An update on the Early Years Collaborative Leith Pioneer Site Graham Mackenzie Consultant in Public Health Medicine NHS Lothian 7 October 2015 @gmacscotland #gethealthystart /GetHealthyStart

Acknowledgements Thanks to Angela Dougall, Andrew Massie, Lyndsey Good, Diane McInally, Jane Stafford, Lesley Fraser and all the teams across Lothian, Simita Kumar, Jen Irvine and many others Granton Information Centre and partners involved in the Tackling Money Worries work Scottish Legal Aid Board for their Tackling Money Worries grant

Learning outcomes Work to reduce impact of maternal and child poverty in Lothian Healthy Start welfare rights advice Introduction to some tools for health improvement Reflections about how improvement science can be used with front line staff

Child poverty in context ¼ children live in poverty Child poverty has a huge impact on health and wellbeing and long term outcomes In comparison 1 child in 10 has speech and language delay 1-2 children in 100 children have fine or gross motor skill delay

Healthy Start Food and vitamin vouchers Low income families Pregnant women (from 10 weeks gestation) and children under 4 £3.10 per week food vouchers

Initial aim To increase uptake of Healthy Start (food and vitamin voucher scheme) to 90% of eligible participants (benefits recipients, child tax credit recipients and pregnant women under 18 years old) in north east Edinburgh by March 2015 “£250,000 into the pockets of families in north east Edinburgh” Focused on staff and women’s knowledge of scheme and registration overall rather than vitamins. Note – this is addressing the consequences of deprivation; still need to work on addressing the causes of deprivation. Current sign up for Healthy Start in Lothian 75% (women and children)

What we did… testing and spread 5) We kept testing – e.g. reaching new populations, support for women to complete the form, other services and beyond pregnancy…. work that continues… 1) We worked with one midwife to understand the process of signing a woman up for Healthy Start by week 10 of pregnancy (Mar 2014) 4) We shared the recommendations and data with team leads, for cascade, and started visiting the other teams (May to Nov 2014). 2) Once we had identified a simpler and faster process to sign up we surveyed other midwives in the same team, neighbouring team then the whole of Lothian (Apr – May 2014) 3) We put the lessons into a simple recommendation sheet and flow chart for pregnant women and their midwife (May 2014).

@gmacscotland /GetHealthyStart

Tool number 1) Project Driver Diagram Would add in retailer factors here now, and are testing ideas with a supermarket and pharmacy

“Drivers” and influences on data Starting point Family factors Staff factors Staff factors Community factors

Results Introducing run charts, statistical process control charts, Pareto charts and more

Process Jan 2014  Jul 2015

Process

Process Jan 2014  Jul 2015

Outcome Jan 2014  Jul 2015

Outcome Aug 2013  Jul 2015

Reasons for not receiving vouchers Pareto Chart 1 2 3 4 5 6 Application not posted/ completed turned down Didn't think was eligible at booking Language/ interpretation Not heard back from DoH Applied too early (7 weeks) Number of women 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Cumulative % Reasons for not receiving voucher by 16 week antenatal appointment @gmacscotland /GetHealthyStart

Team level data (team 3) This is for illustrative purposes, showing the level of sophistication we can obtain using monthly small-area data. Data need to be interpreted with caution

* Would be good to ask all women – ie aiming for 100% for these measures # Aim for these measures depends on local population and capacity of local WRA services. Remember that it’s not just lowest income women who may benefit. Team 3 * * # # (+) A “yes” for either question 3, 4 or 5 on the first slide Documentation of Healthy Start good, with some fluctuations with new staff. Eligibility for Healthy Start increased early on, before slight fall. Documentation of offer of welfare rights advice, and % of women accepting that offer (+), has increased very substantially (highest in Lothian) and is reaping dividends for these women.

Number of women receiving Healthy Start vouchers, Aug13-Aug15 TEAM 3

% eligible w&c in receipt of vouchers (team 3)

Team 3: Children <1 in receipt of vouchers

Team 3: Children >1 in receipt of vouchers

“Drivers” and influences on data Starting point Family factors Staff factors Staff factors Community factors

Scottish Legal Aid Board funded Welfare rights advice Work with Granton Information Centre in north east Edinburgh, with Citadel, Fort EYC, Dr Bell’s Family Centre, midwives, health visitors, Edinburgh Community Food and many others Scottish Legal Aid Board funded

Process

Initial results Worked with families not usually referred for welfare rights advice What do you think impact has been on these families?

Conclusions Huge impact of this work on family finances in north east Edinburgh particularly Has required relentless focus, front line work, sharing data at team and small area level Sharing results with all teams, with hope of repeating success across Lothian and Scotland