A Better Start: tackling inequity through community-wide action on early childhood development

Developmental scientist Clyde Hertzman famously documented how ‘social environments and experiences get under the skin early in life in ways that affect the course of human development’ (Hertzman and Boyce, 2010). Even in high-income countries, inequalities emerge early and have lifelong consequences. A boy born in the northern English seaside resort of Blackpool, for example, can on average expect to live until age 74.7, whereas a boy born in Kensington and Chelsea, one of London’s wealthiest boroughs, will live until 83.3.

A Better Start (ABS) is a ten-year £215-million investment by the National Lottery into five economically disadvantaged communities in England – Blackpool, Bradford, Lambeth, Nottingham and Southend. Launched in 2014, A Better Start provides support to families from pregnancy until a child’s fourth birthday, focused on improving early childhood development outcomes, encompassing language and communication, diet and nutrition, and social and emotional development.

A key driver for A Better Start was the WHO Commission on the Social Determinants of Health (2008). The Commission recognised pregnancy and early childhood as crucial windows of opportunity and made ‘giving children the best possible start in life’ a priority for tackling inequality. And that is precisely what the five pioneering A Better Start communities have set out to do.

Each ABS local programme is distinctive, reflecting unique local contexts and patterns of need. Nevertheless, there are a number of common features of the ABS approach which are outlined below.

Each area has developed its own local strategy, tailored to its unique context. ABS partnerships have made a decisive shift from a past when they tried to fix individual social problems one by one, sticking plaster by sticking plaster. Instead, they are designing whole systems of support, bringing together health, education, police, voluntary, community and private sectors, all to work together with the shared goal of improving early childhood development. It is an approach that puts local people in the lead, harnessing local assets and resources and always keeping child outcomes at the centre.

The process of developing local strategies in A Better Start began with building a shared understanding of the issues and challenges each local area faced. All stakeholders – local parents, voluntary and community organisations, local government, health agencies, researchers – shared their experiences and stories together; they looked at the data; they mapped what was good about the local areas and local services; and they identified what needed to change. It was only through building this common understanding, and taking the time to develop a shared vision, that the partnerships were able to build solid plans and consensus for change. Nurturing trusting relationships and the spirit of collaboration was vital.

A Better Start has created new formal partnership structures to drive forward the vision and coordinate service delivery. The partnerships are each led by a voluntary sector organisation and have very senior-level representation on their Boards from public agencies, including local government, health and police. And crucially, the partnerships are building stronger community voice into their governance structures. In Bradford, a local parent chairs the Board responsible for their multi-million-pound grant; in Nottingham they have stipulated a minimum quota for community representation; and in Blackpool they have established new parent forums in each local children’s centre.

A Better Start marks a decisive shift away from crisis intervention: towards an approach centred on prevention and early intervention. This includes primary prevention activities such as a community-wide campaign to enhance understanding about children’s early social, emotional and language development and to promote appropriate care-giving behaviours. Early intervention involves harnessing opportunities for universal services such as midwifery and health visiting to proactively identify early signs when families may be struggling. This way, support can reach families before problems have a chance to escalate. The programme is guided by the principle of ‘progressive universalism’, recognising that all families need some support, but that some may need additional targeted or specialist help.

Evidence-based services are those that have been evaluated and found to have clear positive outcomes. Science-based means services designed with clear theories and mechanisms of change, rooted in the best available research, but that have yet to be rigorously evaluated. ABS partnerships are also undertaking original research and development to address gaps in evidence.

A Better Start harnesses the expertise of outstanding researchers and practitioners and brings them together with members of the community – people who are ‘experts by experience’. And it is through this exchange that they are able to gain deeper insight and understanding, and to work together to co-design solutions that are not only scientifically robust, but fit the local context and have the potential to be sustained.

Services aim to reduce the stresses and barriers families face, while also seeking to build capacity and capabilities within families and communities themselves. So, for example, strong community engagement work builds trust and is increasing access to evidence-based programmes like Empowering Parents, Empowering Communities which are delivered by specially accredited local parents, to local parents.

Historically, services have often operated in silos. ABS partnerships are focusing on building seamless pathways and progression between services. For example, Blackpool has embarked upon a radical redesign of its health visiting services, embedding innovative practice such as behavioural activation and promotional interviewing into the practitioners’ toolkit. They are also embedding an exciting evidence-based universal programme called Baby Steps – which is co-delivered by health visitors (bringing child health expertise) and family engagement workers (connecting families to wider community resources).

There are no silver bullets. ‘Test and learn’ means using the best available evidence and trying things on a small scale in order to learn from them. It means adapting and refining services and programmes along the way, sharing what works and what doesn’t, as a way of improving the system as a whole.

This unique ten-year investment provides time and space for local partnerships to carefully co-design, implement and embed effective innovations into local systems. An independent national evaluation (Barlow et al., 2017), funded by the National Lottery, will capture learning and add critical new insights to the international body of evidence on what works to improve early childhood development.

Further details
More information is available at: www.biglotteryfund.org.uk/abs Contact: abetterstart@biglotteryfund.org.uk

References can be found in the PDF version of the article.