Research and analysis

Start For Life services: thematic review

Published 7 May 2024

Applies to England

Background

The Family Hubs and Start for Life programme is designed to help meet the commitments that the government set out in ‘The best start for life: a vision for the 1,001 critical days’, published in March 2021. This programme is jointly led by the Department for Education (DfE) and Department of Health and Social Care (DHSC).

The programme has also helped to create a network of family hubs. Its objective is to join up and improve the services provided through transformed family hubs in local authority areas. This will make sure all parents and carers can get the support they need when they need it.

As a first step to meeting this commitment, the government has asked Ofsted and the Care Quality Commission (CQC) to carry out a joint thematic review of Start for Life services. This includes looking at how services are provided through the family hub model.

We make recommendations to improve families’ experiences of Start for Life services and how they are provided through the family hub model. We will share these recommendations with central government. They may be of use to all local authorities that provide Start for Life services. This report also highlights examples of good practice that we identified in the 6 local areas visited. We have included these examples as they are likely to be of use to other local areas looking to improve their Start for Life offer.

Executive summary

In carrying out this review, we recognise that the Start for Life programme is still in its infancy.

Our report is based on thematic visits to 6 local areas. In these local areas, families who access Start for Life services through a family hub have a positive experience. Parents say that they are more confident in feeding their infants and have better perinatal mental health, and that their children achieve better outcomes. Local areas are aware that there is more work to do to ensure all families, including those from seldom-heard groups or those who have a disability, can access Start for Life services in every family hub. Some aspects of the Start for Life programme are better developed than others. Postnatal services that offer support for perinatal mental health and infant feeding are more established than services for expectant parents. The home learning element of the programme for under 2s is less well developed in all areas.

Local areas need more time to advertise universal Start for Life services and family hubs. Parents did not always know what services were available to them. In some areas, family hubs were seen as places for ‘troubled families’. This means opportunities to provide support are sometimes lost.

Parents, professionals and leaders are working hard to ensure panels are representative of the community they serve. Once fully established, parent carer panels should play a key role in co-designing and promoting Start for Life services.

Local areas that kept their Sure Start or children’s centre provision were able to use existing buildings for family hubs. Every hub we visited was welcoming and family focused. However, some buildings were not fit for purpose. For example, some had limited disabled access or did not have the facilities to provide health services.

Co-location of services helps with information-sharing and was welcomed by professionals and families. Some local areas have introduced innovative ways of working to make sure professionals are aware of the needs of the most vulnerable families. However, these methods are too time-intensive to be used more widely.

There are no shared record-keeping systems between professionals, which makes it harder to provide integrated support for families.^{[footnote 1]} This leads to families having to repeat their stories. It also risks making care fragmented.

Family hub staff are dedicated to improving the lives of babies and families. Co-location of staff gives them access to multi-agency training opportunities and has led to improved joint working between health, social care, early years education and family hub team members. Volunteers and charitable organisations play a key role in Start for Life services in many areas. Volunteering with family hub services has enabled some people to move on to paid employment or higher education. Recruitment of health visitors and limited midwifery capacity is a challenge in most areas.

Area leaders have a clear understanding of their community’s needs and plan services to meet those needs. However, it is difficult to measure the impact and outcomes of Start for Life services effectively. Opportunities to measure outcomes in the current reporting framework are limited. Local areas need support to measure impact, including a set of shared national outcomes with optional local additions. Leaders felt that current reporting requirements were time-intensive and could be simplified to free up staff time.

Local area leaders report multiple challenges in using short-term funding to provide Start for Life services. Leaders felt that short-term funding prevented them from planning provision for longer periods of time. They were concerned that they might have to cut services that families have come to rely on.

Current inspection regimes do not consider partnership delivery of an area’s Start for Life provision (although health, early years, education and social care providers are covered by single agency regulatory and inspection regimes). Most local area leaders felt an inspection regime would ensure that the family hub work and programme are given priority. Leaders felt any inspection should be ungraded and focus on the local area rather than individual hubs, looking at outcomes for babies and families as a whole.

Introduction

All families need support from time to time to help their babies and children thrive. The Family Hubs and Start for Life programme guide sets out an ambition for every family to receive the support they need when they need it. The guide says that all families should have access to the information and tools they need to care for and interact positively with their babies and children, and to look after their own well-being. The Family Hubs and Start for Life programme represents a significant step forward in meeting this ambition.

In July 2020, the Rt Hon Andrea Leadsom MP was appointed to lead the Early Years Healthy Development Review. The review found that families often have difficulty navigating their way through the different services available.^{[footnote 2]} They find it hard to ‘re-tell’ their story each time they engage with another service or professional. The Best Start for Life vision is for local services to work together in partnership, with a clear focus on supporting families and babies in the critical 1,001 days from a baby’s conception until age 2. We know from research that giving babies positive experiences during this time leads to better outcomes in physical and mental health and better life chances in adulthood.^{[footnote 3]}

The government has provided £300 million over 3 years to establish the Family Hubs and Start for Life programme. This is intended to improve outcomes for babies, children, parents and carers in 75 local authorities. £81.75 million of this funding is supporting local authorities to create family hubs networks. Family hubs provide better access to a wide range of integrated support service for families with children up to the age of 19, or to 25 for young people with special educational needs and/or disabilities (SEND).

This thematic review included 6 local areas that are participating in the Family Hubs and Start for Life programme, and that had already established family hubs networks.

Our review was designed to evaluate families’ experiences of local services, and to look at whether these services were joined up effectively. We also aimed to identify ways in which families could be further supported to give their babies the best start in life.

We recognise that every local authority area participating in this programme has started from a different point and has different local needs, assets and existing provision to consider. We also acknowledge that each region and place has different priorities for addressing the needs of its local population, and different arrangements for managing multiple programmes.

Methodology

Our review focused on the experiences of families from a child’s conception to age 2. We looked at information-sharing between services that are available to all parents and carers who need them, such as midwifery, health visiting, mental health support, infant feeding support and specialist breastfeeding support. Our review also included safeguarding services and the SEND local offer for all families that need it.

We asked local authorities that were selected to act as trailblazers for the Start for Life and Family Hubs programme to express their interest in taking part in this thematic review. The following 6 local authorities were invited to take part:

• Northumberland
• Sunderland
• County Durham
• Hull
• Torbay
• Isle of Wight

In August 2023, inspectors visited each of these local areas over a period of 2 days. Each visit was carried out by 2 Early Years Inspectors from Ofsted, and a Children’s Services Inspector from CQC. The Ofsted inspectors were on site for both days, and the CQC inspector for one day.

To provide recommendations for local areas and central government, the review focused on answering one key question:

To what extent do families have a positive experience of Start for Life services, delivered through the family hub model?

In answering this question, each team observed Start for Life services that were delivered through the family hubs. They also spoke to a range of health, education and social care partners, including health visitors, midwives, social workers, early years staff and those responsible for outreach work and other family hub staff. They gathered parents’ views through discussions with families attending activities, several focus groups and meetings with representatives from local parent carer panels. The inspectors reviewed each local authority’s self-assessment, which set out their progress against each element of the programme. Senior leaders from children’s services, early education and health who were involved in designing and delivering the programme were also involved in discussions with inspectors.

Local authorities also sent questionnaires out to families to ensure that a large sample of voices were heard.

After the visits, we held individual feedback sessions with all participating local authorities to hear about their experience of the thematic review and invite any additional comments about the future design of a Start for Life inspection regime. Representatives from the DfE, DHSC, Ofsted and CQC attended these feedback sessions.

The rest of the report sets out the main findings of this review. We have set out the findings under the 6 main action areas detailed in the government policy published in March 2021.

Ensuring families have access to the services they need

Seamless support for families

‘…a coherent joined up Start for Life offer available to all families.’^{[footnote 4]}

Across all local areas we visited, there was a consistent and ambitious vision to deliver joined-up services. Areas took different approaches, but where it worked best, GPs, midwives and health visitors directed families to services. This enabled families to get to know what services were available to them, and how to access them. Working together to provide seamless support is not new, and in all local areas that we visited, family hub models were built on previous Sure Start or children’s centre models.

Co-location of services clearly supported information-sharing between professionals and families. In one local area, regular multi-agency meetings about potentially vulnerable unborn babies and their parents enabled agencies to share information and ensured that services were organised around the family in a timely way. In all areas, efforts to provide joined-up services were hindered by the reality of separate data systems. As a result, many families said that they had to re-tell their stories to professionals from different agencies. Local areas are working hard to find solutions to these difficulties; for example, co-location enables professionals to speak to one another about families in their care. One local area had created a shared data platform that enabled staff to share information.

Where families had complex safeguarding needs, professionals were more joined up and often worked well together. In one area, a ‘vulnerable pregnancy pathway’ allowed families to benefit from joined-up services. This meant support was coordinated across agencies. It also reduced duplication and the risk of conflicting interventions. The families were positive about the benefits of this approach. Families who only accessed universal services said that they often had to repeat their stories.

Staff report many benefits of joint working, and understand each other’s roles better as a result. This is facilitated further through training across professions.

All professionals spoken to were working hard to bring together the critical services of midwifery and health visiting, mental health support, and advice on infant feeding with specialist breastfeeding support. Infant feeding programmes, in particular, were well established. Many areas had employed peer supporters from the community, which helped to extend the reach of the hubs. Many of the peer supporters we spoke to were mothers who had themselves been helped by the family hubs, and who wanted to help others to continue to breastfeed their babies. Parents attending feeding support groups said how important these groups were, not just in relation to feeding advice, but also as a place to meet like-minded mothers and develop a social network.

In one area, a family had approached the hub looking for parenting support, particularly in relation to behaviour management. Staff worked closely with parents and extended family members to develop and use positive, consistent behaviour strategies. Staff spoke to the health visitor about the work they were doing, and they were able to follow up this work and see the impact it was having in the home environment. The family told us what a difference this had made to them, particularly in relation to their mental health and well-being.

In all areas we visited, there was a strong focus on the health and mental well-being of parents and babies. In some local areas, dedicated teams supported expectant mothers with pre-existing mental health needs. Professionals felt that this offer supported the growing number of young people with poor mental health and emotional well-being needs who are now becoming parents. Many local areas offered expectant and new parents information on building healthy baby brains, aimed at achieving good development and better mental health outcomes throughout life.

Some aspects of the Start for Life programme were less well developed. In all the areas we visited, parents told us the postnatal Start for Life offer was more firmly established, with antenatal Start for Life services more often in their infancy. Work around the home learning element of the programme for the under 2s was less well developed in all areas. Typically, local areas offered group sessions, such as in the examples below. While the impact of these interventions and projects will not be seen immediately, there is still scope to expand this aspect of the programme.

Since the pandemic, there has been an increase in the number of children with delayed speech and language. One local area identified that, despite this, it was receiving fewer referrals for speech and language support from registered early years settings. To remedy this, early years champions began to work with settings to help them carry out baseline assessments. If they identified a potential delay, they enrolled parents and children on a language builder course. These are designed to give parents and children the skills to practise and develop early language skills, helping parents support their children with better language development. This course has led to a significant reduction in the number of referrals to speech and language services. This is an excellent example of where the right support can mitigate the need for specialist services for children beyond the age of 2. In another local area, parents could access a range of parenting courses, such as Brilliant Babies and Early Talkers. These were all designed to upskill parents and give them the confidence to support their children’s learning at home. Parents attending these courses spoke of the new skills they had acquired. One parent told us that it had given her partner the confidence to read to their child at night. Other areas have offered early education nursery places for 2-year-olds who are not eligible for funding, in order to close the education gap earlier.

A welcoming hub for families

‘… Family Hubs as a place for families to access Start for Life services.’^{[footnote 5]}

All local areas we visited had a vision for their family hubs to be welcoming, family-focused places, where services to support families can come together. Hubs we visited provided everything from birth registration to midwifery, health visiting to mental health support, and parenting courses to advice on infant feeding. It was clear from our visits that local areas that had kept their Sure Start or children’s centre services were able to provide Start for Life services more quickly, by building on established infrastructure. However, despite the activities on offer, a large majority of families we spoke to did not always know what services and support were available to them through the family hubs. While local areas need more time for the new branding to become more widely recognised, there is also a need for all agencies to direct families to services in a consistent and coordinated way. Once families did access services, they soon became aware of what was available and spoke positively about the impact of these services on them and their babies.

Through our visits we found evidence that additional funding has supported innovative practice to address health inequalities. In one area we visited, a GP had set up a twice-weekly drop-in clinic in a family hub. The clinic could be accessed by any family member attending a group for 0- to 2- or 1- to 4-year-olds in the centre. The clinic meant that families who found it hard to access GP surgeries were able to discuss issues and have them considered in a holistic way. In particular, the clinic was welcoming to people who had a low level of health literacy. The co-location of the clinic in the family hubs meant that families had access to a range of other support. The GP found early intervention and holistic practice was more possible working in this way.

However, discussions with parents highlighted some discrepancies in access to services. Some parents with disabilities told us that access to buildings and facilities was difficult at times. Despite the ethos of services for all, many areas told us that they were still not reaching some of the most disadvantaged families. Parents of babies with SEND told us that the offer from family hubs was not always as inclusive of their needs and that some hubs were not accessible to families with wheelchairs. Services such as portage and other specialist support were not routinely available in hubs, and this remains an area for development recognised by the leaders involved in the review. In one area, young people with SEND had been invited into family hubs to act as ‘inspectors’. They gave feedback to centre staff about how they could improve their offer so that families of babies with diverse needs would feel welcome in the centres.

Areas that had birth registrars co-located in their hubs, even just for 1 or 2 days a week, found this to be an innovative and successful way of encouraging parents over the threshold, particularly fathers. This gave the hubs an opportunity to speak to new parents and introduce the activities available, particularly where parents had not accessed services antenatally. In many areas, families were assigned a ‘key person’ in the hub after registering their child’s birth. This person acted as a single point of contact with the family. They were there to welcome the family on visits to the hub and kept them updated about activities and services. Parents found this gave them the confidence to attend activities within the hubs.

In several of the areas we visited, the rural geography made it difficult for families to attend the physical hubs. In these areas, the success of the Start for Life programme relied heavily on the success of outreach staff and projects, as well as on the use of digital technology. One area we visited used play vans to help families access the support available through the family hub. Families reported that this type of outreach work made them feel less isolated. The innovative use of community buildings in rural locations has also extended services beyond the physical hubs and helped to reach more isolated families.

Some areas still face issues related to the perceived stigma of family hubs as places for ‘troubled families’. Families we spoke to said it was only when they came to activities at the hubs that they realised there were services available for all families, not just those involved with children’s social care. In some areas, outreach workers were going to places of work to encourage families who would not usually access these services to come and find out more.

One area identified a large local factory with a number of pregnant women on its workforce. The challenges experienced by many of these women meant they were less likely to seek antenatal care. The midwife was able to reach this seldom-heard group by providing information sessions in the factory canteen. The midwife was also able to work with women seeking asylum by spending time at a local charity. In both cases, through offering a flexible service in a place already accessed by families, the midwife was able to work with families who have additional needs and poorer outcomes.

While physical family hubs exist in all the areas we visited, the buildings themselves sometimes make co-location of services difficult. For example, some buildings are not fit for purpose, particularly for providing maternity services.

All the areas we visited had developed strong partnerships with fathers. They had used funding creatively to improve services and experiences. For example, they had introduced ‘dad champions’, and focused on the mental health and well-being of both parents. Fathers we spoke to felt activities in the hubs were more inclusive of them. As a result, many felt more empowered to be a positive part of their babies lives and more confident in their role as a father.

Overall, parents receiving Start for Life services reported a range of benefits, including having more confidence in breastfeeding, experiencing better perinatal mental health and feeling less isolated.

We heard from families about the enhanced role that some family hubs play in partnership with children’s social care services. When children’s social care services step down from intensive work with families, the hubs can act as a bridge, supporting families as they learn to adapt and move forward independently. In one area, family hubs worked with families for up to 6 weeks after intensive support finished. 60% of these families had children aged under 5 years. Family plans were then reviewed at regular, prescribed times following this work. Feedback from families showed improved behaviour, happier parents and children, and fewer re-referrals.

The information families need when they need it

‘…designing digital, virtual and telephone offers around the needs of the family.’^{[footnote 6]}

In all the areas we visited, local authorities were working closely with health partners to develop virtual Start for Life services based on the requirements of their communities. All areas acknowledged it is important for families to be able to find the information they need when they need it, through access to digital services. In most areas, the virtual offer was less well developed, with most websites still under construction. However, in areas with large rural communities, this virtual work was better developed and included telephone services and virtual activities. One area displayed QR codes to enable parents to find information about the activities and services available through the Start for Life programme. This was particularly successful at reaching parents who did not attend family hubs or GP surgeries regularly because they lived in a rural location.

Ensuring the Start for Life system is working together to give families the support they need

An empowered Start for Life workforce

‘… developing a modern skilled workforce to meet the changing needs of families.’^{[footnote 7]}

Each local area was staffed by passionate professionals and volunteers, all of whom wanted to have a positive impact on outcomes for babies and families in their areas. Every professional we interviewed felt that co-locating and joining up services ensured that the activities provided through the hubs were more effective, purposeful and responsive to the needs of those living in the area. We found teams to be thoughtful and responsive to parents’ feedback, and all saw the upskilling of staff as a priority for ensuring a highly skilled workforce. Joint training between different health and care professionals meant that teams in family hubs were developing a more ‘holistic view’ of the perinatal period. As a result, they were beginning to be able to connect families to other services and support outside their own specialism.

One area provided an example of a mother with postnatal depression who was reluctant to work with professionals. A family worker was able to build a consistent rapport with the mother and, as a result, was able to work with her and provide support for her children, to help them thrive. The family worker was also able to secure multi-agency support from other highly skilled individuals linked to the hub, including nursery staff, health visitors, family support workers and school staff. This demonstrates how well-trained staff within the hub were able to use different strategies to engage with parents.

High vacancy levels nationally in health services, particularly health visiting and midwifery, continue to put a strain on some services. Leaders say they face challenges when trying to recruit to these key roles. Midwives said a lack of capacity meant they were often unable to work jointly with family hub staff. Health visitors also said that unfilled vacancies meant that they could not prioritise important preventative work. Parents spoke about how much they valued the support, knowledge and skills of health professionals working in the family hub team.

In all the areas we visited, family hubs worked closely with charities and volunteer agencies when providing services for families and babies. A growing army of volunteers are supporting families, helping mothers to continue breastfeeding, running a variety of support groups or acting as pregnancy support (‘doula’) for mothers up to and beyond the birth of their baby. Many of these volunteers originally accessed services themselves during pregnancy and afterwards. Interviewees told moving stories about the impact of the support they had received from family hubs, and the difference it had made to them during this critical time. Recognising how much they had valued this support, many wanted to put something back into the community. Some of them had gained qualifications at level 2 and 3 and were working in family hubs themselves. Volunteers and charitable agencies were described in one area as the ‘glue that holds services together’, which recognised the important gap filled by these individuals and third-sector organisations.

Without exception, families said staff in family hubs treated them with respect. They said that staff offered valuable, timely advice that had a positive impact on them and their babies and had improved the quality of family life.

Continually improving the Start for Life offer

‘… improving data, evaluation, outcomes and proportionate inspection.’^{[footnote 8]}

All local authorities understood the needs of their local population. They all voiced concerns about the use of data to measure and evaluate the effectiveness of Start for Life services. Strategic leaders within each local area wanted a common set of goals or outcomes that clearly define what the best start in life looks like. The current reporting requirements do not focus sufficiently on the impact on families, particularly the long-term impact. Local areas asked that there be less of a focus on collecting data on outcomes and more on the experience of families and the difference that services have made to their lives.

In all areas, the parent carer panels are in development. Processes to recruit the right mix of people on to panels require careful consideration, particularly to ensure that fathers and other seldom-heard groups are represented. The use of formal application forms, for instance, is a barrier to some parents. In one area, a third-sector voluntary group had been commissioned to increase the voice of seldom-heard groups. Families said there is work to do to ensure the make-up of panels is representative of the local community.

One local area’s doula project ensured isolated women were well supported when in labour. Early evidence showed that women supported by a doula were less likely to need an emergency caesarean section and were more likely to breastfeed. The project actively recruited volunteers from ethnic minority groups and around half of the women it supported were from an ethnic minority group. This volunteer doula and breastfeeding peer supporter scheme has provided advantages to the local area. Many doula volunteers have gone on to become midwives and nurses. Breastfeeding supporters can gain a level 2 qualification that gives them access to further education and career opportunities.

Leaders asked for recognition from government that Start for Life provision is part of a wider range of services targeting the 0-to-19 age group (up to 25 for SEND). All felt recognition should be given to the complexities of families and the fact that they do not fit neatly into age-specific categories.

Most local area leaders welcomed an ungraded inspection regime, as they felt this would raise the profile of these services across the partnership in the local area and might ensure that funding is more secure. Leaders felt that any inspection activity should consider the local area as a whole rather than individual hubs, and should look at the wider outcomes for children and families. This would allow hubs to target local need appropriately, which would benefit seldom-heard families in particular.

Leadership for change

‘…ensuring local and national accountability and building the economic case.’^{[footnote 9]}

Leaders in each local area had a thorough understanding of their local population needs and a clear vision of how to provide services for 0-to-19-year-olds. All areas worked with health and social care partners to highlight the support available for parents and their babies. However, leaders also experienced several challenges.

Most importantly, leaders said that short-term funding limited their ability to plan services over the long term. They said there was a mismatch between the strategy they wanted to develop and what they were able to do with short-term funding. This made it difficult to recruit and retain qualified staff and build parents’ awareness of and trust in services over time. There was a concern that the services parents had grown to depend on would stop when funding runs out in 2025.

Leaders also found the uncertainty of funding a challenge when setting up innovative projects. Not knowing whether funding will continue raises a number of logistical and ethical issues for leaders. Working effectively with seldom-heard groups takes time, and removing services that have taken time to establish is counterproductive. Short-term funding also makes it difficult to measure impact and outcomes, which may take several years to materialise.

Leaders and professionals said that they wanted to focus more on prevention rather than reactive interventions; however, the reality in many areas is that there is a focus on families in crisis, as staff shortages and financial constraints hinder attempts to work preventively. Flexible, long-term funding would enable leaders to adapt services to local needs and incorporate best practice.

In addition, the roll-out of this programme to only 75 trailblazer local areas led some leaders to express concern about inequity in universal access to services. In one local area, parents at one end of a street were able to access much better joined-up services due to Start for Life funding than their neighbours in the same street who came under a different local authority. In another area, the fact that funding was only available to a small part of a larger local authority area meant that some innovative projects could not be rolled out, as the authority could not guarantee access for all.

Recommendations

Based on our visits to these 6 local areas, we recommend that:

The Start for Life programme be made available and promoted to all families nationally to remove any stigma associated with accessing services and to ensure that all babies get the best start in life.

The government commit to a minimum level of long-term funding for this programme nationally. This would allow local areas to establish services and help to build parents’ trust in Start for Life provision. It would also allow time to gather evidence and ensure that properly trained staff are retained.

Central and local government establish a common set of national outcomes. Process and outcome measures should be considered and devised centrally, with space for local areas to develop additional criteria to meet local need.

Central government review funding-linked reporting requirements, to reduce the administrative burden on local authorities.

Central government support local areas in developing joint recording systems to improve information-sharing across their partnerships.

Central government support the sector to ensure there are enough qualified, experienced health professionals working alongside Start for Life staff when they provide health advice.

1. We understand that the government’s commitment to developing a digital personal child health record seeks to improve information-sharing between professionals once delivered. ↩

2. ‘The best start for life: a vision for the 1,001 critical days’, Department of Health and Social Care, March 2021; ↩

3. ‘The best start for life: a vision for the 1,001 critical days’, Department of Health and Social Care, March 2021, page 13; ↩

4. ‘The best start for life: a vision for the 1,001 critical days’, Department of Health and Social Care, March 2021; ↩

5. ‘The best start for life: a vision for the 1,001 critical days’, Department of Health and Social Care, March 2021; ↩

6. ‘The best start for life: a vision for the 1,001 critical days’, Department of Health and Social Care, March 2021; ↩

7. ‘The best start for life: a vision for the 1,001 critical days’, Department of Health and Social Care, March 2021; ↩

8. ‘The best start for life: a vision for the 1,001 critical days’, Department of Health and Social Care, March 2021; ↩

9. ‘The best start for life: a vision for the 1,001 critical days’, Department of Health and Social Care, March 2021; ↩