Chancellor Gordon Brown hailed them as Britain's 'best kept secret', helping parents in disadvantaged areas with parenting skills and providing play and learning opportunities for their children. Yet the early national evaluation of Sure Start local programmes found that only 26 per cent had shown positive outcomes for children.
In her assessment of public service agreement targets for Sure Start set by the DfES, Kitty Stewart, a research fellow at the Centre for Analysis of Social Exclusion (CASE) at the London School of Economics, suggests that 'some of the targets may simply have been too ambitious'. She adds, 'However, the lack of improvement in several of the health indicators is cause for concern.'
The missed targets include a 5 per cent cut in low weight babies, a 10 per cent reduction in emergency hospital admissions and a 10 per cent reduction in mothers who smoke during pregnancy. In A More Equal Society? New Labour, poverty, inequality and exclusion, a book she co-edited with John Hills, Ms Stewart says these deficiencies may be because 'too much was expected of this relatively low-budget programme, allowing reduced mainstream focus on young children'.
Vidhaya Alakeson, a research fellow at the Social Market Foundation, says that it is arguably too soon to assess the impact of three-year-old programmes, which may have taken two years to set up. She adds, 'There is also an argument that the community-led approach that Sure Start started with is slightly at odds with the Government's target-setting approach. If you have programmes driven by parental needs, that doesn't sit comfortably with demanding a set of demonstrable outcomes.'
Professor Edward Melhuish, of the Institute for the Study of Children, Families and Social Issues at Birkbeck College who has led the National Evaluation of Sure Start (NESS), says, 'From the outset it was recognised that the health targets were ambitious given the possibility for changing people's health-related behaviour in a short space of time and that monitoring changes in health populations have been notoriously difficult to maintain in a systematic way.'
His team produced a report last month, Implementing Sure Start Local Programmes (SSLPs): an In-depth Study, which includes an assessment of the contribution to SSLPs from the health sector. It concludes that GPs are not engaging with Sure Start and that there is 'limited liaison between GP-based health visitors and health professionals working in Sure Start'.
In poor health
This lack of engagement with programmes which cover only one third of poor children is highlighted by Ms Stewart who notes that 'children were conspicuously absent from the priorities for Primary Care Trusts (PCTs) for 2002-03'. She adds, 'It has been left up to Sure Start to deal with child health and up to them to engage with PCTs and it hasn't been working the other way with PCTs giving child health priority.'
Professor Norman Glass, director of the National Centre for Social Research and an architect of Sure Start, says, 'Children's services in health are just regarded as an afterthought because, for the most part, they are long-term preventative issues and they come out bottom of the pile in the NHS, which is dealing with urgent acute cases.'
Low priority
Children's health became even less of a priority when the Department of Health's close ties to Sure Start effectively ended when it ceased to be part of an interdepartmental unit and came under the control of the DfES.
Professor Glass says that while Sure Start programmes have had the opportunity to hire health visitors and to let them work across boundaries in innovative ways, a culture of self-tasking among some NHS staff effectively prevented this from happening.
He adds, 'I know from my own experience as chair of Croydon Sure Start that it was extremely difficult to get the midwives' service, for example, to collaborate because they came under a different managerial arrangement.'
Hugh Thornberry, director of services for the children's charity NCH in the West Midlands, agrees that the complexity of NHS structures, compared with social care and education, and the need to work not only with PCTs but also acute hospital trusts has created difficulties for Sure Start programmes.
'Within one local programme you can have several health bodies which may not all be pointing in the same direction,' he says.
The NESS report also examines the culture clash between Sure Start's locally-based initiatives and the often unwieldy structures in the NHS. It finds that even where PCTs embraced the Sure Start concept of services aimed at early intervention and prevention, often 'professional staff at an operational level can feel threatened by a sense of disempowerment when families (or patients from their perspective) are put in the lead in determining their own needs'.
The report highlights several examples of these conflicting approaches and states, 'The Sure Start approach effectively disempowers the professional.
Moreover, in some cases it challenges the very basis of professional intervention, implicitly suggesting that a friendly, empathetic and egalitarian approach is likely to be more effective than a professional-patient one.'
It's an approach that finds favour with Sandra Shears, manager of Ipswich Sure Start, one of the minority of local programmes to be health-led by the local PCT. She says, 'Our view is that if we get the relationships right with the parents on the ground then we can meet targets.'
Terry Ward, locality director for the PCT and chair of the partnership board covering both Sure Start programmes in Ipswich, endorses this approach. He says, 'In one of our Sure Starts we have a programme being worked on where we don't just tell parents not to smoke but suggest they start with a smoke-free room and then move towards a smoke-free house. This recognises the difficulty there can be in delivering on these things.'
A similar process of encouragement is used to get more women to breastfeed their babies.
Ms Shears says, 'More than 80 per cent of the mothers in our area did not breastfeed their babies. An approach which is hostile to them bottle-feeding doesn't work.'
She says having the PCT as the lead body in the Sure Start programme 'works brilliantly because we get all the information so all the children born in our area are on our database'.
In jeopardy
But there is concern that the involvement of a wide range of community-based organisations in the Sure Start partnership boards is now in jeopardy as the Government prepares to hand more control to local authorities - and that could torpedo efforts to bring the health sector on board.
Mr Ward says that his partnership board includes local authority representatives and that he is not overly concerned as the county has been selected as one of the 21 local authority agreement pilot areas, under which new funding arrangements will be tested. He says that the low birth weight of babies has been identified as a target.
But he adds, 'We are still awaiting details of the new funding arrangements. We understand that some time next year the revenue element of Sure Start funding will be routed through the county council. We don't know the extent to which that will be ringfenced or passported or whether there will be some sort of transitional protection. Until we know for definite, we are trying very hard not to worry about it.'
The Government has indicated that it wants Sure Start local programmes to be mainstreamed and rolled out to more needy children and families through the development of children's centres and that it foresees children's trusts in each area playing a key role in the commission of services.
However, Professor Glass believes that under the new arrangements Sure Start programmes would no longer be able to directly employ health visitors and that they will have to battle for financial priority, with their fate and finances in the hands of local authorities.
A DfES spokeswoman tries to dispel this scepticism, 'We will expect local authorities to deliver particular outputs, as we do with local programmes.
We are already doing this in the 21 local authority agreement pilot areas where funding arrangements have clear outcomes and outputs attached which a local authority must deliver.'
Mr Thornberry anticipates a reduction in the number of PCTs in the near future which, coupled with 'local authorities getting the right arrangements in place', could lead to improved working relationships with the health sector and 'ensure partnership working centred around the child comes to fruition'.
He adds, 'We haven't seen much evidence to date of practice in Sure Start programmes reshaping the way mainstream health services are delivered. They appear to be mostly islands of good practices, with interesting approaches to health visiting and midwifery, but with little change.'
It is clear, however, that whatever shape local authority-led arrangements take, roles need to be clarified and differing outlooks reconciled if the profile of children's health is to be raised and health professionals are to become a key component of multi-disciplinary working and the integrated delivery of children's services.
More information
* 2004192 - Implementing Sure Start Local Programmes: An Indepth Study by the National Evaluation of Sure Start team, and
* 20041921 - Implementing Sure Start Local Programmes: An Indepth Study, part 2 - a close-up on services can be viewed on www.dfes.gov.uk/research - click on published projects.
* National Evaluation of Sure Start, at www.ness.bbk.ac.uk
