The Marmot Review,
Fair Society, Healthy Lives1(2010), sets out the case for focusing investment on early years and advocates a life-course approach to tackling health inequalities, demonstrating that giving every child the best start in life is crucial to reducing health inequalities across the life course.
As the foundations of human development are laid in early childhood, the review proposed an indicator of readiness for schools to capture early years development. While there is currently no ideal indicator for this, the percentage of children achieving a good level of development at age 5 years provides a readily available measure of early development across England. This indicator is based on data collected from the Early Years Foundation Stage Profile (EYFSP). Children are normally assessed by a teacher in the year in which they turn five. The assessment is based on observation of the child’s behaviour and understanding.
In Merton, in 2012, 66% of local children achieved the expected level of development across all six areas of learning, which was above the England average of 64%. This has been an improving picture for Merton, rising from 61% in 2011.
Percentage of children achieving a good level of development at age 5 2010-12.
The gap in good development at age 5 between the highest and the lowest achievers was nearly 30% and had increased slightly from 28.4% in 2010 to 29.6% in 2012. This was similar to London (30.8%) and England (28.6%) (DfE/ChiMat). There is variation in early development by area, linked to deprivation, with lower levels of good development in the east of the borough.
Child development at age 5, by MSOA, 2011 (Source: ChiMat).
Deaths in childhood are very rare but can be used as an indicator of child health. Pooled data for 2008-10 shows there were 53 deaths in children under 15 years old in Merton. 74% of childhood deaths (0-14 years) occurred before the age of 1 year in both Merton and England.
In Merton, the age standardised death rate (ASDR) for children under 15 years is below national rates. The commonest cause of death in the 0-19 year age group was from conditions arising in the perinatal period/prematurity, accounting for 43% of total deaths. In the 15-19 age group the two commonest causes of deaths were cancers accounting for 29%; and external causes, including accidental injuries, also accounting for 29%.
Child mortality in children under 15 years, 2008-10. :Numbers death rates in children under 15 years. 2008-10, pooled data
| || <1 year || <1 as a % of|
| 1-14 years || Total|
| Age standardised death|
rates per 100,00 aged
| Merton || 39 || 73.6 || 14 || 53 || 41.30 |
| Croydon || 78 || 78 || 22 || 100 || 46.79 |
| Wandsworth || 53 || 73.6 || 19 || 72 || 39.90 |
| Richmond upon|
| 24 || 66.6 || 11 || 35 || 30.69 |
| Kingston upon|
| 21 || 84 || 4 || 25 || 27.39 |
| London || 1,747 || 76.1 || 550 || 2,297 || 46.60 |
| England || 9,260 || 74.3 || 3,205 || 12,465 || 45.50 |
Source: NHS Information Centre
Causes of mortality, children and young people 0-19 years, Merton 2009-11.
| || % <1 years || % 1-14 years || % 15-19 years || % 0-19 years |
| Cancer || || 16 || 29 || 7 |
| Circulatory disease || 2 || || 5 || <5 |
| Congenital/inherited || 10 || || 21 || 21 |
| Diseases of nervous system || 1 || 16 || || <5 |
| Diseases of digestive system || || 5 || || <5 |
| External cause || || 11 || 29 || 6 |
| Infectious and parasitic || || || 14 || <5 |
| Neonatal/prematurity || 69 || || || 43 |
| Other || 7 || 11 || 29 || 10 |
| Related to perinatal period || 10 || || || 6 |
| Respiratory disease || 2 || 11 || || 5 |
| Undetermined event || || 5 || || <5 |
Source: ONS Annual District Mortality File, Sutton and Merton PCT
External causes, including accidental injuries, accounted for 29% of child mortality in 15-19 year olds in Merton. This can be compared with hospital admission rates for unintentional injury, which are about the same as the London average for 0-4 year olds, but lower than the London average for 5-17 year olds. See third
Rate of hospital admissions for deliberate and unintentional injury to children aged 0-4 years, 2010-11
After clean water, vaccination (immunisation) is the most effective public health intervention in the world for saving lives and promoting good health and is responsible for the virtual elimination of the previous epidemics of measles, German measles (rubella), mumps, whooping cough and polio.
The primary aim of vaccination is to protect the individual who receives the vaccine. Vaccinated individuals are also less likely to be a source of infection to others. This reduces the risk of unvaccinated individuals being exposed to infection. This means that individuals who cannot be vaccinated will still benefit from the routine vaccination programme. This concept is called population (or ‘herd’) immunity. The World Health Organization (WHO) recommends at least 95% of pre-school children should receive the recommended vaccinations to achieve population immunity.
Routine childhood immunisations, as of June 2013.
The uptake of MMR (measles, mumps and rubella) vaccine has fallen nationally and locally since discredited publicity suggesting a link with autism. Consequently, across London there had been an increasing number of measles and mumps outbreaks in recent years.
In Sutton and Merton, the 2012-13 uptake of childhood immunisations has been low. For example, the uptake of one dose of MMR1 at age 2 was 80.7% compared with 87.1% for London and 92.3% for England. Uptake of two doses of MMR at age 5 was 68.9% compared with, 80.8% for London and 87.7% for England, and there is wide variation by GP practice. Provisional data for Q1-2 (April-September) 2013-14 indicates improvements in uptake of some childhood vaccinations, including MMR1 and MMR,2 in Sutton and Merton.
Percentage of coverage for childhood immunisations to age 5 years, 2012-13.
Charts showing variation in childhood immunisations among geographical neighbours show that in 2012-13 Sutton and Merton had the lowest level of coverage for most childhood immunisations. See the
fifth graphs below.
Proportion immunised for Meningitis C by 1st and 2nd Birthdays, 2012-13.
Proportion immunised for Hib Men C booster by 2nd and 5th Birthdays, 2012-13.
Proportion immunised for diphtheria, tetanus, pertussis and Hib by 1st and 2nd Birthdays, 2012-13.
Proportion immunised for measles, mumps and rubella by 2nd and 5th Birthdays, 2012-13.
Proportion immunised for pneumococcal by 1st and 2nd Birthdays, 2012-13.
Proportion immunised for DTAP/IPV pre-school booster by 5th Birthday, 2012-13.
fourth graphs below show the variation in childhood immunisations between GP practices and indicate that in Merton in 2012-13 very few practices reached the WHO aim of 95% coverage.
Proportion immunised for measles, mumps and rubella – 1 dose by 2nd Birthday, by practices in Merton CCG, 2012-13.
Proportion immunised for measles, mumps and rubella – 2 doses by 5th Birthday, by practices in Merton CCG, 2012-13.
Proportion immunised for DTAP/IPV by 5th Birthday by practices in Merton CCG, 2012-13.
Proportion immunised for HiB Men C by 5th Birthday by practices in Merton CCG, 2012-13.
Proportion immunised for PCV by 5th Birthday by practices in Merton CCG, 2012-13.
Key facts on services
The national Healthy Child Programme: pregnancy and the first five years of life (DH 2009) sets out the importance of delivering early childhood immunisations. Childhood immunisations age 0-5 are delivered by general practices across Merton. Community Health Services are responsible for promoting immunisation to 0-4 year olds, and delivering immunisations to school age children, and managing central data recording systems.
From April 2013, NHS England is responsible for commissioning immunisation services. A Sutton and Merton Immunisation Task Group has been established and an action plan developed to increase coverage of childhood immunisation.
Data recording has been identified as a potential issue affecting the accuracy of published data, and plans have been implemented in Sutton and Merton to improve the data recording systems. From 2013-14 data is due to be available at a borough level.
Recent social marketing research2aiming to understand the barriers and challenges to accessing immunisations in Sutton and Merton highlighted that there was variation in the level of knowledge about immunisation and low awareness of the consequences of not immunising children. Pregnancy was identified as a good time to promote awareness of immunisation. Barriers to immunisation included concerns about side effects; forgetting/ time; negative past experience of parent; access, e.g. knowing about out of hours; issues with childcare; and language barriers.
Key commissioning recommendations
- Commissioners should aim to increase uptake of childhood immunisations to reach the World Health Organization’s aim of 95% coverage to ensure population immunity.
- Commissioners should focus on delivering childhood immunisation action plans, including:
- monitoring the progress on childhood immunisation coverage towards achieving local and WHO targets
- ensuring that improvements to childhood immunisation data systems are monitored and sustained
- reducing variations in uptake by GP practice
- increasing access to immunisation for parents
- improving uptake and access, including delivery of immunisations at weekends
- improving knowledge and awareness among parents, including via health visitors, children’s centres, schools and nurseries.
Key facts on Early Years Services for children age 0-5
The Healthy Child Programme: pregnancy and the first five years of life (DCSF 2009) sets out an integrated approach to improving the health and wellbeing of children and supporting families and sets out recommended standards for service delivery. The Healthy Child Programme (HCP) has been defined as ‘the early intervention public health programme that lies at the heart of universal services for children and families. At a crucial stage of life the HCP’s universal reach provides an invaluable opportunity to identify families that are in need of additional support and children who are at risk of poor outcomes’ (HCP 2009).
[The HCP approach is well established in Merton, with an integrated approach to Children’s Centres and Health Visiting services across the Children’s Centres in Merton.]’’
Merton’s network of 11 children’s centres, delivered through three localities, provides a range of universal and more targeted services for all families with young children living in the borough. Ofsted has awarded a grading of good or above to 100% of the centres that it has inspected.
Map showing Merton’s children’s centres locality model.
An integral part of Merton’s Children’s Centre Services’ delivery is its partnership working with statutory, as well as community and voluntary, agencies. This enables the Children’s Centre Services’ universal offer to include health, early education and information services across a range of determinants of health. This co-delivery of a range of services across the children’s centres includes:
- Midwifery antenatal and post natal services
- Health visiting/Healthy Child Programme (health reviews of newborn/8 months and 2 years)
- Speech and language advice, guidance and early support
- Play and development
- Targeted home visiting
- Evidenced-based parenting – both core and targeted (enhanced)
- Support for employment, training and back to work
- Childcare brokerage
- Advice for income maximisation and financial inclusion
- Housing advice
- Co-ordinated support for children with lower level SEND (special educational needs and disabilities) in settings and the home
- Access to targeted and specialist services, such as mental health, 0-5s Supporting Families Team, CSC, CAMHS
- Pre-schools for [?] to 2 year old funded places
- Advice/access to funded early education.
Family Nurse Partnership
Merton and Sutton are developing a Family Nurse Partnership (FNP) programme. The FNP is an evidence-based prevention and early intervention programme for vulnerable first-time mothers that aims to:
- improve pregnancy outcomes
- improve child health and development through helping parents provide more competent care
- improve parents economic self-sufficiency.
The programme has been developed in the US over 30 years. It provides intensive and structured home visiting, using a psycho-educational approach focusing on adaptive behaviour change during pregnancy and until the child turns 2 years old. The programme is being adopted in England under licence to ensure replication of the original research. Merton was invited to develop a joint programme with Sutton, and, based on 2010 data, it is estimated that about 90 young mothers are eligible in each borough, but due to the rising birth rate and population changes this may be higher.
Early intervention to support children’s readiness for school is important in improving the long-term health, emotional, educational and social outcomes of young people and reducing the risk of negative outcomes such as anti-social or violent behaviour or children not achieving their potential.
A summary of free early education for 2 year olds (national policy being to target disadvantaged children) is as follows:
- Of 2 year olds, 183 (6.4% of the 2 year old population in Merton) were supported to access a place prior to the new statutory duty commencing September 2013
- 67% of the brokered 2 year old places went to children resident in the Mitcham planning area.
- 2 year old places were predominantly brokered in playgroup or pre-school provision.
- As the criteria for funded 2 year old places includes income deprivation factors, location of residents with funded places correlates with deprivation areas. The areas with the largest proportion of the 2 year old population in receipt of a funded place are Pollards Hill, Figges Marsh and Lavender Fields.
- 7% of the 2 year olds with a funded place have some level of additional/special educational needs.
Early education funded provision for 3-4 year olds:
- The majority of 3 and 4 year old funded provision is accessed through maintained schools nursery and Reception classes. Typically all 4 year old (Reception) funded education is in maintained or independent school classes. Independent education figures may be suppressed as not all take part in the free entitlement funding offer.
- Mitcham area has the largest number of 3 and 4 year olds claiming free entitlement in Merton provision (90%); 89% of Merton’s 3 and 4 year old population access their entitlement within Merton.
- 760 children resident outside of Merton access their free place through Merton provision. 60% of these children take up this provision in maintained schools, 22% in day nurseries and 9% in both playgroup and pre-school provision and independent schools.
- 6% of 3 and 4 year olds in Merton’s funded provision have a level of SEN recorded.
- Mitcham planning area residents and the residents of wards bordering it to the west of Morden and Wimbledon have the greater proportion of population accessing funded provision.
Evidence about what works and best practice
Recent evidence from a report,
Conception to age 2: the age of opportunity,3identified both improved outcomes and financial returns on well-designed early interventions. It identified the need to focus on three areas to improve outcomes for 0-2 year olds:
Assess and identify where help is needed:
- Mental health risk assessment as early as possible in pregnancy; Neonatal Behavioural Assessment three weeks after birth.
- In addition to age 6 weeks health visitor assessment, undertake an age 3-4 months assessment of parent-child attunement, and an attachment assessment at age 12-15 months.
Provide adequate support when needed:
- Full implementation of Healthy Child Programme; promote attunement, secure attachment; Family Nurse Partnership; parent-infant psychotherapy; 8% of pregnant women warrant a referral to specialist perinatal mental health services.
- High-quality health-led children’s centres; potential for health visitors to act as team leaders, supervisors and/or mentors; high-quality outreach to engage most vulnerable families; follow principles of highly successful multi-agency work.
Ensure Early Years Services workforce have requisite skills, training, and supervision as follows:
- health visitors are trained to evaluate mother-baby interaction, and carry out motivational interviewing
- all practitioners have awareness of risk factors that can jeopardise infant mental health
- domestic violence – prioritise identification and support by midwives, GPs, other professionals, especially in pregnancy
- ensure a good understanding of pre-birth to 3 years child development, attunement and attachment
- emotional intelligence, skills to form empathic relationships with parents; good quality reflective supervision.
Commissioning recommendations for Early Years
A recent review of the Children’s Centre Services and Early Years Services identified a number of priorities for commissioners and managers:
- Develop an outcomes model of commissioning for Early Years Services, based on evidence of best practice and underpinned by strong data systems.
- Develop early years prevention and early intervention pathways, with clear referral routes for all partners.
- Parental mental health has been identified as a significant factor in parenting; there is a need to increase parent support, including for lower level mental health problems and parental relationships, ensure staff training and awareness, and develop clear pathways into mental health services.
- Children’s centres should contribute further to public health outcomes, including reducing obesity strategy and increasing levels of healthy weight, and breastfeeding.
- Implement a data sharing agreement across early years in order to strengthen the ability to provide earlier intervention for families identified as having additional needs.
- Increase access to immunisations for children through children’s centres in order to increase coverage in more vulnerable/disadvantaged groups.
- Additional early speech and language support accessed via children’s centres would improve school readiness of more vulnerable/disadvantaged children.
- The Family Nurse Partnership should support better coordination of pathways and access to support. A risk management approach will need embedding. Children’s centres are in a good position to work with younger parents who will access the forthcoming Family Nurse Partnership.
- Establish a vision, model and transition plan for the Health Visiting Service as commissioning responsibility for the service moves to the local authority in 2015.
1.^ Marmot, M. et al. (2010). Marmot Review.
Fair Society, Healthy Lives. University College London, Institute of Health Equity.
2.^ Resonant Media (2013).Social Marketing Project Summary Report: Public Health Insight and Recommendations for Sutton and Merton.
3.^ WAVETrust report – a Department for Education (DfE) invited response (2013).
Conception to age 2: the age of opportunity. WAVE Trust/DfE.