John Griffiths: So, you don’t think that the different approaches in terms of outreach across Wales are an issue at all?

[280] Ms Davies: There are three components to that, really. One is the financial constraints, whether they are the main informant of the focus of the service or not. The level of need, which does vary by locality and by population and by community, although broadly speaking, the geographical identification can assist in that. And, thirdly, the opportunity to know what works well and what’s most effective, and I think we heard previously about the need for probably evaluation more focused on outcomes, rather than on quantity of visits, et cetera. So, the variation in the provision by area is dependent on those three factors, I guess.

[281] John Griffiths: Okay, so, perhaps a bit more evaluation and analysis would be necessary to see if the balance is the best.

[282] Ms Davies: Some discussion previously, I believe, about measuring value in terms of quantity of contacts—it may be more helpful to focus on qualitative analysis of outcomes so we know what works, we know what works well, and we can appreciate the journey travelled by children and families rather than measuring things solely by an ultimate outcome or a quantitative measure.

[283] John Griffiths: Okay. If I could move on then to what Public Health Wales have said about two thirds of the people in deprived circumstances actually living outside the geographical Flying Start areas, obviously, that poses questions and challenges. And, obviously, outreach funding is limited, as we’ve heard. Can you point us to any solution to those issues within the current budget as it exists? Are there, for example, elements of Flying Start that might be dropped, which would free up resource to reach more people through outreach?

[284] Ms Dredge: I don’t think it’s a question of dropping anything. I think there probably is scope to look at how it is delivered slightly differently. For example, in terms of the number of local authorities and all of the different—I mean, I’m lucky in Cardiff, I’ve only got Cardiff and the Vale, but my colleague in Gwent has five local authorities. And so what that means is most of those projects are quite small. We have a huge programme in Cardiff and a much smaller programme in the Vale. I’m not really sure why we have so many non-clinical posts across all these local authority areas, when maybe there’s room to look at the management of it slightly differently. That would be my solution.

11:00

[285] John Griffiths: So, you’re saying that, in terms of—

[286] Ms Dredge: Merging some of them.

[287] John Griffiths:—the administration, the administrators, the number could be reduced and money freed up for front-line delivery.

[288] Ms Dredge: I’m not an expert in this field, but I think that it makes life difficult in all aspects of health when you’re working across different authorities, and when you’ve got different programmes with different priorities, it is difficult, isn’t it, to manage and difficult to keep the same focus in each area.

[289] John Griffiths: Has anybody else got any thoughts on that?

[290] Ms Milligan: I don’t see any areas that can be removed. We work with families, working on attachment, infant and parental mental health, delivering key public health messages. Maybe there’s scope for a little bit more flexibility in how we address the need and identify, maybe—. As has already been said, there are some families within the Flying Start area that don’t have the high need, and families outside, so maybe it’s looking at a bit more flexible way of working.

[291] Ms Davies: I think we’ve heard today, and the evidence base is clear, that investment in the first 1,000 days of life matters, makes a positive difference. We’ve also heard today that Flying Start—although the evidence collected can be questioned—but overall, there’s certainly a growing body of anecdotal and other evidence to say it works, and we’ve also heard today there’s a level of unmet need in Wales. So, we’ve got a finite resource, as you’ve mentioned. Whether the cap is removed or otherwise, there will still remain a level of unmet need that probably needs to be looked at in a slightly different way.

[292] There’s definitely a role for greater emphasis on professional judgment, and there are a number of assessment tools, et cetera, that can be used that enhance professional judgment. So, that enables health visitors to undertake a full, robust assessment and then help families decide the level of need and intervention required based on that assessment. So, if there was greater flexibility within processes to allow that to happen, it would probably allow more families who need services to receive them.

[293] John Griffiths: Okay. So, it would be a more intelligent approach, and some families that are getting a certain level of intervention and service delivery now would get less, which would then free up resource for others.

[294] Ms Davies: I think allocation of services would be based on need.

[295] John Griffiths: Okay, and that would be within Flying Start areas and beyond, with a wider outreach programme, possibly.

[296] Ms Davies: There’s a potential for that, but I think appreciating resources are finite, and we are agreed that there aren’t resources to be withdrawn, and there’s potentially a need for more resource, so, there’s an opportunity to achieve change, but it is unlikely to meet the whole level of need across Wales because we know there’s such a level of unmet need already.

[297] John Griffiths: Chair, could I just ask briefly about a situation that I mentioned earlier with a previous panel? I know of two social housing estates next to each other, with a Flying Start facility in one, but because of the postcode element, the other social housing estate isn’t included, and they had spare capacity there, but they were unable to take children and help families from that other social housing estate. Is that a situation that you would be familiar with or would have any views on?

[298] Ms Dredge: I’m not aware of anybody having any spare capacity. To be honest, I think we’re usually running over cap. I don’t think we’ve ever got capacity.

[299] Ms Milligan: I’m not aware of any that have gone under capacity.

[300] Ms Davies: Perhaps the example you give illustrates the importance of good partnership working.

[301] Lynne Neagle: Llyr.

[302] Llyr Gruffydd: Just to be clear, in terms of the outreach element and the cap, everybody seems to be wanting more flexibility, which I seem to agree with, but doesn’t that basically mean then that we scrap the cap or that the cap is changed in some way?

[303] Ms Davies: Scrap the cap—[Inaudible.] [Laughter.]

[304] Llyr Gruffydd: Yes. Well, absolutely, but in this context—. This is your opportunity, basically, isn’t it, because we will be reporting to Government, so you need to tell us what you think would make it better. So, is it as simple as just getting rid of the cap?

[305] Ms Dredge: I think we should be looking at need—assess need—rather than geographical—

[306] Llyr Gruffydd: And not a geographical basis.

[307] Ms Dredge: Yes, but having said that, we still need more, not less, resource.

[308] Llyr Gruffydd: And how you do it is another matter.

[309] Ms Dredge: That’s another matter.

[310] Llyr Gruffydd: But, in terms of a general approach, you think that targeting individual need is a better general approach than lines on maps.

[311] Ms Davies: I think it’s potentially difficult to be totally explicit about that. It’s worth recognising evidence given earlier this morning around the community cohesion and community development component of the geographical approach. Also, targeted resources can be useful in that way, in terms of protecting the ability to meet that need. But, obviously, we know that it excludes other families who have got levels of need as well.

[312] Llyr Gruffydd: But the consensus, then, is that it isn’t sufficiently flexible at the moment.

[313] Ms Davies: Greater flexibility would be useful.

[314] Lynne Neagle: Very briefly.

[315] John Griffiths: I just wondered, Alison: could you say a little bit more about a partnership approach overcoming those problems that I described with the two social housing estates? Just briefly.

[316] Ms Davies: I think it’s probably just principles of good partnership working, where you’ve got a number of agencies working in a geographical area, which may be statutory, third sector or otherwise. It is essentially about looking at the needs of that community and how best to meet them. There are examples across Wales of very good, effective partnership working where innovative solutions have been brought to difficult challenges. So, there are many examples in Wales that can be learned from or applied.

[317] Lynne Neagle: Thank you. We’ve got a lot to get through, so brief questions, please. Michelle.

[318] Michelle Brown: Thank you. We’ve already touched on the possibility of a mixed model. Public Health Wales commented that they thought there would be value in considering a mixed model. You’ve already talked a little bit about that. My very brief question would be: what would your ideal model be? As people who are doing this day in, day out, what would your solution be, if you could wave a magic wand and have whatever you wanted?

[319] Ms Dredge: If I could wave a magic wand, I would like to see the Healthy Child Wales programme continue to be used across, because both services have aligned, so we are using the same core programme. I would like to see a little bit more flexibility in the budget and the way we use that Flying Start money to be able to target more families. But all families need that universal delivery because that’s how we identify the families that need targeting. Unless all families are being seen, you won’t be able to target, and you won’t be able to get them to access services because that’s a lot of the work that the health visitor does. It is that universal access that’s important.

[320] Ms Milligan: I do think that professional judgment comes into it because there will be families, as we’ve already said, within the Flying Start areas that you will visit, and their need is not great enough for Flying Start, but there are families outside. So, professional judgment, I think, would come into it as well to address the appropriate needs.

[321] Lynne Neagle: Okay. Nothing to add? Do you want to ask your second question, Michelle?

[322] Michelle Brown: Yes. When it comes to evaluating the performance of Flying Start, we’ve heard that you count the number of contacts with Flying Start, but there doesn’t seem to be a specific breakdown of how many children have been accessing each part of the service. So, can you explain a little bit about that, and do you think that that is an appropriate measure for evaluating the effectiveness of Flying Start?

[323] Ms Milligan: I use their health visitor contacts. They are broken down—

[324] Michelle Brown: Health visitor contacts, sorry, yes.

[325] Ms Milligan: Yes. I think, the thing is, we work within a skill mix, so we have a team. It might well be that I might go in as the health visitor and make an assessment, and it could be a community nursery nurse who will then go in and deliver that. There are lots of contacts, but to just count the contacts with the health visitor doesn’t take into account how many contacts they are having with the wider Flying Start team.

[326] Ms Dredge: The other thing is that a lot of these families are very transient. Particularly in places like Cardiff and the Vale, they move in and out of private accommodation. That means they move in and out of Flying Start sometimes as well. So, keeping track of them—. What does it mean, ‘benefit from’? For what length of time? During the six months or year that they’ve been eligible for Flying Start, how many contacts have they had? What age was the child when they were having those contacts? So, no, it’s not a good measure because it doesn’t actually tell you anything.

[327] Ms Davies: It’s probably very important to think about: what do we want to know? What do we want to know? What do we want an evaluation to tell us at the end of the day? Then, we can work backwards to: how will we get to know that? That’s about measuring the type of service provided, of which quantity is a part, but a small part. And that’s often about, as I said earlier, the journey travelled by children and families in relation to growth and development and change and also the planned outcome initially. So, we probably need a far more mature and refined way of measuring the outcomes of Flying Start.

[328] Ms Milligan: Just picking up on one thing that Sandra just said, sometimes, a family will move into the area and the child might be two and a half, so they won’t have very much contact because they haven’t always lived in a Flying Start area.

[329] Ms Davies: Also, there’s probably a need to be clear about what comparators are used. So, if we are looking at Flying Start areas, then that’s one component of understanding the change that’s been undertaken in that area per se, but there’s been some mention earlier about the comparison of the level of change with non-Flying Start areas. Those non-Flying Start areas used as a comparator need to be carefully chosen to make sure that information and that comparator is accurate.

[330] Lynne Neagle: Thank you. Darren.

[331] Darren Millar: Just on that point, before I ask another question, if I can, there are no directly comparable areas to Flying Start, are there, because otherwise they would be Flying Start areas? The only thing you can compare between one Flying Start area and another is the relative progress, I suppose, of the young people in those areas because of the slightly different approaches that might be taken by each local authority. That would be correct, wouldn’t it?

[332] Ms Davies: Postcode is one comparator, but there may be aspects of children and families and specifics around interventions that can be looked at that would be more of a realistic comparator, rather than postcode itself.

[333] Darren Millar: I accept that. I noticed you were in the gallery earlier on—I get the privilege of being able to see who’s up there—and you will have heard some of the questions and the responses we were getting from the previous witnesses. Certainly, the postcode situation at the moment is a limitation to you being able to use your own professional judgment to determine who best needs the support, who needs the support more than others. The point I’m making is that you can’t compare area with area, but you can compare children in and children out of, but with similar levels of deprivation, a Flying Start area—yes?

[334] Ms Dredge: To an extent, but thinking about Cardiff as an example—sorry, that’s where I work—we have a really high BME community, therefore the needs of those children—I noticed you were focusing quite a lot on speech and language, and most of these children don’t speak English. So, when they start school a lot of these children don’t speak English. In the first year, the class teachers are struggling even with basic communication. So, you can’t compare a Flying Start area in Cardiff with Powys; there are completely different populations. Some of the fundamental social issues might be the same, and the safeguarding issues and all of that, but there will be different influences depending on where these children live.

[335] Darren Millar: That’s a very important point that you’ve made there and I think we’ll certainly have to pick that up in terms of evaluation. Can I just ask about health promotion messages? I think you mentioned earlier on, Alison, in your opening remarks about this being an important aspect of Flying Start. To what extent do you think that Flying Start is adding value to the existing public health agenda in terms of the public health messages that are getting out there? Particularly when you look at the fact that we’ve already got relatively successful immunisation programmes in Wales, both within and without Flying Start areas. What value does Flying Start add to that?

[336] Ms Davies: Just to go back to your previous point as well, Darren, we know the broader determinants of health are broad: postcode and housing is one, so that ties in with the comparator from before. In terms of the added value brought by Flying Start around the health promotion and prevention of ill health agenda, it’s significant because of that opportunity to provide a quality, intensive service to a child and family, which may not be accessible via the universal services because case loads are greater and there’s a level of unmet need outside the Flying Start areas. So, it’s that opportunity for bespoke, individualised, intensive support that can make a difference.

[337] Ms Milligan: I think as well the relationship we build, that you’re able to build because you’ve got a smaller case load—

[338] Darren Millar: That trust and confidence.

[339] Ms Milligan: Yes. Therefore, our clients are more likely to take on the advice that we give, because you have that very therapeutic, trusting relationship developed.

11:15

[340] Darren Millar: Yes, I get that.

[341] Ms Dredge: Well, from my perspective, I agree with everything that these two ladies have already said. But, in terms of the health promotion messages and the work that they’re doing, they work very hard to constantly look for innovative ways to spread the message of immunisation, as an example, and to increase uptake. But what they also do, and we work closely in partnership with them—. What they benefit from as well is having thinking time, and, in generic services, we don’t have thinking time; we’re constantly reacting to situations. But we’re able to benefit from their thinking time. So, they share a lot of their innovation with us. What we also do is, wherever possible, we share training. So, our staff are able to give the same messages; they just don’t see the clients as often. So, it benefits more children by us doing that, but the difference is that we don’t have the same level of access, because we just don’t have the time. So, Flying Start is benefiting the broader population as well, and I just thought I ought to make that point, you know. Over the years, I think most areas have developed good relationships between the two services to enable that to happen.

[342] Darren Millar: Can I just ask about this issue of the BME community? Because you’re the first to raise it. To what extent is Flying Start helping to improve health promotion messages specifically among the BME community, given that you’ve got this targeted resource that isn’t there generically?

[343] Ms Dredge: You’re asking me specifics about Flying Start, now, and it’s not a service I manage. To my knowledge, they have done various things, such as they produce videos and DVDs for families in different languages, so that they can do health promotion messages. I know they’re doing things like that. They also run clinics in those areas. We share clinics in those areas. So, where Flying Start and generic families are coming in, we work together and share those clinics, which helps our resources, but it helps them to get good access to their families. Because they’re not GP-allocated, they can be working with a lot of GP practices. It’s harder for them to build the relationships with the practices, so they benefit by sharing clinics and having that contact with the practitioners as well, the other practitioners in the family healthcare teams—I can’t remember what they’re called.

[344] Lynne Neagle: Okay. Thank you. Llyr.

[345] Llyr Gruffydd: Thank you. I see that the RCN tells us that speech and language support in the early years in non-Flying Start areas can be patchy and inconsistent. I just wondered if you’d tell us a bit more about that.

[346] Ms Davies: I think we’ve heard that there’s some specific focus on speech and language therapy in Flying Start areas. Whether that’s resource or service development in relation to that aspect of—[Inaudible.]—for young children’s growth and development going forward. Our members have told us that there is less consistent access to speech and language therapy in non-Flying Start areas at times. Obviously, that’s something to consider in terms of this agenda going forward, because it creates an inequality for children within and outwith those Flying Start areas.

[347] Llyr Gruffydd: So, is it that we are seeing the resource being sucked in, in terms of workforce, for example, to Flying Start areas, which isn’t a bad thing for them, but, of course, then, other areas might have to go without?

[348] Ms Davies: There are probably a number of factors in terms of the speech and language therapy workforce and where that workforce chooses to be and why. From our perspective, I think it’s important because, for children in non-Flying Start areas, where health visitor case loads are higher, there’s less of an opportunity to undertake that preventative work and therefore more of a need for speech and language therapy. So, there’s that balance of inequality.

[349] Llyr Gruffydd: So, is the workforce sufficient in that respect? Because I thought I knew that there weren’t enough practitioners out there.

[350] Ms Davies: I think the health visiting workforce—I understand the chief nursing officer is undertaking a review at the minute, and we hear of great variety in terms of case load numbers. So, we know that, for the M4 eastern corridor, there’s probably a higher level of case load per health visitor than in other areas. Certainly, we know that, as Flying Start proves, the quality and intensity of service provided to children and families early on makes a great difference later. So, yes, the more health visiting resource we have, the more likely we are to support children in the first 1,000 days.

[351] Llyr Gruffydd: Well, now that you’ve mentioned health visitor numbers—. We have heard about whether the capacity is there or not, and there have been examples given to us earlier. And I’m just wondering to what extent are you content that enough is being done to address the lack of numbers, if you like.

[352] Ms Davies: I think that’s an important consideration when we look at health visitors and nurses. So, we need to make sure that our commissioning of student nurse numbers is right at the beginning, so that we’re looking at the whole workforce need. Very often, we are concentrating on nurses who work in acute services, and, more greatly, primary care, and the independent sector, all of which are obviously essential services. Health visiting is one of those services as well. So, we really need to get commissioning numbers right up front. We also need to understand the level of education and training that’s available to nurses who wish to become health visitors, and we know that that training has recently changed to a modular model, which means that it’s likely to take longer to train health visitors than previously. It’s also reliant on other service areas to potentially support nurses to come in and undertake that training. And, also, our experience with district nursing, when that training became modular, was that fewer district nurses completed the training. So, these are all factors we need to think about.

[353] Another factor relates to the fixed-term contract nature for health visitors working in Flying Start. Because the funding is cyclical—

[354] Llyr Gruffydd: Yes. We touched on that earlier.

[355] Ms Davies: —not all health boards will provide a permanent contract, and, therefore, the attractiveness of working with a fixed-term contract isn’t always there.

[356] Llyr Gruffydd: So, you’ve listed very valid issues there that we need to think about—your words. Is the Government still just thinking about them, or is there actually something happening to address some of these issues?

[357] Ms Davies: Well, I’m aware that the chief nursing officer has recently held a think tank in relation to the health visiting workforce. There is always work being undertaken to positively influence the commissioning figures for student nurses in Wales. Those are the aspects that I’m aware of.

[358] Llyr Gruffydd: Okay. I raised earlier as well the big variation between local authorities and the number of Flying Start health visits per child, or visitor contacts, I should say, per child, from three and a half per child in Blaenau Gwent up to six in some other areas. What’s your view on that? The suggestion was that there’s a combination of factors, but part of that is, I’d imagine, numbers of health visitors.

[359] Ms Milligan: I think as well you need to factor in sickness, staff who are off, vacant case loads. I think all of those will have a bearing on the number of contacts.

[360] Llyr Gruffydd: So, you’d agree that it’s—

[361] Ms Dredge: There are not enough health visitors, no.

[362] Llyr Gruffydd: Yes. Not enough bodies out there to provide for these—

[363] Ms Dredge: But that’s not just a funding issue. That’s about other things, such as more health visitors now retiring earlier, doing retire and return, going down to part-time hours, and higher case loads as a result. Higher case loads are impacting on people’s well-being, and so they’re retiring perhaps earlier than they would have done. So, there are all sorts of issues that come into play there, but, essentially, we haven’t got, across the board, enough health visitors.

[364] Llyr Gruffydd: The previous panel referenced people retiring and the demography of the sector, if you like, or the workforce—

[365] Ms Dredge: An ageing population.

[366] Llyr Gruffydd: Yes. An ageing population, yes. So, how sustainable is the service then, longer term, unless we crack this nut?

[367] Ms Dredge: I think that the—

[368] Llyr Gruffydd: We’re not panicking yet, are we?

[369] Ms Dredge: I think that we are looking at ways of developing the service, and we are currently looking at introducing a family skill mix in terms of registered nurses to undertake the modular training because we just don’t have enough students going through.

[370] Llyr Gruffydd: And are you happy that Government, health boards, local authorities, are all working together and pulling in the same direction on this, or does something need to happen to bring them all together to address some of these issues?

[371] Ms Davies: I think it’s an interesting question in terms of long-term sustainability for nursing per se. And I think, when we look at media coverage, and other sources of information with regard to the NHS per se, and nursing, then we probably would be wise to undertake quite a lot of work to enable our children and young people, who receive the service at the minute, to consider a career within health and nursing going forward. Obviously, we’ve had the ‘Train. Work. Live.’ campaign within Wales and the outreach outside of Wales. I think more of that, and more longer term planning about how we have a sustainable and health social care workforce in Wales—this is a component of that.

[372] Llyr Gruffydd: Part of it, yes. Thank you.

[373] Lynne Neagle: Thank you. Mark.

[374] Mark Reckless: Are you sure we get value for money from Flying Start?

[375] Ms Milligan: Absolutely. I think we are in the forefront, the health visitors, of the team within Flying Start. We’re very much able to work proactively with these families from day one, so, absolutely, I think so, yes.

[376] Mark Reckless: Alison.

[377] Ms Davies: My perspective is: Public Health Wales provided that very useful evidence base about the investment in the first 1,000 days of life that makes a big difference, going forward. We’ve got the ACE work that illustrates that to us as well. We’ve got some evaluation around Flying Start, and I think, if we further refine the way that we evaluate interventions, rather than contacts—

[378] Mark Reckless: Why is the evaluation so poor around Flying Start? Why don’t we have double-blind academic studies? Why don’t we have good comparators of the areas, compared to perhaps smaller areas in other local authorities of similar—?

[379] Ms Davies: I’m not sure I can answer your question as to why. Your perception is that the evaluation is poor; I can only reiterate the need for good evaluation. That would help us, going forward, then, to make sure we were investing—

[380] Mark Reckless: Sandra, I know you said you didn’t manage the programme, but do you feel confident value for money is delivered by Flying Start, or is that something on which you wouldn’t feel sufficiently sighted to give a judgment?

[381] Ms Dredge: I think that, in the most part, yes. I think, as we’ve already discussed, there are probably some tweaks that could be made to increase the spread and the eligibility. I wouldn’t want to see any money taken out. I’d love to see more money put in, because all the evidence base is here around the early years, and these children are, for the most part, the most vulnerable. The postcoding does confuse that a little bit, but they are by no means the only vulnerable children, and so we really need to look at how we can extend the scope of the programme.

[382] Mark Reckless: But what evidence have we got that the specific interventions we see through Flying Start work in reducing inequality, the stated goal of the programme, or improving outcomes for the children who benefit compared to those who don’t?

[383] Ms Dredge: I think, reiterating what people have said before, and on the previous panel, a lot of it is about journey travelled, rather than these just basic figures about things. As I’ve already mentioned—speech and language. Some of these children don’t even speak English, so, you know, you have to start from a base point. They’re hard-to-reach families, they don’t engage easily with services, therefore, getting them to engage can take several visits and several contacts. Getting them then to access GP services is another distance travelled, because they wouldn’t have done it before. Therefore, that is a benefit to the children and to the families, but it’s not something we’re measuring. What else can I think of?

[384] Ms Milligan: I think there seems to be a lot of quantitative data, but not a lot of qualitative data.

[385] Ms Dredge: All the work that is done, for example, around prevention of accidents—how do you measure that? Because, by nature of the fact they’re then not having an accident, you haven’t got an accident figure to measure. But it’s difficult with the accident figures to tease out which are Flying Start, which are non-Flying Start.

[386] All I can talk about is knowing that, when you speak to schools, and I manage school nursing as well as health visiting, the teachers, by and large, say that they can definitely tell the difference with children who have been through the Flying Start programme, because they come into school and they’re better able to concentrate, they’re able to sit, and they’re ready to listen, because they’ve been having all of the additional services, they’ve been into childcare. So, I don’t know how much difference it’ll make to their actual academic outcome in the end, but the fact that they’re able to sit and listen and concentrate gives them that flying start.

[387] Mark Reckless: You raise accidents. Surely, when a child goes into accident and emergency, their address is taken—what is stopping Welsh Government or academic researchers assessing is that accident rate higher or lower for children from Flying Start areas, and is it going up or down relative to other areas? Why hasn’t—? There are very large sums of money being spent in this area, and, certainly, assessing the degree of evaluation that’s been done, I’m disappointed in the quality of that work relative to the amount of money on its own. I’m not disagreeing with what you say about the outcomes are good, but I just wish I could see that through clearer, robust evaluation, in addition to the more anecdotal reports, which you rightly share.

11:30

[388] Ms Dredge: I think if you want more robust evaluation, one of the things that we have to sort out is things like IT. We’ve got a fantastic IT system in Cardiff. We use electronic records and we’re the only area that’s really got them going at the moment—we use PARIS system. And, a decision has been made, now, not to go with PARIS, but to go with a different system, so, gradually, that’s coming in, but that will take time. The systems don’t talk to each other. Collecting data is therefore very difficult. When you look at immunisation figures, they’re not correct. When you look at GP practice figures, they’re different to the child health figures, they’re different to what the NHS Wales Informatics Service have got. The IT systems need to be sorted as a priority, I would say.

[389] Mark Reckless: So, when we see 2016-17 statistics for vaccinations, saying only 82 per cent in Flying Start areas have had the full vaccination, a slight decrease, at below the 86 per cent outside—

[390] Ms Dredge: That may not be correct in all areas. The IT systems are not good.

[391] Mark Reckless: You just don’t think we can rely on those figures.

[392] Ms Dredge: No.

[393] Ms Milligan: And, that’s already not reflected in Cwm Taf, which has 97 per cent.

[394] Mark Reckless: Yes, we had your colleague before—. Again, congratulations.

[395] Ms Davies: A couple of key points there. One is that we know that there’s an evidence base that Public Health Wales put forward around the effectiveness of investing in the first 1,000 days of life. We also know of the issues when that investment is not made. I agree that we probably need a more refined evaluation process for Flying Start in Wales, so that we can demonstrate the effectiveness. Although the information is anecdotal from practitioners and others around the impact made of Flying Start, from our education colleagues and families themselves, it would definitely be worth capturing that so that a picture is put forward to support that this is the way forward.

[396] Lynne Neagle: We’ve come to the end of our time, so can I thank you very much, all of you, for attending and for answering our questions? You will be sent a transcript to check for accuracy in due course. Thank you very much.

[397] Ms Milligan: Thank you very much indeed. Thank you.

11:33

Ymchwiliad i Dechrau’n Deg: Allgymorth—Sesiwn Dystiolaeth 3
Inquiry into Flying Start: Outreach—Evidence Session 3

[398] Lynne Neagle: Our next evidence session is with the Flying Start managers’ network. I’m very pleased to welcome Sarah Mutch, who is Flying Start manager at Caerphilly County Borough Council and chair of the all-Wales Flying Start managers’ network; Liz Wilson, Flying Start health and social care manager, Carmarthenshire County Council; Hannah Fleck, service manager community well-being, Conwy County Borough Council; Claire Lister, head of integrated adult and community services, Conwy County Borough Council; and Sarah Ostler, Flying Start co-ordinator, Merthyr Tydfil County Borough Council. Welcome to all of you and thank you for attending. If you’re happy, we’ll go straight into questions from Members, and I’ve got John Griffiths first.

[399] John Griffiths: Thanks, Chair. Good morning, everyone. Your paper described the outreach provision in nine local authority areas in Wales. I think we’d be interested in the picture right across Wales, and whether that situation in the nine is the situation in the others as well. And, are the criteria for outreach provision very different across Wales?

[400] Lynne Neagle: Who’d like to start?

[401] Ms Mutch: If I start then, please. These were the nine responses, I suppose, from the local authorities that responded quite quickly, and I think sometimes that is the issue, where not everybody can respond as quickly as others. I think the nine reflects the diversity across Wales, and the reason for doing the two sections, one around the outreach and one around the alignment, was to give a flavour of the range of methods used across Wales. So, it probably reflects similar across Wales. There is Flying Start outreach guidance, which we all look at and use, and I think most people use a JAFF, or a referral criteria of some sort, for the actual outreach element because it is quite small. So, therefore, you have to have a criteria, otherwise you would open it to everybody. Does anybody want to—?

[402] Lynne Neagle: No? Okay.

[403] John Griffiths: I think we’ve already heard this morning quite a number of approaches to outreach, and what that outreach consists of. Do you think that that sort of variety is necessary to respond to the different needs across Wales, or do we need more consistency?

[404] Ms Mutch: I think in the past we have done workshops as well to look at whether we can get a consistent model across the whole of Wales. However, because our communities are very complex, and the needs of families can be very, very, different, we came up with the conclusion that no one size fits all. It goes back to the core Flying Start programme, so it’s not like we do anything that is outside of the Flying Start delivery. So, there is a kind of consistency across the 22, but the referral criteria very much have to reflect the local needs of that population. And also, we’ve been talking about the flexibilities and things like that, where you’ve got the other programmes, and those are very different in each local authority. So, you have to look at each local authority and how they deliver their Families First, their Supporting People programmes as well.

[405] John Griffiths: So, do you think it’s entirely a matter, then, of meeting local needs and about variety of local needs, or are there other factors at play?

[406] Ms Lister: I think there are other factors at play, depending on how the other grants that we have are accessed and delivered. So, as Sarah said, the grants are arranged in a variety of ways around the different local authorities. So, for example, in Sarah’s local authority, if you use your Families First grant to actually match the provision that Flying Start have, that’s not available in our local authority, so that’s an issue as well, I think, the way the grants are structured. We’ve all, over the years, developed our grant responses that are very, very different across the 22 authorities. The population needs are very different as well, so, that’s another big test at the moment, and big pressure.

[407] John Griffiths: Okay. Would anybody like to add anything to that?

[408] Ms Wilson: I think the rurality, as well, in some areas of Wales; it is difficult, if you’ve got your Flying Start concentration, so you rely, then, on your Families First, and the other element of that is you’re relying on different organisations like the health services, the health boards, and their commitment into the outreach and what they can provide as well.

[409] Lynne Neagle: Okay, thank you. Llyr.

[410] John Griffiths: Could I just—

[411] Lynne Neagle: Very quickly, then.

[412] John Griffiths: In my experience, there was a Flying Start provision within a community centre on a social housing estate. Another social housing estate next to it wasn’t within the postcode, and there was spare capacity at that facility and the people running it told me, ‘We’d love to take children from that other estate, but because of the postcode issue, we’re not allowed to.’ Is that something that you’re familiar with?

[413] Ms Lister: Yes. Yes, that’s a real test, and that’s a real pressure in terms of the use of the postcode, particularly when we look at our uptake of Flying Start. Our numbers are reducing because our population is much more diverse now. We’ve got our families, who you perhaps would want to encourage to access the Flying Start provision, who live outside the Flying Start catchments because of housing need. We’ve got high requirements of private rented properties, so, many of our families are spread across the county now. So, our numbers are reducing and we can see that year on year. That’s a real challenge. So, yes, the postcode is definitely a barrier.

[414] Lynne Neagle: Thank you.

[415] Ms Ostler: I think it’s just about being reasonable in that situation, and I’m very much going back to how we use the grants. Obviously, what we’ve got coming is the funding flexibility. And in that situation that you described, where you’ve got a group that isn’t up to capacity with Flying Start families, we would look at using other grant sources and co-facilitating groups, so that it’s open to a wider community other than just Flying Start. It’s about the best use of resources.

[416] Lynne Neagle: Thank you. Michelle.

[417] Michelle Brown: Thank you. Do you know how many children across Wales are benefiting from the outreach programme?

[418] Ms Mutch: The children aren’t recorded separately. So, the apportionment is 2.5 per cent of the uplift, but it varies from Monmouthshire with about five children, up to Cardiff with 54. So, it depends on your cap number and therefore the amount of money you get and therefore the amount of 2.5 per cent of the uplift. So, it was based on 2.5 per cent of the expansion. For example, in Caerphilly, we went from 1,252 to 2,483 in the total programme. The 2.5 per cent is based on the 984 difference, which gives us 24 children in the outreach, which is why you need very specific criteria. Again, the difficulty, particularly with the childcare element, is you may have spaces this term, but you may not have spaces next term. So, how do you give consistency to families? Equally, you might have spaces this year for the neighbouring estate, but you might not have next year. So, again, it’s about the expectations and how you manage that, as well.

[419] Michelle Brown: It does seem to be a very, very small number of children.

[420] Ms Mutch: Yes.

[421] Michelle Brown: There’s a lot of money spent on Flying Start; I appreciate that the lion’s share of that will be spent in actual Flying Start areas, but how many children outside of the Flying Start areas are being reached? And how many of those children actually need to be reached? Because Flying Start doesn’t—. It covers the main areas of deprivation, but there are plenty of other pockets of deprivation around Wales that Flying Start doesn’t seem to be reaching. So, do you have any comment on that?

[422] Ms Mutch: I think it goes back to what we were saying about the flexibilities and looking at the other grant streams. So, like Claire said initially, in Caerphilly, Families First will deliver all of the elements apart from the childcare. The childcare element is a very, very small element in Families First for children with additional learning needs. So, it’s much more targeted outside of those areas. So, families who are in disadvantaged communities can access provision. It’s not the same nationally, but the guidance for Families First only changed last year. So, you may see, with the flexibilities projects, that there’s greater reach. But obviously, we wouldn’t capture that within Flying Start; that would be captured in the other programmes.

[423] Ms Lister: I think the grant flexibilities will enable us to meet the needs of the population that require the provision. Because, for me, it’s very clear that those families who would be considered to be in deprivation don’t necessarily live within Flying Start postcodes anymore because of housing, so they are dispersed amongst our communities.

[424] Lynne Neagle: Okay, I’ve got Llyr and then Darren on this.

[425] Llyr Gruffydd: You mentioned that it’s a challenge to provide that consistency when numbers go up and down, well, how do you do it then, because you have to manage that now?

[426] Ms Mutch: Yes. We manage it within our Flying Start areas, because we’ve got the case load numbers. So, a lot of us will projection plan for all our places. Many of us use mixed economy provision. So, we buy on a per-place or on a per-number-of-places basis, but we can manage our budgets against those projected numbers. The difficulty comes if you have a targeted approach outside of Flying Start areas. How do you predict how many might need it at any one point in time? It becomes far more difficult.

[427] Llyr Gruffydd: So, how do you do it then?

[428] Ms Mutch: I suppose, in our area, Families First would do that. Within Flying Start, we know when they’re born, so we can plan for the two-year-old childcare, for example, from when they’re born. The rest of it, we plan on a per-year basis.

[429] Llyr Gruffydd: You just go from year to year.

[430] Ms Mutch: Yes.

[431] Ms Wilson: There are some difficulties, though, in new social housing developments. The flexibility would be beneficial here, because, from a Hywel Dda health board perspective, there was a housing development of 200 houses in the Pembrokeshire area, and these families were moved into the new social housing, and they were families who already existed in Flying Start, but they were outside of the postcode. So, that was quite a big impact on both service areas, then.

[432] Llyr Gruffydd: That’s a lot of people.

[433] Ms Wilson: Yes. And, it’s managing that, really. I think more flexibility would allow us to do that. But also, it’s the organisational buy-in, because I know health boards are very concerned about the risk element, obviously, with the staffing when they do bid for Families First grants as well, because the grants are not as predictable [correction: guaranteed to continue], and then you’ve got the risk element if the grant finishes.

11:45

[434] Lynne Neagle: Darren.

[435] Darren Millar: Yes, it’s just a very brief one. This 2.5 per cent cap, how was that arrived at? Was there any discussion with you, as Flying Start managers? Where did it come from? Was it a finger-in-the-air job or—?

[436] Ms Mutch: I have no idea, but I think, initially, it was more of a pilot to look at what’s the potential, and I think that’s where then they started looking at flexibilities and virements between programmes and things like that, and it’s been much more on a local authority basis. What it did give us was a small amount to actually work out, ‘Well, how would it work in this local authority?’ So, it’s given us that kind of ability to pilot things that the programmes, all of the programmes, are far more evolved at now, and our thinking as local authorities, as public bodies, has become far more evolved. So, I think we’ve got a more mature discussion when we’re going into potential flexibilities, et cetera.

[437] Darren Millar: But if you were to set flexibility criteria—clearly, at 2.5 per cent, you are finding it difficult. Everybody seems to be finding the postcodes difficult and the flexibility level very difficult. Where would you set it at? So, if you were required to keep postcode eligibility, what sort of tolerance in terms of that flexibility do you think would be more appropriate?

[438] Ms Lister: In terms of the grant flexibility programme for next year, we’ve got a 100 per cent grant flexibility within Conwy.

[439] Darren Millar: One hundred per cent.

[440] Ms Lister: One hundred per cent grant flexibility within—is it nine?

[441] Ms Fleck: It’s five initial grant funding streams that have been identified, with five others that are under consideration.

[442] Ms Lister: So, we’ve got the opportunity to really look at the provision in a different way, and also look at the outcomes that’ll be measured as well, so we’ve got a really good opportunity ahead of us. I think there are nine of us as pilot organised local authorities able to do that next year with the full flexibilities, with the provision being extended to the other local authorities, I think—

[443] Ms Fleck: Fifteen per cent they’re able to look at, therefore—

[444] Darren Millar: Okay, so that’s going to shift from the 2.5 per cent right up to 15 per cent, so—

[445] Ms Mutch: And it’s the virement between programmes. So, that’s the difference. This is not purely about Flying Start funding. This is about the other big grants—

[446] Darren Millar: So, there’s a transfer of cash in from other areas, the grant streams that you mentioned earlier on.

[447] Ms Wilson: Yes, it’s the deprivation grants—the primary deprivation grants.

[448] Ms Ostler: What’s worth noting is that 2.5 per cent on the uplift—yes, it is minimal, but, actually, it came with no additional funding, so we were required to reach those additional families without any uplift to the budget. So, I think that’s why it was kept at a minimum at the time, because there were some authorities, like ours, who’ve always been working just above our cap number to take additional families into the programme. That’s obviously got those financial implications then.

[449] Lynne Neagle: John, on this.

[450] John Griffiths: I was just going to ask about—so, we know that two thirds, then, of those families in deprivation are outside the Flying Start areas. You say there’s quite a lot of flexibility with different programmes. So, to what extent are the services that Flying Start provides reaching those two thirds that are outside the Flying Start areas?

[451] Ms Mutch: I think that the reality is that it depends on each local authority as to how they’re using their current funding streams. So, for example, within Caerphilly, we’ve matched Families First and Flying Start, so, other than the childcare, the rest of the Flying Start programme is, in effect, contracted—we’re contracting the same services. So, we’ve joint contracted. So, the reach is very good; if they need it, they get it. However, that is not the same across every local authority, and it depends on how the different programme managers have aligned their programmes. There is far more alignment now, but the synergy may be at different maturity levels. But, moving forward—

[452] Ms Lister: Moving forward, the future could look quite different, though, in terms of the way that we’ve got the opportunity to do things very differently on a community basis to understand the needs of communities, so to use the five deprivation grants in a very, very different way, in a flexible way, so you can reach out to the families to meet their needs. From our local authority perspective, what I want to do is look at the foundations of Flying Start and say, ‘Actually, this service needs to be open and accessible to all, because parenting is hard for everybody. It is difficult.’ So, we actually want to make that offer available to everybody. The childcare offer is the bit that will be difficult, because, obviously, there are huge financial implications to that, but we want to explore that, because I know that, in my local authority, it’s families who are working who are struggling. So, we’ve got a shift in terms of the need as well. So, we do need to look at that and think about it. We might not have the answer, we might not be able to afford it, but we do need to think about it at least, and give it some consideration as part of next year’s flexibilities.

[453] Lynne Neagle: Okay. Thank you. Hefin.

[454] Hefin David: So, given your answers and the complexity of the funding, is it simplistic to say that you can ring-fence money for outreach within the budget? Is that too simplistic, or are you finding ways of being creative to do that?

[455] Ms Fleck: I think it’s possibly a little simplistic to think about it as ring-fencing, because you’re almost then seeking to engage a certain number of outreach cases. You might be stretching that need and, in effect, providing an element of disempowerment for that family that’s actually doing really well to make sure they fit the criteria. Conversely, it’s about making sure that we are really realistic that actually we’re making as best use of that 2.5 per cent as possible and those referral pathways into the outreach provision, and also to understand the stretch of that outreach provision, because for some families it’s about accessing speech and language therapy in a really timely fashion at the point at which they’re needing it—it’s not about intensive health visiting; it’s not about childcare costs. And I think there are times when, outreach, we look at it and you might think, ‘Well, actually, this is interesting because this appears to have been effective at gaining childcare costs without any other need, potentially, being as clear, and actually was it a childcare cost need or is it about how somebody’s presented something at that time?’, because you would anticipate with outreach there’d be more need than simply one element of Flying Start’s offer. So, how are they engaged and engaging in other aspects of that programme?

[456] Hefin David: So, does that happen elsewhere?

[457] Ms Wilson: In Carmarthenshire, I think it’s beneficial when they’re doing—. We’ve got a lot of transient population in certain areas, so, through the outreach programme, if we’ve got things that we haven’t finished, like unmet need in the general programmes that we are delivering, we’ll keep them as outreach until we’ve finished that piece of work, and it assists then in our transition into Families First services. So, it allows you that scope to do that.

[458] Hefin David: So, you’d need a degree of flexibility within the budget, rather than saying, ‘This is how much we’ve allocated this year’.

[459] Ms Wilson: Yes, definitely.

[460] Hefin David: Is that the same in Merthyr as well?

[461] Ms Ostler: It’s absorbed within our budget within Merthyr; we don’t have a ring-fenced amount for outreach as such, because we don’t know what needs are going to come through from the families that are in receipt of outreach provision. But there’s an acknowledgment that those costs for outreach will be absorbed within the budget on the basis that the maximum children we support would be 16, and that’s happened to date. 

[462] Ms Mutch: I think in the paper you’ll see the national picture. A lot of the authorities will look at that transient nature, where families move out, and then some local authorities will also target a particular population. So, Cardiff has got targeted work in there as well. So, there are differences nationally as well where there are particular communities of interest that need more services.

[463] Hefin David: So, how would you articulate that as a strategy in your Flying Start delivery plan? It’s not easily done, is it? How do you do it?

[464] Ms Mutch: There’s an outreach element in the delivery plan that we actually put in what we do.

[465] Hefin David: So, you describe what is happening rather than a plan to deliver?

[466] Ms Mutch: It’s a bit of both. So, the delivery plan goes in every January, between December and January, and it’s about a negotiated plan—‘this is what we aim to deliver next year’. It’s not necessarily as specific as numbers, and a lot of authorities have given you what they would put in their delivery plan as part of the evidence, and also the alignment element because, again, different authorities are in different positions as far as the alignment. So, the Welsh Government then uses both of those sections to explore how you’re going to deliver it next year.

[467] Lynne Neagle: Hannah, did you want to come in?

[468] Ms Fleck: I did, but I’ve forgotten my points. [Laughter.]

[469] Hefin David: It happens to me all the time; don’t worry about it. That’s okay.

[470] Lynne Neagle: Hefin.

[471] Hefin David: No, I think that’s fine. It was very clear—the whole picture.

[472] Lynne Neagle: Thank you. Darren.

[473] Darren Millar: Thanks. I just wonder: do you think it would be a better approach for the Welsh Government to take if they simply set the outcomes that they want you to achieve as local authorities, and allowed you to spend the deprivation money in whatever way you felt was best?

[474] Ms Lister: It’s actually slightly better than that, I have to say, because we’ve been given the opportunity to have a discussion about the outcomes that we want to see for our populations. So, it’s turning it slightly on its head. In preparation for that, one of the things that we’ve done is identify through all of the deprivation grants what it is that we have to do, the returns on, what is it that’s currently being measured, but, actually, what is the understanding in terms of the need of the communities, because we might want to measure something else. Because some of the measures that we have to, and the outcomes that we have to, achieve at the moment, I wouldn’t say they’re meaningless, but they don’t evidence the change that you’d want to see.

[475] Darren Millar: Yes. So, if this is about reducing inequality, if they just gave you three or four key performance indicators that they wanted you to shift, and allowed you to determine how best to influence those factors—[Inaudible.]—communities it would be easier, wouldn’t it, I assume, because you’d be able to tie it in with some of the other work you’re already doing as local authorities.

[476] Ms Lister: Yes.

[477] Darren Millar: Okay. That wasn’t the question I wanted to ask, though. It was about open referral criteria. Do any of your local authorities at all allow people to self-refer in, or for—

[478] Ms Fleck: In relation to outreach, or in relation to Flying Start?

[479] Darren Millar: In relation to outreach specifically.

[480] Ms Fleck: Specifically.

[481] Darren Millar: So, if they’re outside of an area, but they’re in desperate need—

[482] Ms Fleck: We don’t prohibit it.

[483] Darren Millar: You don’t prohibit it. So, you’ll consider anybody, basically.

[484] Ms Fleck: We would consider it. Because, actually—. There’s a difficulty, isn’t there, because, actually, for somebody to identify that they are in that level of position, often it’s a situation where they’ve maybe got more self-awareness. They may have identified very covertly with somebody who’s then more likely to access an advocate to say, ‘Actually, these are the needs that have been identified.’ Because, actually, once somebody’s identified those needs, it’s the needs we’re looking at, it’s not the referral point and the source. It’s about that individual’s individual needs.

[485] Darren Millar: So, you would consider, basically—.

[486] Ms Fleck: We would consider that.

[487] Darren Millar: The reason I ask is that there are times when individuals have contacted my office, living outside of the area, but there’s a mum in school and it’s making a real difference to her and her family, and she’s inside the area. I would assume that it’s through those sorts of conversations around the playground or whatever—

[488] Ms Fleck: It’s often word of mouth, yes.

[489] Ms Ostler: Ours would still only be in line with the criteria. So, in Merthyr, in particular, it’s for families who’ve been assessed to be high or medium risk, who move out of the Flying Start area. So, they would still need to meet with that criteria, because if it was too open—. We’ve discussed the minimal amount. It’s a small amount for outreach. If we were to open that, it would open the floodgates. So, it would still have to be—. Self-referral would still have to be within the set criteria.

[490] Darren Millar: To what extent has the fact that there is an opportunity for outreach raised expectations to some extent? Are there people coming and saying—

[491] Ms Ostler: It’s not something that we openly publicise for the reasons that I’ve just mentioned around it being a very small amount of numbers. So, we don’t openly publicise it to the community. We work with the professionals within the Flying Start programme, who are aware of the criteria, and, in our case, it would very much be a health visitor or a childcare provider who knew a family were going to be moving out of area and would make that referral for them then.

[492] Ms Mutch: And I suppose, to add to that, it depends on your programmes that are set up. So, again, in Caerphilly, Families First, they can self-refer. Similarly with JAFF, the joint assessment family framework. Either families can self-refer, or a professional can refer. But, when the professionals are looking at that referral, it may well be that that family could qualify for Flying Start outreach as well. And so they will have a discussion with us then about how we can enhance that package, and that’s primarily with the team around the family team.

[493] Darren Millar: Thanks.

[494] Lynne Neagle: Thank you. John, on evaluation.

[495] John Griffiths: I think we’ve probably adequately covered that, Chair.

[496] Lynne Neagle: You don’t want to ask anything else on that. Okay. Do you want to go on to the other questions you were going to ask, or—?

[497] John Griffiths: I think we’ve probably—postcode eligibility I think we’ve probably dealt with as well.

[498] Lynne Neagle: Okay. Llyr.

[499] Llyr Gruffydd: Yes. Thank you. You say in your paper that Flying Start has a very clear evidence base, however the outreach element principles don’t fit the evidence base. Could you elaborate a little bit? I know we’ve touched on some of this, but I just want to understand why.

[500] Ms Mutch: I think the Flying Start programme, how it was constructed back in 2006-07, was very much based around the EPPE research, the effective provision of pre-school education. That was done within England, and that was done in the year 2000, and they tracked those children right the way through. So, actually, it fundamentally underpinned the evidence for the Flying Start programme. I suppose the issue with outreach is that a family wouldn’t necessarily have all four core elements—they don’t necessarily live in the geographical area, the needs may be very different and they’re targeted, whereas the research evidence it was based on was raising a whole community aspiration. So, the evidence is slightly different. It’s not to say that outreach wouldn’t work—

[501] Llyr Gruffydd: That’s what I was going to ask. Are you suggesting that—

[502] Ms Mutch: No. It doesn’t say that outreach wouldn’t work, but it doesn’t work on the same fundamental principle as the Flying Start, geographical—there’s a lot of research now around a place-based approach. And that’s where the flexibilities and the community projects come in.

[503] Llyr Gruffydd: But that undermines the outreach approach, then, really. What you’re saying is that we don’t really know whether this is doing anything.

[504] Ms Mutch: The outreach element is very small. Families First is doing a lot of evaluation. Supporting People does a lot of evaluation. They would give you a better reflection on a targeted programme and intervention and evaluation around that. The place-based approach, which is more of a Flying Start programme evidence base, is different. But on the outreach, the evaluation is around case studies—around whether it’s made the difference to meet the needs that have identified the need for that referral.[1]

12:00

[505] Llyr Gruffydd: So, how would you address that deficiency, then, because it sounds a bit as if we’re suggesting that, really, outreach is just a nice thing to do, but we don’t really know whether, because there are other things that could potentially do a bit of this as well—? Are we suggesting that outreach is just a bit of an add-on that isn’t necessarily achieving what we’d like to think it is?

[506] Ms Mutch: No. I think if you look at it more, it’s about the place-based approach being extended and how you meet, like you said, the isolated pockets outside, but you can’t apply the same evidence principles to those.

[507] Llyr Gruffydd: No. So, should we just make it universal then?

[508] Ms Mutch: If you’ve got loads of money. [Laughter.]

[509] Llyr Gruffydd: Well, that comes back to the mixed model stuff, doesn’t it, and the regional approach? It’s how you put it back together after taking it apart.

[510] Ms Lister: I think from my basis, it’s about having the fundamental principles of Flying Start as a universal provision. As I said before, parenting is difficult for everybody at some point, whether that’s at 3 o’clock in the morning or at the school gates—parenting is difficult and we need to be able to support parents because what we want is for those young individuals to have a really good grounded start in life. On a place basis as opposed to a postcode basis, which is different because place is much wider, you are then able to do that, but the grants need to be able to be flexed, which is what we’ve got the opportunity to do. I think the outreach is good because I think it does enable us to continue programmes; it enables us to target where we’ve got dispersed communities or dispersed families, but, as you say, the evidence of it isn’t going to be strong. A place-based approach is the way to go.

[511] Ms Wilson: I think you’d have evidence on an individual case study basis because obviously it has made a difference to those families, but it’s about being able to—we are all doing it—work smarter in collaboration and plan strategically with the other programmes. It’s about having the flexibility to develop that further, I think; that’s really important.

[512] Lynne Neagle: So, just to clarify: there’s been no official evaluation of the outreach element of Flying Start in any area in Wales.

[513] Llyr Gruffydd: So, you would rather that we start from a universal perspective, albeit with a limited budget, and then decide what we can provide within that context and whether then you adopt a more pick-and-mix approach in terms of which streams are provided in various places. Would you prefer that kind of approach, rather than the geographical approach that’s currently in place? Because as much as we’d wish for more money to be available, I can’t see that the budget is going to double overnight.

[514] Ms Lister: I think that what has actually happened is that we’ve been given the opportunity in the pilot or the pioneer areas—sorry, pathfinder areas; they’ve got different names for everything—to flex the four deprivation grants: so, Supporting People, Families First, Flying Start and the legacy fund, and employability has come into it as well. So, there are five in fact, not four, but those first four are the fundamental ones. Depending on how we’re able to flex, because obviously the funding is committed to various projects across those programmes, you could, in essence, start from scratch, and you could identify the needs of a population. If that population needed the core offer—the universal offer—you could do that, using the pot of money. But that’ll be a big ask, because obviously money is committed.

[515] Ms Ostler: I do think that there is something to be said for the geographical approach though, in the sense that providing services to a whole community reduces the stigma of accessing those services—it creates a balance of families accessing them. And, going back to the EPPE study that Sarah mentioned, there was evidence there to suggest that families who were coming from different socioeconomic backgrounds, the children who came from more disadvantaged backgrounds benefited much more from being in that mix of provision. It is about raising aspirations for the whole community, so I think there is definitely something to be said for that geographical targeting that we’ve seen in Flying Start and we’ve seen that it has worked around raising the aspirations of communities.

[516] Llyr Gruffydd: Because the other point made around the value of the geographical approach as well was that you actually build communities and work in developing capacity, but if we’re looking for health outcomes, would you say that the stigma aspect is more important than the other sort of community cohesion aspect?

[517] Ms Fleck: I think it’s both.

[518] Llyr Gruffydd: Yes.

[519] Ms Fleck: We’re still using the stigma—[Inaudible.]—people accessing something because you have a problem; you’re accessing something because you live within this community and it’s accessible. It’s about how things are phrased. There is almost an anomaly here in that, certainly in aspects of our community, Flying Start is aspirational for families that are not within the Flying Start area, families who do not have those additional needs that we would anticipate were being met through Flying Start, who are not just about managing but are comfortably resourced, families who don’t otherwise feel that they’re accessing their potential entitlement. And that’s a really interesting turnaround for what was a programme focused on outcomes around deprivation that has actually had a significant impact and people would actually like to aspire to be within a Flying Start area.

[520] That’s an unintended consequence, but there’s something about the universality of the programme that’s enabled people to feel that, ‘Actually, this is something that I have a value in too, regardless of everything else.’ And there are aspects of that that reflect that there are things that are available within Flying Start that, no matter the financial resource available to you, you will not be able to access easily, necessarily, in other parts of our community, because there aren’t enough of that particular kind of health professional or there aren’t enough of those particular types of groups within that particular community. There are some assumptions that may be made around what Flying Start was able to offer in those communities that would almost bring it up to the same level of other communities. But, actually, for some of those communities, it took it slightly further, and that’s almost a disconnect to the opposite direction as a result, in terms of what was provided for families.

[521] Ms Wilson: Can I add something? With regard to community regeneration, we’ve had an area in Carmarthenshire where there was no childcare or nursery provision, and we’ve made huge improvements there through having the Flying Start childcare and then the childcare going to be based in school. You know, there’s been a lot of regeneration around that community. You mentioned about stigmatisation of health needs. It’s all part of it, because our environment, as we know, the housing and everything really reflects on our health. So, I think it’s about working more collaboratively together, really, and improvements in that way.

[522] Lynne Neagle: Thank you. Mark.

[523] Mark Reckless: On this perennial debate between universality and the targeting of public services, I wonder if you could just respond specifically to the suggestion that we’ve had in evidence from Public Health Wales, who suggested that there may be value in considering a mixed model for the future of Flying Start, with some elements retaining a geographical focus, but others becoming more focused on individual need. Would that be a sensible approach to take, do you feel?

[524] Ms Mutch: I think we’ve had discussions around this as well, in that, again, those flexibilities, looking at what elements would be able to be extended to the more universal: the parenting, particularly antenatal provision, through to those early health interventions. Not so much the health visitors, because everybody’s got a health visitor, but the more intense health provisions that can be offered. Where the geographical nature works well is the childcare element in some of that group-based community provision, but you could actually extend it out, and that is about looking across all programmes with those flexibilities.

[525] Ms Wilson: I think you’d have difficulty at the moment, obviously, with the health visiting, because there is a deficit from the Healthy Child Wales programme nationally of health visitors. So, we are currently looking at skill-mix models, but I do think there’s a lot of work that is going to impact on this, like the development of the acuity tool and looking at the case loads of health visitors. That is going to have an impact, because I know that, outside of Flying Start, the cases are a lot higher. But also, in Flying Start, we’re supposed to be 110, and a lot of our cases are 150 to 160, because of that four-to-five age range that a lot of us have got, you know? So, there’s a lot to be looked at, and there’s a lot of current development ongoing, which is going to impact.

[526] Mark Reckless: Can I just come a bit more to the figures there of children who benefit from the programme? The figures we’ve got, we’re slightly frustrated with, because the beneficiaries are defined by every child has at least one sort of contact with a health visitor within the programme areas, and I just wondered—. I think, Sarah, you gave some numbers for Caerphilly earlier, so I just wonder: are you able to tell us, of the numbers you cite, how many of those are getting the extra health visitors, how many then are benefiting from the childcare, from the parenting programmes, from the language support—just to import magnitudes.

[527] Ms Mutch: I think the reality is we all track children. We know which children are in childcare, which children’s parents are accessing the parenting programmes, et cetera. Nationally, we are looking at how we can better reflect the outcomes of the families that have accessed all four elements and their needs, et cetera. Nationally, there’s a data-tracking project to look at whether we can match long-term outcomes. The cumulative case load count gives us an estimate of reach—but I think that’s what it is, it’s an estimate of reach. For example, our cap number is 2,483 in Caerphilly, but we are regularly hitting 2,600 to 2,800 in a year, because our children move in and out, you have new births, and actually that doesn’t always reflect the four and five-year-olds. So, that’s probably an underestimate of how many children we’re actually reaching, but it’s almost as good as it can be without having to identify every single individual child.

[528] Mark Reckless: Of those 2,483, how many parenting programmes would you deliver over the year? How many specific language support programmes? How many people would benefit from those? Just to give us some idea how that compares to the 2,483.

[529] Ms Mutch: Every term in Caerphilly we deliver 16 parenting programmes—every term, so that’s multiplied by three for the year. On a parenting programme, there can be an average of 12 parents. What we try to do—. Some of the parents will go on to other groups and programmes, but we probably hit about 25 per cent of each cohort because, zero to one, they’ll have one type of programme, one to two, they’ll have another. There’s kind of a menu of services delivered.

[530] What you will have also is the bespoke packages. We all do bespoke packages with families, which are more intense, home-based provision. You’d have less of those, but you’d hope you’d have less of those because those are for families that are most in need. Again, you identify outcomes, and we all measure distance travelled, et cetera. So, you hope, over time, that you actually upskill the entire community. I think that’s the general principle of the Flying Start programme nationally.

[531] Lynne Neagle: Are there any figures, though, for the number of children who benefit from all four elements of the programme?

[532] Ms Mutch: There would be, but you wouldn’t be able to take it from the workbook, because you’d have to look at it as ‘a child at the end of their journey at four’—do you see what I mean? So, at any one time, you’ll have your babies coming in, the parents may access antenatal and then go on to a postnatal programme. So, in any one year, you’re looking at a snapshot. So, you would only be able to do that through an evaluation process, and they are doing a longitudinal study of the children that have gone through the programme and what they’ve accessed. We probably are at the stage where we’re starting to look at that, and that is probably something we’re looking at for the future, with the link to SAIL, which is the anonymised database in Swansea University. That will pick up far more about the children going through and what they’ve actually accessed.

[533] Ms Wilson: What I would say is we have universal key messages for each service area, like speech and language, dietetics—so all families get access to that within the Flying Start programme. So, you have that level for key health, speech and language development, readiness for school—that is given to every family and child within the programme.

[534] Lynne Neagle: Thank you. Mark, did you want to come in on speech and language?

[535] Mark Reckless: I just have one in particular on the numbers. Did you say you had 16 parenting programmes—?

[536] Ms Mutch: Per term, yes.

[537] Mark Reckless: Per term, three terms a year, 12 parents on each.

[538] Ms Mutch: On average, yes.

[539] Mark Reckless: So, multiplying that through, I was thinking just below 580. Then, you had the statement that about 25 per cent would benefit, but then I got a bit confused when you said there were different ones for different age groups. So, would particular parents go on more than one programme?

[540] Ms Mutch: You can’t count them more than once, though. So, when you’re doing the return, every parent has an offer of a parenting programme relevant to the age and stage of their child every year. So, every year, there’s an offer. Actually, it’s quite intensive. The idea is you build on—you have a parenting menu and you build on that menu.

[541] Mark Reckless: So, the take-up each year is around 20 per cent and then some people will take it up and benefit again in future years, such that they’d have more than one.

[542] Ms Mutch: And you might have some that will take it up more when their child is two and three because they’ve got toddlers and they really want it then. So, you might have lots of those and you might have less antenatally, because parents think they’re all right until they’ve had a child and then they realise that there’s a lot to learn—as we all do. [Laughter.]

12:15

[543] Mark Reckless: Can you give me an estimate of what proportion of parents would attend, rather than simply have an offer, at least one parenting programme over the period when their kids were zero to five—and I take it you’d say, ‘If they were in the area for the whole of that period’. What’s your overall penetration?

[544] Lynne Neagle: And, before you answer that, I understand they’re measured on the basis of attending one class. Have you got any figures for completed parenting courses?

[545] Ms Mutch: We all measure on 50 per cent completion, 75 completion, and 100 per cent. So, we all look at how many parents have actually properly completed a course. I wouldn’t know nationally—we’d have to go back to the data set and have a little look at that—but I think a fair proportion of our parents have done at least one course.

[546] Mark Reckless: A majority?

[547] Ms Mutch: I would say probably the majority.

[548] Lynne Neagle: John.

[549] John Griffiths: Do we know whether those parents that might need the parenting classes more than others are accessing them as we would want? Do you get down to that degree of assessment?

[550] Ms Ostler: One of the things we’ve looked at in Merthyr is marrying up the parents who have accessed parenting programmes against the family assessment tool that’s undertaken with health visitors. So, it’s changed now to a different assessment tool, but, if I use it, what it was, health visitors would go into a family and they’d look at different vulnerabilities as to whether they are high, medium or low risk, and we’ve married that up against people who have attended parenting to know where we need to do some more targeted work with families. It’s my thinking that every parent should go on a parenting programme, because, like you said, it is a difficult job for us all at some point, but to try and do some more of that targeted work, really, to marry up the families who are obviously high risk, that have got some extra vulnerabilities there, and marrying them up to attending parenting. So, there’s some targeted work done there.

[551] Ms Fleck: But, equally, there are certain circumstances where a group is not the right approach. So, whilst you might cap groups, actually it’s the one-to-one conversation and repeated interaction with that trusted professional—be they a health professional, social care professional, neither, per se—actually, who is doing that repeated information, and, for some of our families, it’s getting to the point where maybe they might one day consider going to a group, but, in the interim, making sure that they’re having consistent messages about, ‘Actually, you’re doing really well here. Have you thought about doing this differently?’ and understanding that it is going to be different approaches for different families, depending on those different needs.

[552] Ms Wilson: The key is the relationship building in the beginning. That’s the key, and then you can engage them and then move them on to a group. But it is all about trust, because some of them are very, very complex. So, that is why it’s important to have a mixed model, really.

[553] Ms Mutch: And across Wales you’ll probably find most local authorities will say that our highest need families have a lot more around the bespoke packages. Health visitors are more intense with those, and we have more referrals around bespoke packages in the home, because they may not be ready to go to a group, sometimes ever, but you do very much—. You take the principles that you would learn on the parenting programme, and you do it on a one-to-one basis in the home. It’s much more bespoke around that family and their needs.

[554] Lynne Neagle: Thank you. Michelle.

[555] Michelle Brown: Thank you. What data do you gather on uptake of the different parts of your services, and what data do you collect on the outcomes of those, of each part of your Flying Start service?

[556] Ms Mutch: We do collect a lot of data, and I think we report on the aggregated data into Welsh Government. Each local authority also collects additional data, maybe on distance travelled and other outcome measures that they track. The mechanism for reporting all of those into Welsh Government is in development, and that’s the data-tracking project that I talked about earlier. So, they are looking at how they can build a much richer picture of outcomes using the anonymised database called secure anonymised information linkage. So, that’s kind of a future development, but I think, at the moment, we capture that on a much more local authority basis. We know where our children are and what they’ve done and what they’ve achieved, and a lot of us—. Cardiff did a presentation at the last network around where their children are—the first cohort of children—and where they are with their foundation phase profile now, at age seven, and where they’ve moved geographically, and it was quite interesting information. So, there are a lot of local authorities that are doing that performance management on a very localised basis.

[557] Michelle Brown: Anyone else?

[558] Ms Wilson: I think we work towards our family support strategy and work collaboratively, then, to have joint outcomes from that. But each individual programme has got input into that and, like Sarah says, then, it’s an individual-programme basis as well, and I think there are quite a few mixed models of evidence-based tools that we use in Flying Start for parenting in different areas.

[559] Michelle Brown: The 2013 national evaluation survey of Flying Start found no significant difference between the outcomes outside Flying Start areas and inside Flying Start ideas. Do you have any comments about that? I’m sure you do.

[560] Ms Lister: I think it’s too early.

[561] Ms Mutch: Yes. As a national group of co-ordinators, we all agree that actually it’s too early to look at outcomes. Some of the information Cardiff has got now—. Because, if you think about it, in 2013 those children were only into full programme, being born in 2008. So, they’re not really coming through. You’re starting to see a difference and I think it was the programme  in 2008, and, if you looked at how we deliver the programme now, in 2017, it’s far more mature. To give you an example, the number of parents attending parenting programmes in 2008 in Caerphilly was 30. So, comparative to now, it’s poles apart, so I think there was a difference in the maturity level of the programme and the delivery, and therefore you’re going to have that in the impact of the outcomes. I would say, actually, the outcomes—. What would have been helpful is to get a baseline before we started Flying Start to know whether those trends were very different and whether we’d actually turned the curve with some of those children, even with the immaturity of the programme that we were delivering in 2008. What we need to do is track those outcomes now, because our first main cohort of children coming through the full programme and through foundation phase was in 2016, so that’s the date to start looking at the programme and the data trends now. We were also in expansion in 2013, and so there was an issue around changes in the programme. We doubled the size of the programme between 2011 and 2013, so I think that’s had a significant impact as well. It will be interesting to look at, over time, how the trends are changing, and I think that’s why it’s got to be longitudinal.

[562] Ms Wilson: I think, as well, if you look in schools where there was no nursery provision nor childcare provision and then you go back to each individual school and they say that the children in Flying Start are school ready, there’s such a significant difference in the classrooms. They’re ready to learn because they’re used to that environment. So, it’s these measures that, if we had a baseline, we would have been able to capture, but we all know that they are there.

[563] Ms Ostler: I think what was on the— I think what’s an encouraging document to read is—. There’s a Flying Start evaluation looking at educational outcomes that’s using existing datasets. That’s actually available on the Welsh Government website, and, in that, it talks about the fact that attainment has been consistently improving in Flying Start areas at a faster rate than in non-Flying Start areas.

[564] Ms Mutch: That was published this year.

[565] Ms Ostler: Published in February 2017. And it also talks about the fact that the attendance for children living in Flying Start areas has improved greater than that in non-Flying Start areas, the school attendance, and that’s very much one of the things that we encourage in Flying Start childcare provision, good attendance, and of course that’s good habits and behaviours that are being formed going into school. So, that references that in that evaluation report, and one of the other things it references in that evaluation report is the early identification of children with special educational needs and how children with ALN are being identified a lot earlier, so their needs are being addressed earlier, and of course that transition into school is a lot smoother. So, that was quite an encouraging report, I think.

[566] Lynne Neagle: Mark.

[567] Mark Reckless: You say the report was encouraging, but it also stated that:

[568] ‘The regression and matching analysis suggests that there is no significant direct impact of Flying Start on educational attainment.’

[569] Ms Ostler: I think one of the difficulties has been this inability—and we’ve just referenced it—to say how many services a particular family has accessed. So, they may have had a Flying Start health visitor, but how much intensity of support have they received in the rest of the programme? I think it is difficult, the fact that there’s been a change in curriculum since the Flying Start programme, and that we’ve had key stage 1 and now we’ve got the foundation phase. That has made it more difficult. It did talk about statistically significant, but I think the fact that in Flying Start areas we are seeing that improved attendance compared to non-Flying Start areas—in the educational outcomes, I’d take that as a positive.

[570] Lynne Neagle: Sarah, you said that it’s too early to look at outcomes, but it’s been running in some areas for 10 years now, so—

[571] Ms Mutch: It’s starting—

[572] Lynne Neagle: —can you really realistically say that?

[573] Ms Mutch: No, and that’s what I said: it’s about the immaturity of the programme when it first started delivery. So, it actually designed—. I’ve been in the programme from the beginning, 2006-07 was its start, and that was a six-month starting point for the programme. It didn’t actually hit full roll-out in many areas until after 2008, as in all four core elements. The data is quite interesting as well because, at the moment, the evaluation is based on the schools that the Flying Start areas are linked to, and, actually, what the Cardiff research showed when they tracked the children is they didn’t stay in that area, and I think that’s quite interesting. So, actually, all the evaluation work that we’re doing, we’re trying to demonstrate an outcome, but, until we actually use the SAIL database and track those individual children and match them to their actual outcomes—. The Cardiff analysis that they did was actually quite enlightening, and the geographical spread—that they moved from Flying Start areas—was quite interesting, and I think that looks at—. We don’t know: is there social mobility? Have we actually improved parents? We’ve got some areas that are very transient, and parents do move on and up and, if they are getting employment, do they move out of the area? In which case, are you going to see a difference? And until we actually match the children that are going through the actual programme with what their outcome is at the end of the foundation phase, I think it’s a very difficult position to be in. I don’t think we can actually say—. We can say there’s a correlation, perhaps, but I don’t think it’s a 100 per cent correlation.

[574] Lynne Neagle: Michelle, have you finished your questions?

[575] Michelle Brown: Basically, yes.

[576] Lynne Neagle: Do you want to ask about recruitment and retention?

[577] Michelle Brown: I think I’ve lost my track, sorry. [Laughter.]

[578] Lynne Neagle: You were—. Llyr.

[579] Llyr Gruffydd: Yes. I’ve raised previously recruitment and retention of—. Sorry, I’m having—.

[580] Lynne Neagle: Health visitors.

[581] Llyr Gruffydd: Health visitors. Thank you, yes, yes. I’m told that I raised previously health visitors. Is that something that you see at the coalface, that there is, you know, a shortage, and is enough being done to address that? Or what is being done? Because people are telling me that people are aware of what needs to be done but the impression I’m getting is that there isn’t definitive action. And I’m not just pointing to Welsh Government, because it’s about a combination of working between Welsh Government, local authorities and health boards, and others, I’m sure.

[582] Ms Wilson: What I would say is it’s not just health visiting, it’s nursing in general.

[583] Llyr Gruffydd: Yes, okay.

[584] Ms Wilson: And, obviously, we’ve got the new Nurse Staffing Levels (Wales) Act 2016 now that’s come in, because, obviously, to be a health visitor, you’ve got to be a registered nurse. We are looking at—. We’ve always had band 5s in Carmarthenshire because there was a period where I had 4.6 vacancies in the health visiting element, so we had to employ band 5 staff nurses to do some of the work, but they are looking now at this kind of route into health visiting, but we have got to be aware, then, what you are doing, you’re taking staff nurses from already overstretched NHS services where there are staffing shortages.

[585] Llyr Gruffydd: But the result of that is—I think you mentioned earlier—that you’re not hitting the 110 children per health visitor. And is that a common feature across the programme?

[586] Ms Ostler: It’s not in every area. I’m aware that it is in some areas, but, in the Cwm Taf Local Health Board area, we don’t have an issue with recruitment. I’m not sure what the secret to that is—people must have heard what a wonderful place Merthyr is to work—but we’ve not experienced that issue in the 10 years that the programme’s been running, so—. And I’m not quite sure about—

[587] Llyr Gruffydd: So, you’re consistently hitting the 110 children per health visitor.

[588] Ms Ostler: Yes.

[589] Ms Mutch: I think there is a difference between different health boards. Some health boards will offer permanent contracts regardless of whether health visitors are grant funded or not.

[590] Llyr Gruffydd: Right, okay. Well, that’s an important point—

[591] Ms Mutch: Other health boards—our health board—won’t. So, if they’re grant funded, they’re on one-year fixed term contracts. So, I’m advertising now and those staff are going to be given a six-month contract until the end of March.

12:30

[592] Llyr Gruffydd: And then you wait and see what happens.

[593] Ms Mutch: They’re not going to come. And they are recruiting for the Healthy Child Wales programme, so they’re offered a permanent contract or a fixed-term. So, unless they really want to stay in Flying Start—

[594] Llyr Gruffydd: Yes, there’s a big issue there.

[595] Ms Mutch: Thank goodness I’ve got some really dedicated health visitors, but that is an issue.

[596] Ms Lister: Terms and conditions definitely is an issue.

[597] Llyr Gruffydd: Terms and conditions.

[598] Ms Lister: Terms and conditions and the length of the contract is definitely an issue across the piece.

[599] Ms Fleck: That’s not unique to health visiting. I think you have to be really clear that’s not a—

[600] Ms Lister: It’s everybody that works within the programme.

[601] Ms Wilson: I think, as well, it is your relationship with your local health board, because when we did have staffing problems, we did a joint recruitment day, and doing things like that as well is really important. I have been fortunate enough that I’ve always been able to offer permanent contracts, and I think it’s because of my dual role, but there are still difficulties because there are not enough staff out there. There’s not enough staff to deliver the Healthy Child Wales programme, and our programme is more intense than that, obviously, so across the board there are staffing issues.

[602] Ms Fleck: [Inaudible.]—has paid for additional courses, but it’s having enough people to fill those courses as well to run them. So, it’s a challenge.

[603] Ms Wilson: We are currently one of the areas that are doing a modular approach this year. So, one of my band 5 staff nurses is doing health visiting in a modular approach. It will take her two years to qualify, but for me, that’s a kind of grow-your-own model, and it has worked quite successfully in our service. I’m not saying it would work everywhere, but it has in ours.

[604] Llyr Gruffydd: Okay, thank you.

[605] Lynne Neagle: Darren.

[606] Darren Millar: I just wanted to ask about your engagement with the third sector. Obviously, there’s a lot of engagement with the health service, but the third sector, of course, potentially provides an opportunity to reduce some of the outlay, the costs, of delivering some of the services. I know that there’s a relationship, for example in Conwy, Clair, with organisations that have been delivering some parenting courses, and I can see some nodding from Sarah there on the end of the table. Is that something that you’d like to see develop further in order to allow the resources to go further for the individuals that you’re supporting?

[607] Ms Fleck: Yes. I suppose the complexity is that as soon as you’ve commissioned that, you haven’t lost your responsibility to deliver it, so in that sense we’ve still got the responsibility around whatever it is that we purchase in. We have got a lot of work that we’ve been doing around trying to improve and be more clear about what our needs are from that sector, because I think historically local authorities haven’t always been explicit about what they want in exchange for funding, and it’s much easier within something like a Flying Start programme—they’ve got very detailed and clear elements to be able to do it. It’s more explicit, therefore, when you want to work with an organisation like Home Start, how that works closely with what you’re trying to achieve. But it also then goes back to the surety of funding, and that does make a big difference, particularly in the third sector. We don’t necessarily see that reduction in cost because we’ve got the reduction.

[608] Darren Millar: I know you’ll have service level agreements and things like that with some organisations. Putting those completely aside, what I’m thinking about in particular are some of the faith communities that are already embedded in these Flying Start postcode areas that might be able to offer completely free support with the delivery of parenting courses and childcare provision because they’ve got volunteer networks. Now, I appreciate you will want to supplement that in terms of the child development side of things perhaps, and on the childcare—

[609] Ms Fleck: And it’s not about stopping that and it’s not about squishing what is happening and is developing naturally within those communities. In terms of, for example, parenting programmes, one of the things that has been quite rigorous in the approach to Flying Start has been about the quality of what a parenting programme is—what is a good parenting programme compared with a not good parenting programme. That’s the polite version of it, I think, and that’s where it becomes quite difficult, around different organisations that may be motivated by different factors, as to what they then bring forward as being an acceptable parenting programme, compared with what has been agreed. To some extent it’s possibly seen as prescriptive, but actually it’s about that quality standard around parenting programmes.

[610] We’re really clear that the model that we were developing in Conwy, which is around the rolling out of the elements of the Flying Start programme into our communities more widely, is about working with that broader community and making sure that we’ve got the third sector, in its phenomenal diversity—from those really large organisations that have charitable status to that tiny, local couple next door that do something around that street—engaged in that offer, and it’s trying to make sure we’re working with them, so that we’re not ever at any point saying, ‘Well, don’t go there, because we’re doing this actually.’ We’re all doing this and we’re all working towards the same overall goal.

[611] Darren Millar: I should put on record, Chair, a declaration of interest here. My wife delivers some positive parenting programmes in Conwy, and in fact in other places in north Wales as well, for a charity, so—.

[612] Lynne Neagle: Okay, thank you, Darren.

[613] Darren Millar: Unpaid by the local authority, I hasten to add. But it’s a great relationship, that’s all. I’m just thinking about how we can milk more out of that for the taxpayers’ benefit.

[614] Ms Lister: I think the flexibilities will enable us to do that again. I think it’s going to open up some doors, and as Hannah rightly said, we’ve already started to map out, actually, what is happening out there—not what’s being delivered; what’s happening out there in the communities. So, where can people be directed to that’s right on your doorstep, that’s just a natural part of what you’re already participating in? So, we just need to understand that a little bit better.

[615] Darren Millar: That’s an interesting point, actually. I mean, to what extent has that been mapped—some of that stuff?

[616] Ms Lister: We’re doing it on a pilot basis because the map is huge, and obviously we wouldn’t know, necessarily, what’s been delivered or, I suppose, what’s taking place in every small community.

[617] Darren Millar: It’s got echoes of our youth work inquiry there, doesn’t it?

[618] Ms Mutch: Just to add briefly to that, on a national basis most local authorities have already looked at what was in their area before they started, and so have only developed maintained provision—childcare provision—where there was no other.

[619] Darren Millar: Where there’s a gap, yes.

[620] Ms Mutch: And actually, it’s working with the third sector in its entirety, because a lot of us have mixed-economy provision and they are run by, sometimes, those who were previously volunteers, but they’ve now become our workforce and we’ve upskilled them and given them the business skills. And working with any volunteers is about how we get them into regulated provision. So, it’s making sure they don’t become unsafe, because there are a lot of pitfalls around the legislation. We’ve worked quite broadly, I think, outside of Flying Start, using our expertise.

[621] Darren Millar: Yes, great. Thanks.

[622] Lynne Neagle: Are there any other questions from Members? No. Okay. Well, can I thank you all very much for attending this morning and for answering all our questions? You’ll be sent a transcript to check for accuracy in due course, but thank you again for your time. Thank you.

12:37

Papurau i’w Nodi

Papers to Note

[623] Lynne Neagle: Okay. Item 5, then, is a paper to note, which is a letter from the children’s commissioner to the Minister for Lifelong Learning and Welsh Language regarding the Additional Learning Needs and Education Tribunal (Wales) Bill after Stage 2 proceedings. Are Members happy to note that? Thank you.

Cynnig o dan Reol Sefydlog 17.42(ix) i Benderfynu Gwahardd y Cyhoedd o Weddill y Cyfarfod Motion under Standing Order 17.42(ix) to Resolve to Exclude the Public from the Remainder of the Meeting
Cynnig:	Motion:
bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(ix).	that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(ix).
Cynigiwyd y cynnig. Motion moved.
[624] Lynne Neagle: Item 6, then, is a motion under Standing Order 17.42 to resolve to exclude the public for the remainder of the meeting. Are Members content? Thank you.
Derbyniwyd y cynnig. Motion agreed.
Daeth rhan gyhoeddus y cyfarfod i ben am 12:38. The public part of the meeting ended at 12:38.

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[1] Eglurhad/Clarification: ‘You would need to go back to the individual local authorities for Flying Start outreach case studies.’