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Chapter 3: Development and delivery of Sure Start Services

'We have continued to provide integrated and non-stigmatised services to all, but also targeted the most vulnerable families'. (Sure Start Contact Officer)

Introduction

Thirty-one Sure Start Contact Officer interviews were conducted in total and thirty questionnaires were completed. Respondents were asked to fill in detailed questionnaires prior to being interviewed and 30 did so. This was an open ended questionnaire seeking views on the progress and impact of Sure Start Scotland Services; service provision, use and gaps; the service planning process and the evaluation and monitoring of services. Follow up telephone interviews were conducted to clarify and expand questionnaire information and to ask additional questions, for example about training and views about the future. Interviews were also conducted with the two local authorities who did not submit a questionnaire, thus covering some of those questions. In the one Local authority where no follow up telephone interview could be conducted, the planner interview did take place which covered some of the same ground. The questionnaire data was input into Excel for analysis and the qualitative interview notes were analysed by question using Microsoft Word. This chapter focuses on the Sure Start Contact Officers' views about how Sure Start Scotland services have developed since the last mapping exercise in 2001, what difference it has made to how services are delivered, whether and how any specific groups are targeted, whether there is provision for emergency places, and how integrated packages of care are provided. Illustrative examples are drawn from the data provided in the questionnaires and interviews to demonstrate the range of services provided. Lastly, issues related to staff and parent training are discussed.

Service Development since 2001

Since 2001, Sure Start services have developed with most local authorities reporting an expansion of existing services and new developments. The evidence obtained in this mapping exercise supports this in two ways: the number of services that were put in place after 2001 reported in the quantitative data templates and the descriptions provided by the Sure Start Contact officers in both the questionnaires and the telephone interviews.

From the quantitative data templates, 104 (44%) services were already in place before 2001, but the data show a year on year increase in the number of services since that time (see Chart 7 below). This suggests a continued emphasis on developing Sure Start Scotland, increasing levels and types of provision to meet need and to support the Sure Start Scotland objectives. 56 (24%) of services were set up in 2001/02; 25 (11%) in 2002/03 and a further 50 (21%) in 2003/04. Although some services may be short lived projects, the qualitative evidence suggests that local authorities try to continue services once they are established, either by continuing to fund through Sure Start or by mainstreaming them. It is unlikely that the new services reporting were mainly replacing existing ones; instead provision is being extended and enhanced. The year on year increase in numbers of places also supports this suggestion.

Although the short term nature of funding was identified as a factor hindering the development of Sure Start Scotland in both this (see Chapter 6) and the earlier mapping exercise, many local authorities have also moved towards integrated and more strategic planning (see Chapter 5). Embedding Sure Start services within the overall planning for Early Years was one way of ensuring continuity of provision and some respondents remarked on this process. It can be seen as a key indicator of the success of integrated planning and the place of Sure Start within it. The priority given to early years in general, and Sure Start type provision in particular, now seems to be mainstreamed; although as noted throughout the remainder of this report, there is still room for improvement.

Chart 7: Development of services over time

Use of a range of funding streams

As noted in the introduction, Sure Start Scotland is now part of a range of early years' policies and associated funding streams. This mapping exercise sought to find out both quantitatively and qualitatively whether local authorities were drawing on a range of funding streams to develop their Sure Start Scotland services. The quantitative information suggests that this is certainly the case, with 174 (71%) services being funded from more than one source and only 72 (29%) of services being funded solely from Sure Start Scotland funds. A range of additional funds were reported as being used, including Changing Children's Services Fund, Health Improvement Fund, New Opportunities Fund and Better Neighbourhood Services Fund, as well as mainstream funding, as the following examples illustrate:

'But in a council such as ……, I think the fact that we have grown all these services is quite remarkable in a short period of time, with joint funding from Early Years, childcare partnership monies and SS…so it's not just SS and I think that's important to state as well, that we have probably pulled in over £2 million in the past 3 years from other sources of funding to develop services from 0 - 5 so we've been pro-active in searching for money'.

'There are very few services entirely funded by Sure Start in (Local authority), many have funding from other sources also'.

The following example, given by Stirling local authority, demonstrates how a range of funds is used to develop an integrated service for children aged 0-12, showing how early intervention can be built upon to provide support as children grow older.

Stirling

Fallin Nursery & Out of School Care ( OSC) was funded from a pool of 6 funding streams including Sure Start :

- Provides 0-5 early education and childcare, 50 weeks per year from 8.30am to 5.30pm Monday to Friday

- Provides Out of School Childcare 5-12 years 50 weeks per year

- Provides transport to and from surrounding villages (Eastern Villages encompasses a number of ex-mining communities and has a high level of social, health and other problems associated with poverty)

- Provides targeted family support through a nursery based Family Support Worker and links directly to the specialist Family Support & Community Childcare Initiative working with families affected by substance misuse

- Offers opportunities for the wider community to engage with and contribute to the development of the service

- Effective transition and liaison with local primary schools supporting the Integrated Community Schools agenda.

Fallin Nursery & OSC caters directly for the most vulnerable families in the Eastern Villages area, supporting the needs of families in difficulties and those of working parents - often in low paid jobs. Children needing extra help are identified through the profiling and Staged Intervention systems and packages of additional support and care can be accessed through the family support input. Prior to this service opening, Fallin itself and each nearby village was served only by a part-time nursery class for children aged 3-5 years. The impact of the new service has been significant in ensuring that children can be cared for locally with their needs being identified and met appropriately at an early stage within a non-stigmatised environment.

The further information on the planning process provided in Chapter 5 suggests considerable movement towards integration of planning and funding streams across local authorities. Further issues relating to the integration of services at planning and delivery level are discussed in that chapter and below in relation to integrated packages of care.

Expanded and integrated services

The qualitative evidence provides additional information on how local authorities have developed Sure Start in the context of early years' services. The two main ways in which Sure Start Scotland was reported to have developed since 2001, as reported in the questionnaires, was through the expansion of services and through improved integrated and collaborative working, the latter being a key theme throughout this mapping exercise. The following examples, from a range of Sure Start Contact Officers, illustrate the development of Sure Start:

'Some of the initial pilots ...have been consolidated and/or expanded. Investment in capital for new build or improvement of buildings to create Children's Services Centres has created the opportunity for various models of joint delivery……..new partnerships have developed new pilots……Advice from the Scottish Executive that Sure Start should be considered as core funding rather than a short term 'initiative' made a fundamental difference to the way it has been used (in this Local authority). This has allowed us to invest in services and particularly in staff in a way that we could not otherwise have considered'.

'Services are more established and continue to develop within local communities. Inter-agency working has also improved and developed with services complementing each other. I feel there is more awareness with regard to the aims and objectives of Sure Start Scotland both with local families and other agencies and departments with (Local authority)'.

'There is a much greater involvement in the development and delivery of services from a wide range of professionals, in particular health '.

Other points that were noted were issues such as the variety of provision, flexibility, responsiveness to local need, enhanced as well as expanded resources, development of centre-based provision, movement towards mainstreaming of provision and the targeting of vulnerable families within universal, non-stigmatised services:

'In (Local authority), services for children under 3 have been made available since 2001 using the majority of our Sure Start funds in the context of developing integrated, mainstream, universal services. We do not specify any of our services as "Sure Start Services" as they have all been developed with a wider remit for 0-5 (and 5-12 in some cases) plus family support. Vulnerable families with children under 3 are one of the target groups provided for within these wider children and families services'.

'We have enhanced the resources of a number of our projects to enable the projects to develop/respond to the demand for the services, through either expanding places for children or by providing additional resources to support intensive working with parents and families. In addition, where initiatives have proven to be successful we have extended these initiatives to include or expand the services offered by other projects e.g. additional resources allocated to support nursery parents was expanded from the initial involvement of 10 establishments to 17. It is our belief that our projects have continued to develop to support families with very young children'.

'Initially Sure Start Services were seen as separate from other services and were also thought to be services that needed to be targeted either on a particular geographic area or a particular vulnerability. (Local authority) does retain one particular service that needs both requirements, i.e. geography and vulnerability; however, Sure Start funding has increasingly been used to make mainstream services more accessible and more responsive'.

The following examples provide illustrations of expanded services and a new development that has responded to need:

Western Isles

Roinnagan is a childcare support group based on a family centre model. This service runs 2 days a week in a resource centre in Stornaway and provides a total of 18 places (2 of which are reserved for children with additional support needs). The majority of referrals are made through social work and health. Each child has an individual development plan focussing on learning and development through play. Each child's needs are reviewed regularly through a multi-agency review. Support and feedback is given to parents within the home or the resource centre. Transport is provided for children in outlying areas. This service impacts on both the parent/s and the child by enhancing social, emotional and educational skills, improving resilience and coping mechanisms. In addition, the service offers a respite service for parents and provides them with the skills and confidence to help address difficulties.

Renfrewshire

A family centre which, through Sure Start resources, was expanded to provide nursery places for children aged 0-3 years and support to parents and families. The service provides a range of flexible places to vulnerable children in order to respond to the varied needs and demands. The centre is open 52 weeks per year. The service is also resourced to enable support to parents and families using the service. This is done through one to one support with the parent or family and group support to address a range of issues as follows: parenting classes, behaviour management, self esteem, personal development, and through working with groups of parents and their children to offer advice and guidance on parenting issues. A lot of the work with families is done jointly with other agencies.

South Lanarkshire

Crèche support to new parents to give them 'Breathing Space' was identified by local health visitors via the Communities that Care process as a need, to reduce stress and prevent difficulties developing in the parent child relationship. This initiative is being rolled out via the Early Years Integrated Family Support Teams, with parents requiring this additional support being identified by these teams, community midwifes and health visitors. The crèche is provided by the Integrated Children's Services mobile crèche.

A few local authorities mentioned difficulties with expanding and developing Sure Start Scotland services in their local authorities, because there had been so little progress prior to 2001 that they were starting with very little provision, or because of funding or staffing difficulties as the example below indicates, although even here, positive progress was reported:

'We've had some difficulties with staffing and cuts in funding, probably the development has not been as great as it could have been. There's been considerable success in terms of how we've begun to develop services and we can certainly target the funding to address the criteria……(these are) more flexible so (we're) looking at under 5s not under 3s. So it's allowed us to develop, build on integrated services but also to develop initiatives. Overall I would say it's been very successful'.

Further examples of service development

Sure Start Contact Officers were asked during their interviews whether they felt any new and/or innovative practices had been introduced as a result of Sure Start Scotland. Several respondents said that Sure Start had brought about new approaches to working with parents/families and had enabled imaginative and innovative developments. Many of these related to working with health colleagues and were used in the interviews as examples of good practice in joint working and service development. Thus, although working with health was still identified as an area for further improvement, it was also an area where new developments were bridging professional boundaries leading to innovative work and new types of service.

New posts have been developed in many local authorities. For example, in Highland, community early years workers will sit alongside health visitors, although line managed by social work. In Clackmannanshire, a new Public Health nurse post has been developed to make Clackmannanshire 'baby friendly' and increase breastfeeding rates, linking closely with other health professionals. Specialist substance misuse worker posts were now developed in some local authorities, such as Aberdeen City, where they had not been before. New forms of assessment and early identification of needs were also being developed across several local authorities. The 'Moray Integrated Developmental Assessment Service, assesses children with special needs locally, whereas previously this was carried out in Aberdeen. In Stirling 'The development and piloting of a multi agency single assessment framework is currently a priority piece of work'. Family Support Teams have also been developed in many local authorities since 2001, for example in South Lanarkshire, Early Years' Integrated Family Support Teams link to targeted Early Years' establishments, local health visitors and Community Midwives, and a school based team that is co-located in targeted school bases alongside colleagues from a variety of departments from all agencies. In Highland, Family Support Workers are supported by Senior Family Liaison Officers.

Sure Start Contact officers provided many examples of what they felt were new or innovative services often aimed at early identification of need and thus prevention. Two examples are provided below, but there are many others, such as the Early Start service for autistic children in Midlothian, and 'Just Dads' Groups' in Clackmannanshire to name but two. The following two illustrations provide further examples of developing Sure Start. In the first, a peripatetic Play Development worker can provide support across a rural local authority area. In the second, joint working enables a nursery nurse to provide support within the home to vulnerable families:

Dumfries and Galloway

Play Development Service is commissioned from SPPA, it employs one peripatetic Play Development worker in each of the four old local authority districts. The PDW works with groups of parents and children together, delivering Play Sessions which are designed to improve parent-child interaction, parents understanding of their child's developmental needs, and parents enjoyment of their children. For the most part it's a secondary service and groups come in the first instance through other services such as midwifery, health visiting and family support. We intend that it will assist in improving children's social, emotional and physical development and readiness to learn, by involving their parents actively.

Fife

The Acorn Project provides Nursery Nurse intervention in the home to families with children under 5 years where there are early signs of parent/child relationship and behavioural difficulties. The Nursery Nurses are 'mentored' by health visitors in primary care settings and receive ongoing clinical supervision and training by clinical child psychologists. The approach involves helping parents to develop their play skills (using the Parent/Child Game) to improve parent-child interactions, strengthening attachments and relationships. Referrals come from health, social work and Home Start (voluntary sector).

The project is audited regularly using the HADS scale (measuring Anxiety & Depression in Parents) and the Behaviour Checklist (measuring Behavioural problems in children). Between March 2002 and March 2004, 29 families were involved with the service. Results showed 56% of parents indicated a reduction in anxiety and 67% of children improved in terms of their behaviour. The Nursery Nurses have also delivered group sessions about the importance of play at various community venues including a local high school.

CASE STUDY: Service Providers' Views

More detail about the variety of Sure Start provision was obtained through the two case studies that formed part of this mapping exercise. The views of service providers were sought to provide a richer account of service development in the two areas. Both case studies demonstrate the range of targeted, universal and integrated services that have developed. In each case study area, telephone interviews were conducted with a selection of service providers in order to get some detail about the diversity of services and issues related to their delivery and impact. The topics covered in the interviews were: a brief description of the service; how it has changed or developed; groups not being covered who should be; how the service helps young children and their families; how the respondent would like to see early years services developing in the future. Seven service providers were interviewed in total.

Aberdeen City

In Aberdeen City, a number of specialist posts have been mainstreamed since 2001, providing greater continuity. The Authority is also working to maximise crèche provision with an on-going review. The Management Group has widened to include health and the voluntary sector: 'This provides a clear focus for Sure Start within the integrated Early Years' strategy'. The following examples demonstrate Aberdeen City's commitment to addressing the needs of very vulnerable children and their families: 'Projects have been developed to address specialist needs e.g. children affected by substance misuse, children affected by homelessness, travellers and teenage mothers'.

Service 1: The Travelling community

A voluntary sector service operates across different local authorities to provide support for settled and temporary gypsy travellers. The service is funded from 17 different funders, including Sure Start Scotland. In Aberdeen the service is trying to make the traveller site more attractive; Sure Start and Child Care Partnership funding is being used to develop services for the pre-fives, but other services are also being developed, for example: youth clubs, women's group and literacy sessions. The respondent felt that the provision that has been set up in Aberdeen has been very successful. 40 different children under five (25 of whom are under three) have been involved. There is one two hour session once a week with sessional staff. The aim is to negotiate access to learning for young children including taking them out on trips. Water play and sand play are provided, for example. The feedback from the sessional workers is very positive and an evaluation has just been completed of the service. Parents too seem positive. Although the service is for under fives, since the notion of family is so strong amongst this community, older children are not turned away and in fact even teenagers have enjoyed the play. Increasing the service hours would require Care Commission registration and the building needs to be upgraded for that. Other difficult issues relate to child protection and they work closely with social work, including training.

Service 2: Post Natal Depression project

A voluntary sector service providing group support for mothers with post natal depression. Sure Start funding has been used since the inception of the project. Service users self refer or are referred by health visitors. There are both drop in sessions and specific groups; group support can continue for up to 2 years. Clients also have CPN support for 6-8 weeks; they are helped to access other services such as Homestart. Crèche support is provided through another provider; this means that the children are nearby but not in same building. The parents are able to talk freely. The service supports about 50 mothers a year, of which about 12 are self referred. There have also been 12 partners involved. They did try a support group for fathers but this hasn't worked yet; this is something the service would like to develop. Men have come forward and parents have been involved in raising awareness. This respondent said that the service was very integrated and links with other provision. The service is getting better known by health staff and by women themselves. In terms of service development, this respondent would like to see support for grandparents who may be providing support and more focus on the impact on children and their development, which may require more crèche worker training. Overall PND is a key area for preventive action.

Service 3: Outreach work

A voluntary sector service that is providing outreach work to families; this is part of a much larger service for those with mental health difficulties, including residential provision. People are referred to all the outreach services, for example by health visitors or from the maternity hospital. The services are advertised in doctors' surgeries and elsewhere. The respondent said that groups are a very good way of getting people included; the focus here is on prevention before social work intervention is necessary. The groups help to build confidence and assertiveness and communication skills for dealing with professionals, dealing with each other and dealing with children. The difficulty is getting people to the groups; once they are there the groups are popular. In response to this, five members of staff are training for the mini-bus driver test so that clients can be picked up. Outreach can help families who have no other support and who may not be in touch with services, and their children have no routine until they go to nursery. Giving an example of how the service has helped, the respondent described a young, homeless pregnant woman who was supported to go the maternity hospital, to deal with her relationship with the father, and then after the birth supported by home visits and through groups. This demonstrates the effectiveness of an integrated package of care. When talking about future developments, this respondent said the ideal would be to have no one left isolated; the service currently manages the number of referrals but would need to expand if more people knew about it.

West Lothian

Initially, West Lothian established 'Sure Start as services which could support any parent who requested advice or assistance in giving children the best start in life thus avoiding the stigma which is frequently associated with support given to families in need'. They were also targeting the most vulnerable by concentrating on areas of high deprivation. They are now focusing more on targeted, vulnerable families 'whilst continuing to maintain the activity based locality groups'.

Service 1: Family Assessment and Support Team

This is a voluntary organisation service. This supports children under eleven and their families. For the under threes, there is a parenting group, parent and toddler group. Sure Start provided funding in the past but now money comes from other streams. Some groups though are co-facilitated with Sure Start suggesting good integration at the level of service delivery. The service aims to balance social work type interventions with preventive work. There are good links across agencies at practitioner level and at management level, so the respondent feels that the service is well integrated. They are also constantly monitoring and assessing needs. The parent support group is particularly well attended and has run for several years. The service impacts on children and families by helping parents to understand a child's behaviour and development; it also helps build self-esteem and confidence.

Service 2: Parent Action Worker within Communities Team

This post is within Social Policy in the council but involves a lot of partnership with Sure Start. It is a unique post in Scotland and involves working with play groups, toddler groups, Sure Start groups and others. The service aims to empower parents to have a voice and improve childcare provision to enable parents to get into education to do child care related qualifications. This involves going out to groups and using a community development approach; developing skills - for example arts and crafts; first aid training and IT skills for parents and children. This is very flexible training and parents themselves are involved in decisions. The training programme has developed considerably and additional support is provided to help parents take an SVQ in Early Years' Childcare. Level 2 is done in college. The training and development involves close working with Sure Start, involves parents and helps improve the childcare workforce locally too.

Service 3: Scottish Childminding Association

Sure Start funding provides for specific projects in West Lothian. The childminders have basic training and continuous training, including in first aid and are supported by a development worker. The first service is a specialist childminding scheme for school aged parents. The development worker from the SCMA supports the childminder while the Sure Start worker supports the young mother. The service provides support while the young mother is still at school. The second service is a linked childminding scheme providing emergency childcare for families 'in crisis' but who do not require full social work attention. The service might be a child minder supporting another family member to care for the child if the parent is unable to do so, for example for health reasons. Or, a child minder might be used to enable the family to make hospital visits. The provision is very flexible and may last for over a year; however it is not necessarily full time provision. Transport is also provided as the childminders are not necessarily in the locality. The council decides if the need is to be met by social work or Sure Start. Sure Start decides if their criteria have been met. The service is oversubscribed. In both cases, the respondent felt that not everyone knew about the service who needed it or could refer people to it.

Service Provision 4: Scottish Pre School Play Association:

This large voluntary organisation has two staff on the ground in West Lothian, and they are currently recruiting for one more. In terms of playgroups the major problem is keeping staff and committees in place. The association, through these workers, looks to see what provision is in an area and what is needed; they also support a group if this is needed to keep it running successfully. These posts are either full or part funded by Sure Start. Other funding comes from the Early Years' Childcare Partnership; some playgroups are also pre-school education providers. At playgroups children are supported in a variety of ways. Some children stay there and do not take up a nursery place; some groups are from birth to three, some take an older sibling. The respondent thinks there is good coverage in West Lothian, and there are attempts to get services in the most deprived areas. The respondent described good working relationships across agencies and joint working on the ground; all partners are equally valued. There are regular meetings and also evaluation of the service through reports from the provider and statistics. In the future, joint working will include health visitors, especially in identifying the training needs of parents (for example in terms of child development). In terms of impact, if a parent is attending a toddler group, she can get support from peers and develop an awareness of what play can do in terms of the development of the child. For the groups this can be supported by a member of staff, who needs to build up a good relationship with the group and who can provide some activities.

These detailed views of a small sample of service providers across the two case study areas highlight examples of how these two local authorities have developed and extended their Sure Start services. Issues relating to integrated provision in both local authorities seem to be models of good practice, where integration at service delivery and management levels ensure parents and children can access services to meet their needs. Capacity building is also highlighted through the provision of training for parents and childcare workers and development posts seem to be useful. Both local authorities are tackling the need to reach the most vulnerable while maintaining a non-stigmatised, preventive approach by outreach and other work within hard to reach communities. Some services support parents to access mainstream provision or to generate community based provision such as a new play group. Other services are developed to meet the needs of specific communities or groups and are often flexible in their approach and reach beyond the early years.

Integrated delivery of services

The scale of developments highlighted above through the quantitative and qualitative data was discussed further in the interviews conducted and through specific questions in the questionnaire. Local authorities identified innovative change, the development of new posts, some capital spend, and a growing level of integration. As noted above, the most common change that Sure Start has made to service delivery since 2001 was that it has helped to enhance practices for integrated and joint working. All the Sure Start Contact Officers said that they were attempting, wherever possible, to work with other agencies both internally within the local authority and externally with other service providers and other agencies such as health. A few local authorities were already working in such an integrated manner, but for most this has been achieved, or is on the road to being achieved, through developments in the past few years. Many examples were provided of such joint working, for example, in East Ayrshire 'Learning Partnerships' are based around nine secondary schools. In these Learning Partnerships, secondary schools, primary schools, local nurseries, family centres, health and social work are all working towards an integrated agenda to better meet the needs of families in the local community. Heads of four family centres sit on the learning partnership and school nurses are attached to all nine learning partnerships. The following examples also show how service delivery is becoming more integrated:

Clackmannanshire

NCH Tullibody Family Project: Working closely with NCH we have continued to develop and adapt the services delivered in the Tullibody Family project. The model of work is preventative in nature and relies on an integrated approach from supporting agencies such as health, education, housing, social work and appropriate community groups. The services are planned and delivered within a co-ordinated policy framework which takes into account the key policies of NCH and those of the council. The project, in co-operation with parents, provides both direct services and support to families, including mutual support initiatives. The services provided include a multi-cultural learning environment, individual and group support for parents and children, home visiting, befriending, counselling, advocacy and a sessional day care service for children 0-3. The service provides centre-based and outreach family support services. The service delivers intensive family work and works closely with the Tullibody Healthy Living Initiative. The service meets all of the Sure Start Scotland objectives and has a significant impact on children and families in the Tullibody community.

Inverclyde

Family Support Services: Family Support Workers are based in 5 Children and Family Centres. They support the most vulnerable families in their local community. They offer varied services, including: emergency childcare, family learning groups, self-help groups, positive behaviour groups and stress management. Family Support Workers work closely with colleagues in social work services and health services to offer an integrated service. Family Support Workers offer one-to-one support to families at home. This can involve basic parenting skills, establishing routines and safety issues.

Shetland Islands

The Pre-School Home Visiting service provides regular support and advice for parents with children with additional support needs. A planned programme is prepared and implemented by the pre-school home visiting teacher or the part-time pre-school home visiting nursery nurse. Parents are encouraged to work with this programme. The planned programme is about developing the child in all aspects including social and emotional. Other professionals are generally involved and thus the child's health and ability to learn are addressed. As all concerned work together, the family is strengthened. Parents benefit from all agencies working together with a shared agenda. The family is supported until the child has attended mainstream schooling or a special needs class/department for one term, thus smoothing the transition from pre-school into school.

Involvement of health in the delivery of integrated services

Although quite frequently noted as an area where further improvement in integrated working could be made, the involvement of health in the planning and delivery of services has developed considerably across many local authorities since the 2001 mapping exercise (see Chapters 5 and 6 for further discussion). In many local authorities, health visitors were linked to centres or more rarely actually based in centres. Visiting health professionals provide sessions such as baby massage, dietary input or parenting skills, although other staff were also being trained in these areas. The table below shows the extent of such visiting sessions and the importance of the health visitor role linking to services.

Chart 8: Visiting sessions

In many local authorities, relationships and integration with health in terms of service delivery was working well, for example with health visitors. However, involving health colleagues in planning and at a more strategic level remained an issue for some. For example, one Sure Start Contact Officer said:

'There are repeated references from the Scottish Executive and indeed from the health board themselves to 'For Scotland's Children' and the need for health to take lead roles etc … health are working very well on the ground, health visitors, social workers and teachers get on superbly on the ground…but we will never enact 'For Scotland's Children' from 0-3 until health owns the responsibility for the delivery system of the services'.

However, for others, joint working and integration with health had developed well:

'Health is very heavily represented in the Early Years' group. Health has a part to play in the Early Years' services from the very beginning'.

'Health are always partners of ours in almost everything. Even things like the play development service where all the money's in one service, but the service only works because of the partnership working with the other agencies, they couldn't do it on their own, and health are major and highly important partners in most things …there's not a single thing we're doing that's on it's own. And they (health) have put in resources as well, but that's one of the complications because their personnel system is different'.

Integrated packages of care

In addition to reporting an increase in joint working and integration in terms of service delivery, Sure Start Contact Officers also talked about how families received integrated packages of support. It would seem that there has been considerable development towards the provision of integrated packages of care, but as in other areas of development, precisely how this operates and whether it is being monitored varied across local authorities:

'I think sometimes there's a bit of confusion around what integrated services are and how we provide it'.

'No statistics but anecdotal evidence that children and families involved in centre-based care are also receiving other services. It is important to recognise the different strengths of various projects and the very different contribution they make to families' lives. There is no tracking system to monitor this. The level of support is different between outreach projects and it is common for families to 'progress' between one project and another'.

Many talked about how parents and their young children are likely to receive a range of services to meet needs, and that this may often be very flexible and change over time:

'Many families receive a package of support from more than one service but not necessarily integrated and co-ordinated'.

'All our services are intended to be just one part of a wider picture, but where this is formalised the Sure Start components would not be the co-ordinating partner'.

The following example shows how different services may typically be accessed by a family over time, as they are supported by Sure Start. The example shows how parents are involved in identifying need and how the package of provision can change over time to meet the evolving needs of the family. Thus, a typical selection of services that a family may avail themselves of over the course of a period of about a year through the Family Support Team would be:

Angus

Introductory home visits, to assess and plan with the parents what is wanted / needed.

Over a period of time, parents attend a weekly parent and baby group, where mutual support through discussion and activity; health issues, child development issues, housing etc. may be discussed…the parents set the agenda.

Access to Toy Library / Book Lending Library is encouraged.

"Groovy Grub Lunch Club". Attend once per week, parents and baby and older infant. Parents take turns in assisting in the preparation of a healthy lunch for themselves and their peers and infants, and then enjoy eating it at lunchtime.

Access (Drop-in facility on site) the Sure Start health visitor, or Sure Start Mental Health Promotion Worker to discuss any issues / concerns that parents may have.

"One-off" home visits to address issues of a personal nature etc., this could include welfare rights, housing advice, domestic violence etc.

If wished / assessed as needed, commission Community Childminding for a few hours per week for a limited period in order to provide respite for parents as well as quality care for the infant(s).

Provide safety equipment, for example stair gate, fire guard etc.

Integrated packages of care, however defined or described, were thus seen as essential support for vulnerable families:

'Integrated packages of care has proved to be a lifeline and the only way of delivering services to many of the families who have been supported through Sure Start. For some families more than one service has been essential to keep a family together. The strength of Sure Start is built on the basis of partners coming together to deliver a service that is tailored to the individual needs of children and families as one size does not, as we know, fit all'.

The following examples, provided in two of the Sure Start Contact Officer questionnaire responses, shows how families are supported through an integrated package of care:

Working closely with health visitor services and housing, a young single mum has been receiving support. She has a young baby and appears to be suffering from low nutrition/(anorexia)…The young girl is from a well known local family where alcohol and drug misuse is a significant family issue…The young mum had recently secured a tenancy for herself and her baby. The young mum appears herself to have been a child who has suffered from foetal alcohol syndrome as well as being very thin throughout and since the birth of her baby. The young girl was experiencing difficulties bonding with her baby and was unclear about what she should do to nurture her baby. There were also concerns about ensuring the baby was receiving sufficient nutrition as the mother often 'forgot to eat' herself. Through a mixture of health, family support, baby day care, parenting/play and nutrition work on a mix of centre-based and outreach basis, the young girl is starting to slowly bond with her baby and develop her ability to nurture her child. The health visitor is very pleased with the progress in the young mum and the baby although support will continue to be required for sometime.

One family with three children under five, one aged six. Mum suffering from long-term depression, not coping. Youngest child aged two, still not speaking and three and four year olds exhibiting significant behaviour problems. Previously this family would have been supported in a piecemeal fashion by a range of providers in a range of locations. A multi-purpose nursery centre, with Sure Start funded health visitor involvement, an early intervention project, a respite care facility for two year olds and a range of parent-focused services can now respond to this family in a holistic way and, importantly for mum, in one place. The two year old is offered three sessions of day care weekly and has within three months made significant progress. The two year old is visibly happier and more content, is moving about much more confidently and is beginning to talk and become more sociable. The 3 year old has a morning place plus lunch and the four year old has been offered all day care. The six year old has been offered two out of school sessions, which means that two afternoons a week mum only has the baby and the three year old. Mum looks better, has participated in soup making sessions and regularly borrows books and puzzles and games from the nursery's lending resource. In addition, Mum has made friends with other mums and was seen recently in the parents' room offering great support to a Dad who was describing his difficulties to her. Behaviour of all four children has settled. They all benefit from the substantial snacks and school dinners on offer and the health visitor has arranged for the three year old to get his eye problems sorted out after a run of non-attendance. Mum hugged the nursery head and called her a 'life saver'. This is not an uncommon scenario.

Although recognising it is difficult to assess the numbers of integrated packages of care provided, the questionnaire asked Sure Start Contact Officers about the proportion of children who received a Sure Start service who also had an integrated package of care. The definition of integrated package of care for this purpose was a co-ordinated approach built around the needs of children and families that has led to parents and children receiving more than one service. Twenty-seven provided an estimate of this. Just over two fifths (41%) of local authorities said that 75-100% of children were receiving an integrated package of care. Just over a quarter (27%) of local authorities said that 50-75% of children were receiving an integrated package of care. Just under a quarter (23%) said that 25-50% of children were receiving an integrated package of care and only 9% said that 0-25% of children were receiving an integrated package of care.

Chart 9: Percentage of Children Receiving Sure Start Scotland Services with an Integrated Package of Care

Providing integrated packages of care

Although it was clear from the questionnaires and interviews that many families would be receiving a range of services, flexibly provided to meet changing needs, the extent to which this was co-ordinated varied across local authorities. The most common ways in which such packages were co-ordinated were through family centres, admissions panels, the initial referrer or some kind of 'Early Years' group or integrated children's services group. Many, however, used their referral process to assess need and co-ordinate support. Many were paying particular attention to the referral or admissions process to support integration, for example through the development of joint assessment frameworks or an integrated children's services implementation process:

'A child in need model of assessment and support is currently being developed for all agencies to use and this will promote a more systematic service….'

'The development and piloting of a multi agency single assessment framework is currently a priority piece of work'.

'The Home-link service in particular has established secure links with other agencies such as health visitors and social workers, and the voluntary organisation Home Start. There is a considerable amount of liaison takes place where 'integrated packages of care' are carefully designed to support vulnerable families'.

Provision of emergency places

The majority of local authorities said that they were able to respond to requests for emergency places most commonly in relation to: daycare, nursery, respite, crèche, community childminder and family centre places. A total of 102 out of the 246 services where information was provided for this mapping exercise provided some kind of crisis support. From the 30 questionnaires, 27 local authorities said that they could provide emergency support; responses varied from one local authority saying they 'would do their utmost to help' to another where 'In some projects places are kept free for emergency referrals'. Emergencies were accommodated or dealt with in different ways, sometimes through the usual referral or admissions process, sometimes a service would be provided which would then be followed by more formal assessment and some had access to a supplementary budget for emergency places.

The following example shows how such emergency provision might operate:

A young mother, fleeing domestic violence, had hoped to stay with relatives. When this fell through, she had already given up the lease on her flat. The Sure Start team liaised with another Local authority for this woman to access Sure Start projects there and supported her through the housing crisis and offered support around the domestic abuse issues.

Targeting of specific groups

Although the overwhelming ethos adopted by local authorities in relation to Sure Start was to provide support for vulnerable children and families, in a non-stigmatised way, through universal services, this did not mean that there was no specific targeting, for example of particularly vulnerable groups or of specific geographical areas. As one Sure Start Contact Officer noted:

'So the whole Sure Start philosophy here was to take mainstream good quality childcare that should be accessible by every child and overlay it with layers of increasing specialism'.

Targeting those with additional support needs is described as enabling parents and children to access universal services more effectively, as the example from Dundee City below illustrates:

Dundee City

Sure Start Early Intervention Projects: three early intervention teams consisting of two extra staff members (a nursery teacher and a nursery nurse) have been established. The nurseries are co-located with child and family centres, and a new service for children aged 0-3 has been established. The projects are focused mainly on children aged 2-4 years and set out to provide additional support for young children whose development and learning may be compromised by a range of social, emotional and/or health related problems. To date more than 150 children have benefited directly from the Sure Start Early Intervention Projects. However, this work has had significant implications for a wider population of children as early years professionals have worked together to improve support for children and families and to develop new approaches to tackling common issues. The teams have developed a range of strategies to improve support for all children. However, a clear implication of the additional resource has been that in all 3 nurseries, children with complex additional support needs have been integrated into mainstream nursery settings.

Local authorities work to meet the needs of vulnerable families with very young children and through this they are able to meet the needs of specific groups:

'We hope that making services easier to use will mean that those who were hardest to reach in the past will have more chance of benefiting from them'.

The quantitative data obtained on services provided suggests that a wide range of supports are provided to different communities, as the following table demonstrates, with young parents being the group supported by the largest number of services. However, these data do not necessarily suggest specific targeting, as provision may be part of a more universal service.

Table 1: Support to Specific Groups

The meanings attached to the concepts of targeted and universal services are variable, with some targeting being achieved by prioritising particularly vulnerable groups, by ensuring mainstream provision is accessible, or by developing specific services to meet the needs of particular groups. The following examples from the interview data illustrate some of these differences:

'I think we feel, within family support, that having specific target groups in…(Local authority) is very difficult because of the population, that we actually need services that are flexible enough to respond to the needs of all parents, not just parents with a learning disability or parents with drug misuse problem or parents with a mental health problem. The groups of very vulnerable parents are small and scattered and that's why our 0-3 intensive outreach team manages to do the work it does because they will go out to all parents who are vulnerable rather than specific groups. For the nature of our area, that seems to be the most helpful approach'.

'I think the whole admissions policy sets out our store on the type of people we should be targeting, and we're very clear that Sure Start is not a universal service obviously and that Sure Start is wholly used to target the most vulnerable groups'.

'We certainly don't do ethnic minority very well. We need to focus a bit more, we don't do it because in practice it doesn't bubble up as a major issue in (Local authority) but we should be wise enough to know that minority issues don't bubble up very obviously in many places anyway until it hits the fan. If it doesn't bubble up it probably means that we're not reaching out properly, and that goes for travellers and other minority issues. So we've a lot to do, a lot to catch up'.

During their interviews, most of the Sure Start Contact Officers said that they did currently target some specific groups via Sure Start funding; the main ones mentioned are shown in the table below, with the most popular responses at the top. However, these figures should be treated cautiously as they are compiled from semi-structured interviews and are not comprehensive.

Table 2: Groups targeted by local authorities via SS money

The balance between supporting vulnerable families through universal or mainstream provision and developing specifically targeted services was different in different local authorities, reflecting the nature of service provision and delivery, the ethos and also the needs of the population being served. However, almost all Sure Start Contact Officers mentioned the way in which universal services, or targeting within universal provision can help to overcome stigma:

'There is less obvious stigma about "vulnerable parents" accessing services within Centres which cater for a variety of parent and children's needs'.

'Within (Local authority) we have continued to provide an integrated and non-stigmatised service to all, but also targeted the most vulnerable families'.

Overall, local authorities orient their services around the needs of vulnerable families both through universal provision and, where appropriate, the targeting of specific groups. As noted above, the concepts of universality and targeting are differently understood and operationalised within an overall ethos of non-stigmatised provision. Such flexibility seems useful especially as local authorities are increasingly moving towards integrated service planning and delivery. A range of provision linking mainstream and more targeted approaches may best meet the diverse needs of families and family members.

Staff and parent training

The area of staff and parent training was also highlighted by many local authorities as something that had been developed further since 2001. Supporting the development and retention of a skilled workforce was considered important as was supporting parents to improve their skills as parents, and also through other training. Training was also described as something that supported inter-agency working. In the interviews, all the Sure Start Contact Officers were asked whether they had been able to offer any staff or parent training as a result of Sure Start (or Early Years) funding; although not all offered staff training with Sure Start funding, all responded positively that they had been able to offer and usually develop staff and parent training.

Staff training

Staff training included a range of possibilities, for example: training in a range of parenting programmes; breast feeding support; child behaviour programmes; local authority specific programmes such as Fit Ayrshire Babies or Play @ Home. The interviews suggested how important such training was in developing services, meeting the needs of vulnerable families and in developing the workforce:

'If you can help parents to get their children to sleep properly, you've then got a parent who's able to address issues in the day because they won't be sleep deprived. That's why we've trained a lot of our early workers in sleep counselling - so a lot of our community learning Sure Start workers, a lot of our social workers, health visitors as well, they've done the Sleep Scotland training. That's been very effective; it's been very very helpful particularly for some of these children whose sleep patterns are very different'.

'I mean even things like the inter-agency training, some of the most successful things, we had things like the working with parents who use drugs for home visiting workers. This was provided by…at the time. Something like that makes a fundamental difference to the way someone approaches their work, it's quite intensive and challenging training, it's actually making people think about how they approach this and their own prejudices'.

'Workforce development - linking that very closely with the needs that we have within childcare and linking that again through Sure Start as well, and there's been a lot of work done in that area, to build up accredited learning opportunities. So not only are we looking at it as training that has an impact on the level of service delivery, we're also looking at training with a clear pathway for people so they can recognise the benefits of it and particularly with employment opportunities'.

Parent training

Staff and parent training were not always seen as separate activities, as sometimes both were trained together and also parent training may lead directly into work with children and families, as the following example suggests:

'We encourage parents to participate in all our training programmes, whether it's accredited or not. We certainly try to ensure that, in terms of the workforce development, we are looking at that as a means of improving the workforce. We don't see the two things as separate; parents can participate and become part of the workforce'.

From the service information received, there was evidence of considerable support in the form of different training for parents, as noted in the table below:

Table 3: Parent Training

The most popular form of training was some kind of parenting training, and a number of different types of parent education are offered, such as Mellow Parenting and Triple P, and staff are trained to deliver this. Other types of training include training around health related issues, literacy, child development, meeting specific needs or problems, or supporting parents into education and training. Much training is delivered in family centres and is supported by crèche provision. In the example below the Sure Start Contact Officers explain the range of training developed, in the first example across the local authority and in the second within a specific project.

Scottish Borders

In terms of training for parents - we've developed three courses of our own, we deliver a lot of group work courses to parents but in terms of parent training we've developed three courses that are Scottish Borders council owned courses which are: Stay and Play, Play and Learn and Play and Health. The first two we deliver, that's to do with learning to play with your child and also moving your child on and preparing them for nursery education, and Play and Health is a course that was put together by health colleagues from dental health, speech and language, health visiting, dietician. It's a course that we deliver, but it's basic health information for parents of children 0-3. We do something called basic parenting which we provide for our parents with learning disabilities. That's a course that's been put together using a variety of materials. There's also a lot of parent training in the teenage parent group about baby brain development and breastfeeding and weaning, there's a lot of parent training going on in that group.

North Lanarkshire

The biggest single project is the Home Link Project which is located within our Community Services Department. The project works on an outreach basis providing group support sessions to vulnerable parents and their children. The service responds to local demands and a range of support sessions are provided in local communities in a variety of accessible locations including community buildings and nursery centres. Families are mainly referred from other agencies notably health but can also self-refer. A range of courses is offered for different needs and abilities ranging from parent/child play sessions to more formal training such as the Pram to Primary package. The project meets objectives by supporting parents in their parenting role and the approach adopted has facilitated the development of good relationships with groups of very young parents. The project meets objectives by supporting parents in their parenting role, valuing them and giving them confidence and this has had a positive impact on the parent/child relationship and consequently on children's health and development. Parents are also encouraged to move beyond the project itself with routes to learning being identified and promoted.

In addition to the types of training outlined above, parents are also supported in more informal and unmeasurable ways through ad hoc contacts while accessing services.

Summary and Conclusion

Sure Start has developed considerably since the last mapping exercise. While Chapter 2 focussed on the range of services and numbers of children supported, Chapter 3 has looked in more detail at how services have developed. 56% of current services for which data were obtained have developed since 2001, suggesting a continued growth in provision, reinforced by the growth in the number of children supported reported in Chapter 2. 71% of services were funded from more than one source, suggesting integration in both the planning and delivery of services. Sure Start Contact Officers reported that Sure Start had enabled an expansion of services since 2001 and greater integration of services and joint working, especially at service delivery level. Although the overall picture is optimistic, a few local authorities did note that development had not been as great as hoped, on account of funding or a poorer baseline of provision before 2001. Relatedly, although this mapping exercise reported greater integration, especially greater involvement of health, for a large minority of local authorities, involving health was still proving difficult. Local authorities also identified innovative change, the development of new posts and some capital spend as characterising the development of Sure Start in their areas. Overall, the development of Sure Start includes:

• Expansion and increased integration of services.
• Improved joint working, especially at service delivery level.
• Innovative practice, including working with health in the delivery of services.
• The provision of integrated packages of care, whether formally co-ordinated or not
• Targeting the most vulnerable families, often through universal provision.
• Targeting those with additional support needs, such as children with special needs.
• Provision of staff training, especially supporting inter-agency working.
• Provision of parent training to support parenting skills, child development and access to education and employment.

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