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Financial Impact on Early Years Part 2

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THE FINANCIAL IMPACT OF EARLY YEARS INTERVENTIONS IN SCOTLAND- Part 2: JOINT MINISTERIAL FOREWORD.

In November 2010, we published a bespoke study quantifying potential savings from early years investment in a Scottish context. The study showed that investment in the early years can yield savings in the short, medium and long term and provided clear cut evidence to demonstrate that investment of resources in the early years can generate financial saving, as well as meeting our primary goal of improving outcomes for our children and families.

Since then, the case for investing in Early Years and Early Intervention has been strengthened by the progress made on the implementation of the Early Years Framework and by further UK studies authored by Graham Allen MP and Frank Field MP. The recent publication of the work carried out by Scottish Early Years Champion, Professor Susan Deacon will also assist in demonstrating that not only is investing in the Early Years and Early Intervention the right thing to do, but that it can have demonstrable economic benefits.

In addition, one of the ambitions of the Healthcare Quality Strategy is to deliver the most appropriate treatments, interventions, support and services at the right time to everyone who will benefit, and to eradicate wasteful or harmful variation. Improving outcomes and reducing costs by systematically implementing a coordinated and evidence based approach which has the child and family at the centre is also at the heart of the Strategy. This is delivered in partnership between NHS, Local Government and the Third Sector

The current financial situation is challenging. We know that there are difficult decisions to be made about where to direct resources. Part II of the economic modelling work has been developed to provide further support to local partners in Scotland's councils, NHS Boards and elsewhere to decide on how best to set their budgets to support local children, families and communities. Investment in preventative and early interventions to realise benefits is central to the refreshed NHS Scotland Efficiency and Productivity Strategic Framework.

This economic modelling work is based on the findings of the Scottish Collaboration for Public Health Research and Policy and their "Interventions for Promoting Early Child Development for Health" Report. We are very grateful to them for allowing us to reference their work in this way. The package identifies a range of interventions across a broad spectrum of need. These are considered to be an appropriate and realistic way of improving outcomes for children in Scotland, tackling the inter-generational cycles of poverty, poor educational outcomes, unemployment and crime which have bedevilled too many of our communities for too long, whilst lowering demand for future public services.

We commend this study to our partners in local government, the NHS, our justice system and more widely. This work will serve to support effective local decision-making processes in these difficult times, supporting collaborative working and providing useful food for thought. We continue to believe that investment in the early years is certainly an investment worth making - both in terms of improving the lives of current and future generations of Scots and making the best use of increasingly scarce resources.

THE FINANCIAL IMPACT OF EARLY YEARS INTERVENTIONS IN SCOTLAND - PART 2

SUMMARY OF RESULTS

· The Financial Impact of Early Years Interventions in Scotland report [1] was published in November 2010. This report set out our estimates of the potential savings to the public sector that could be realised if an effective package of early interventions could be put in place, for the short, medium and long term.

· The report adopted the proportion of the child population who are looked after in a community setting as a proxy for those with a moderate level of need, which equates to approximately 700 children/parents in each age group, over the pre-birth to 5 years old cohort. The proportion of the child population who are looked after in a residential setting was adopted as a proxy for those with a severe level of need, accounting for approximately 80 children/parents in each age group, over the pre-birth to 5 years old cohort. The looked after population was adopted as a proxy measure as it relates to a group with relatively high, and differing, levels of need. It is however a small proportion of the overall child population, and a conservative estimate of the size of the moderate and severe groups.

· We then sought to identify what such a package of interventions could comprise. Discussions with a key group of Early Years experts have led to a focus on the package of interventions set out in the Scottish Collaboration for Public Health Research and Policy's (SCPHRP) document: Interventions for Promoting Early Child Development for Health [2]. This package identifies a range of interventions across a spectrum of need, and was deemed to be an appropriate and realistic way of improving the outcomes for children in Scotland, whilst lowering future demand for public services. This package is not intended to reflect current or future Scottish Government policy, rather this modelling has been undertaken to highlight the likely cost of an evidence based approach to Early Years Interventions.

· Universal service provision is set out in the SCPHRP report as the crucial component of service delivery to individuals with a low spectrum of need. It should be acknowledged that access to, and the quality of, universal services play a crucial role as a gateway to the specialist health and social care support that children and families with moderate and severe levels of need require. Estimating the cost of universal provision is beyond the scope of this report.

· Cost information was collected from Scottish delivery partners and from UK based programmes which most appropriately fitted this illustrative package and could be effectively directed towards those with a more intensive level of need. The table below sets out the estimated unit cost of the interventions as identified in SCPHRP typology for moderate and severe needs, for which Scottish/UK unit cost information is available:

Intervention Type

Estimated Cost of Intervention

Pre-Primary Education (part-time) - vulnerable 2 year olds

£3,022 per child/per year.

Parents as First Teachers - Pre-birth to 3 years old.

£373 per person in the first year of delivery, £292 per person/per year thereafter.

Family Nurse Partnerships - Pre-birth to 2 years old.

£3,000 per person/per year

Targeted parenting interventions for 3 and 4 year old children at elevated risk of Disruptive Behaviour Disorders

£273 per child over the 4 year implementation period, £130 per child/per year for ongoing delivery.

Ante-natal support for pregnant women who misuse substances - Pre-birth

£349 per person/per intervention

Cost per pre-school child healthy weight intervention - 3 years old.

£300 per child/per intervention

Smoking Cessation aimed at pregnant women - Pre-Birth

£300 per person/per intervention

· At an individual level, the estimated total additional public spending on a child and parent with moderate needs would be £1,849 over the pre-birth to 5 years old period. For a child and parent with severe needs, the estimated total additional public spending is estimated to be £11,220 over the pre-birth to 5 years old period.

· National information campaigns are identified in the SCPHRP typology as an important intervention, but are not delivered to a specific population. Information campaigns can cost between £120,000 - £737,000 per year, depending on scale, and those campaigns set out in the typology are currently being delivered in Scotland. Play@home is a multi-level intervention, using play as a 'safe' way to address key parenting issues, from birth to age 5. This is an evidence based programme already being delivered in every Health Board area and is undergoing evaluation. This programme costs £360,000 per year.

· Our modelling suggests that the annual additional cost of delivering the recommended package of interventions would be between £2.2 million and £3.7 million, at a national level. This package is costed against the estimated moderate and severe needs population, as set out in the previous report. The moderate needs population is approximately 700 children/parents in each age group and the severe needs population approximately 80 children/parents in each age group, over the pre-birth to 5 years old cohort. It is accepted that this may be a conservative estimate of the level of need, and that delivery partners may choose to deliver programmes to a wider population. It should be noted that for a number of the interventions costed, it is assumed that the intervention would be delivered by existing practitioners, and there would therefore be an opportunity cost of reallocating resource away from other programmes.

· This model assumes that Early Years programmes have the potential to reduce future public costs associated with not having the best start in life by 100%, and that impacts persist through life. On this basis the package would result in an increase in public spending for a 2 year period across the moderate and severe groups. After this period, the effectiveness of the package, coupled with the increasing number of cohorts affected, would offset the cost of the intervention package, and reduce future public spending.

A. Background

1. A wide range of economic studies suggest that there are significant long term returns to early investment in children during the pre-birth period and up to the age of eight years [3]. These long term changes in the capabilities of young people will significantly contribute to the delivery of the Government's Purpose of increasing sustainable economic growth with opportunities for all of Scotland to flourish.

2. The Financial Impact of Early Years Interventions in Scotland Report modelled the potential short term savings from investing in early years / early interventions from pre-birth to aged five and suggests that there are potential net savings of up to £37.4k per annum per child in the most severe cases and of approximately £5.1k per annum for a child with moderate difficulties in the first five years of life. While these savings may be modest in comparison to the well known longer term savings they are still significant.

3. The model also demonstrated that there are potential medium term net savings to the public sector that can be realised 10 years after the early years period. It is estimated that the total potential saving resulting from 100% effective interventions early in life (pre-birth to aged eight) could initially be up to £131m per annum, in the medium term. In the longer term, a failure to effectively intervene to address the complex needs of an individual in early childhood can result in a nine fold increase in direct public costs, when compared with an individual who accesses only universal services.

4. An obvious question is whether or not it is realistic to assume that a package of Early Years interventions will in fact mitigate the additional moderate and severe needs of individuals. There is a wide range of evidence to suggest that this is in fact the case for individuals once they reach 9-18 years of age and in their later life. Currently there is less formal evidence around the 0-5 age group, although the evidence from neurosciences suggests a strong theoretical basis for intervening at this stage and we are starting to see some empirical evidence that is consistent with this early success [4]. The Scottish Government assembled an expert group that was asked to design a package of interventions that will tackle the additional moderate and severe needs of individuals. Our discussions suggest that such a package is a realistic objective and in the Expert Group's judgement the package would be capable of mitigating needs over the first five years of life as well as in later life.

B. Overview of our approach

5. Our approach has been to focus on the package of interventions as set out in the Scottish Collaboration for Public Health Research and Policy: Interventions for Promoting Early Child Development for Health paper [5] (see Annex A). The approach taken does not look to recommend or prescribe any specific programmes, particularly licensed programmes, but instead has attempted to set out indicative costs of the types of interventions as discussed by the group. Furthermore, this package is not intended to reflect current or future Scottish Government policy, rather it has been undertaken to highlight the cost of an evidence based approach to Early years Interventions.

6. Scottish Government analysts have estimated the cost of these interventions using information collected from Scottish delivery partners and from UK based programmes that most appropriately fit this illustrative package.

7. To remain consistent with the November report, this report continues to use the proportion of the child population who are looked after in a community setting as a proxy for those with a moderate level of need, which equates to approximately 700 children/parents in each age group, over the pre-birth to 5 years old cohort. The proportion of the child population who are looked after in a residential setting was adopted as a proxy for those with a severe level of need, accounting for approximately 80 children/parents in each age group, over the pre-birth to 5 years old cohort. The looked after population was adopted as a proxy measure as it relates to a group with relatively high, and differing, levels of need. It is however a small proportion of the overall child population, and a conservative estimate of the size of the moderate and severe groups.

8. It should also be noted that targeted parenting interventions are interventions that are delivered to a wider population than the moderate and severe need populations identified above. For example the proposed targeted parenting interventions are focused on 3 and 4 year old children at risk of, or already displaying, serious Disruptive Behaviour Disorders (DBDs), with approximately 6.7% of the general child population exhibiting moderate levels of difficulty and a further 3.3% displaying severe behavioural difficulty in comparison to their same aged peers, with targeted interventions designed to address their level of need.

9. Where it is possible to identify the areas where some or all of these measures are already in place or being implemented, the cost of this provision has been removed commensurate with an estimate of the affected population, resulting in an estimate of the total additional cost of delivering this package of interventions. A number of the costs estimated in this report represent the ongoing cost of delivering these interventions. There may be additional start-up/implementation costs incurred as a result of adopting these programmes. Estimates of these costs are beyond the scope of this report.

C. PACKAGE OF INTERVENTIONS

10. The information below displays the source and estimated unit cost of each intervention.

· Pre-Primary Education (Part-time or vulnerable 2 year olds) - £3,022 per child/per year.

Pre-Primary education cost estimates are taken from Scottish Government Analytical Services estimates. It is likely that these costs are an overestimate, as the cost per pupil figures take no account of the likely small marginal cost of taking on extra pupils, up to that point which capital/staff would have to be invested in prior to increasing capacity above a certain threshold.

· Parents as First teachers (PIFT) [6] (Also known as "Born to Learn") - £373 per person in the first year of delivery, £292 per person in the second.

Parents as First Teachers unit cost information was taken from The Centre for Excellence and Outcomes in Children and Young People's Services (C4EO) data, which sets out year 1 and year 2 costs for the service. This has been applied over the pre-birth to 3 year old period, consistent with the approach being adopted in Scotland.

· Family Nurse Partnerships [7] - £3,000 per person/per year

Family Nurse Partnership data were taken from the "Second Year Pilot Implementation in England Report", which sets out the average cost per client. These estimates include staff and administrative support costs. It should be noted that in those areas where Family Nurse Partnership is currently being piloted, the client group is all first time mothers aged 19 and under. This is a wider group than that estimated in our report, and the cost of delivering services to this population would exceed those estimated nationally in this report. It should also be noted that this is a licensed programme, with strict fidelity criteria that must be adhered to when it is implemented. These criteria, of necessity, can limit the pace of rollout.

· Targeted parenting interventions for 3 and 4 year old children at elevated risk of Disruptive Behaviour Disorders- £273 per child over the 4 year implementation period, £130 per child/per year for ongoing delivery.

Parenting programme costs have been estimated using NHS Education for Scotland (NES) data estimates. NES is developing a proposal for dissemination of the Incredible Years and Triple P parenting programmes, aimed at targeting 3 and 4 year olds throughout Scotland [8] at risk of developing or already exhibiting serious DBDs. This estimate does not include staffing costs, but instead assumes that existing staff resource can be redeployed to deliver these programmes. These programme costs have been estimated for delivery against approximately 10% of the child population, and therefore represent the average cost. For those in the severe needs group, this cost would likely be higher. Implementation is estimated to take place over a 4 year period. Triple P is currently being delivered in Greater Glasgow and Clyde, therefore the national cost estimate includes an indicative costing for Incredible Years.

· Ante-natal support for pregnant women who misuse substances [9] - £349 per person/per intervention

The estimates of ante-natal support for pregnant women who misuse substances is taken from the National Institute for Health and Clinical Excellence (NICE) guidance on Pregnancy and Complex Social Factors. This involves the provision of a full-time midwife.

· Pre-school Child Healthy Weight Intervention [10] - £300 per child/per intervention

The evidence base supports the importance of establishing good nutritional habits during the pre-school (age 2-5 years) period. Children at risk of becoming overweight or obese can be identified from age 2, and from age 3 specialist weight management programmes for those already overweight or obese, combining diet and physical activity advice and support, have been shown to be effective. . These intervention can be delivered to children along with their families at any age between 3 and 5 years of age, but have been attributed to 3 year olds in the analysis. This estimate includes practitioner time, written programme materials and room hire, clinical supervision and quality control, and training. However it does not include continuing professional development of practitioners, team meetings, admin support, wider social marketing activities to promote uptake of the programme or a contribution to general maintenance of offices, other infrastructure or senior management time.

· Smoking Cessation aimed at pregnant women [11] - £300 per person/per intervention

Cost per intervention data for smoking cessation was taken from the National Institute for Health and Clinical Excellence (NICE) report "Economic Analysis of Interventions for Smoking Cessation Aimed at Pregnant Women". This estimate includes the cost of a series of group support sessions and pharmacotherapy. However it does not include continuing professional development of practitioners, team meetings, admin support, wider social marketing activities to promote uptake of the programme or a contribution to general maintenance of offices, other infrastructure or senior management time.

· Interventions not included in the per head/national costings:

We have been unable to obtain a unit cost for support for accessing services/advocacy, though a proportion of Local Authority social care expenditure is currently focussed on advocacy work.

Cost per intervention data for Breastfeeding is not available at this time, though a number of Breastfeeding programmes are currently operating in Scotland.

Health Visiting [12] costs £44 per visit, data were taken from the NHS Information Services Division Scotland costbook estimates for 2009. Health visiting costs have not been included in the overall national and individual cost estimates, as these services would be delivered as required according to need.

Play@home (£360k per annum) - a multi-level intervention, using play as a 'safe' way to address key parenting issues, from birth to age 5. This is an evidence based programme currently being delivered in every Health Board area and is undergoing evaluation.

D. Interpretation of our results

11. At an individual level, the estimated total additional public spending on a child and parent with moderate needs would be £1,849 over the pre-birth to 5 years old period. For a child and parent with severe needs, the estimated total additional public spending is £11,220 over the pre-birth to 5 years old period.

· The moderate needs estimate was calculated assuming the child and parent accessed Parents as First Teachers from pre-birth to 3, smoking cessation in pre-birth, a child healthy weight intervention at 3 and access to Play@home between birth and age 5. The severe needs estimate was calculated assuming the child and parent accessed Family Nurse Partnerships from pre-birth to 2, Parents as First Teachers from pre-birth to 3, smoking cessation in pre-birth, ante-natal support for pregnant women who misuse substances, pre-primary education at 2, a child healthy weight intervention at 3 and access to Play@home between birth and age 5 .

12. Our modelling suggests that the annual additional cost [13] of delivering the recommended package of interventions would be between £2.2 million and £3.7 million[14], at a national level. This package is costed against the estimated moderate and severe needs population, as set out in the previous report. The moderate needs population is approximately 700 children/parents in each age group and the severe needs population approximately 80 children/parents in each age group, over the pre-birth to 5 years old cohort. It is accepted that this may be a conservative estimate of the level of need, and that delivery partners may choose to deliver programmes to a wider population. It should be noted that for a number of the interventions costed, it is assumed that the intervention would be delivered by existing practitioners, and there would therefore be an opportunity cost of reallocating resource away from other programmes.

13. The national estimate was calculated by applying the per head costs estimated above to the moderate and severe needs populations estimated in The Financial Impact of Early Years Interventions in Scotland report. The moderate needs population is approximately 700 children/parents in each age group and the severe needs population approximately 80 children/parents in each age group, over the pre-birth to 5 years old cohort.. However, the estimate of the cost of a tiered parenting programme used the Scotland wide (minus Greater Glasgow and Clyde) estimate of approximately £2.5m over a 4 year implementation period, with a further £0.7m per year thereafter for ongoing delivery. This is to remain consistent with the estimates provided, as they were costed on a national basis. Triple P is currently being delivered in Greater Glasgow and Clyde, therefore the national cost estimate includes an indicative costing for Incredible Years only in Greater Glasgow and Clyde, of approximately £0.3m over the implementation period, with a further £0.07m per year thereafter for ongoing delivery .

14. The moderate and severe spectrum of risk interventions in this package have been costed against the moderate and severe needs populations, as described above. It is accepted that for some interventions it may not be appropriate/feasible to limit access for those not accounted for in these groups. This could potentially lead to an increase in demand for some services. While this report does not account for the financial impact on these groups, or the additional cost of providing services to them, it is not unreasonable to suggest that there will also be benefits to these additional groups in the short, medium and longer term.

15. Assuming that the package of interventions can reduce future public cost associated with not having the best start in life by 100%, and that impacts persist through life, then the package would result in an increase in public spending for approximately 2 years across the moderate and severe groups. After this period, as the effectiveness of the package, and the number of cohorts affected, offsets the cost of the intervention package we estimate future public spending on these groups would fall. Analysis shows that should the package of interventions prove to be successful in reducing future public cost by just 10%, then public spending would still only increase for a 2 year period, but future public spending would reduce at a slower rate.

ANNEX A - Scottish Collaboration for Public Health Research and Policy - Framework for Early Childhood Interventions

Annex A

Source: Scottish Collaboration for Public Health Research and Policy: Interventions for Promoting Early Child Development for Health - An Environmental Scan with special reference to Scotland (2010) https://www.scphrp.ac.uk/node/103

[1]http://www.scotland.gov.uk/Topics/Research/by-topic/children-and-young-people/EarlyYears

[2]https://www.scphrp.ac.uk/node/103

[3] See Cunha and Heckman (2006) "Investing in our Young People", and Doyle et al (2007) "The Timing of Early Childhood Intervention", Working Paper, University College Dublin

[4] For example, see New Economics Foundation (2010) "The economic and social return of Action for Children's East Dunbartonshire Family Service" for an evaluation that points to such early success.

[5]https://www.scphrp.ac.uk/node/103

[6]http://www.c4eo.org.uk/costeffectiveness/files/vignettes/ID104_vignette_completed_with_refs.pdf

[7]http://www.iscfsi.bbk.ac.uk/projects/nurse-family-partnership-implementation-evaluation

[8] Data from NHS Greater Glasgow and Clyde (NHS GGC) are not included in this proposal as NHS GGC have already commenced the comprehensive implementation of their Parenting Support Framework. Tailored collaboration between NHS GGC and NES in relation to parenting is being undertaken.

[9]http://guidance.nice.org.uk/CG110

[10] National Institute for Health and Clinical Excellence (NICE) (2006). Obesity guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. Available: www.nice.org.uk/nicemedia/live/11000/30365/30365.pdf

[11]http://www.nice.org.uk/nicemedia/live/13023/49421/49421.pdf

[12]http://www.isdscotland.org/isd/6480.html

[13] The total cost of the package less those interventions which are currently being implemented/delivered.

[14] We have performed some simple sensitivity analysis of plus or minus 25% on the numbers of children with moderate and severe additional needs that gives the range of £2.2 million to £3.7 million.