Guidance

Early years high impact area 6: Ready to learn and narrowing the word gap

Updated 19 May 2021

Applies to England

Health visitors have an important role in leading the delivery of the Healthy Child Programme: Pregnancy and the first 5 years of life. This is a universal prevention and early intervention programme and forms an integral part of Public Health England’s (PHE) priority to give every child the Best Start in Life: ‘Ready to learn at 2 and ready for school at 5’. This comprises child health promotion, child health surveillance, screening, immunisations, child development reviews, prevention and early intervention to improve outcomes for children and reduce inequalities. Parents are the experts in their child’s health and wellbeing and health visitors work in partnership with parents to promote child development, assess need and identify problems or issues at the earliest opportunity.

Early childhood is an important period of rapid brain growth. Attachment and good maternal mental health shapes a child’s later emotional, behavioural and intellectual development. Getting a good start in life, building emotional resilience and getting maximum benefit from education are the most important markers for good health and wellbeing throughout life.

Enabling children to achieve their full potential and be physically and emotionally healthy provides the cornerstone for a healthy, productive adulthood. Socially disadvantaged children are more likely to have poorer oral health and speech, language and communication difficulties than their peers, which has implications for their educational attainment and future life chances. Children with learning disabilities or with complex health care needs will have individual needs, which may include problems with eating and drinking. It is essential that awareness of nutrition and hydration and the importance of exercise begins in childhood, to promote a healthy lifestyle and prevent and, or manage constipation from an early age.

Family circumstances, vital for development in the early years, have deteriorated for many. Rates of child poverty have increased and inequalities in many social and economic outcomes are widening.

Parenting approaches are key to children’s development in the early years, but it is important to recognise that parenting is also related to families’ social and material circumstances. Marmot states it is easier to parent more effectively when social and economic circumstances are favourable and when stress and anxiety are lower. Reducing child poverty is an essential health and equity strategy, as well as important for influencing other outcomes throughout life.

PHE’s ambition, ‘ready to learn at 2, ready for school by 5’, means that by school entry, every child will have reached a level of holistic development which enables them to:

• communicate their needs with a good vocabulary and understand others
• get dressed and go to the toilet independently
• eat independently
• take turns, sit still, listen and play
• socialise with peers, form friendships and separate from parent(s)
• enjoy good physical health or have disabilities and complex health needs identified and managed appropriately to maximise access to education
• have a healthy weight for height range and be well nourished and physically active
• attend the dentist regularly and have good oral health
• benefit from protection against infectious illness, having received all childhood immunisations

The foundations for achieving a good level of development are laid throughout the first years of life. Supporting every child to achieve the best start is a central part of the health visitor’s role, working in partnership with parents to promote child development and to assess needs and identify problems or issues at the earliest opportunity, including signposting to specialist support if needed.

Health visitors lead the 2 to 2 and a half year health and development review as part of the Healthy Child Programme: Pregnancy and the first 5 years of life. This review enables health visiting teams to assess a child’s progress, aiming to optimise child development and emotional wellbeing, reduce health inequalities and promote school readiness. The health visitor may work in partnership with other members of the multi-disciplinary team, including nurses or allied health professionals such as learning disability nurses, occupational therapists or physiotherapists to support children with a learning disability or complex health care needs.

The review provides the health visitor with an opportunity to Make Every Contact Count, promoting the importance of healthy lifestyles and the value of health as a foundation for future wellbeing. This may include, for example, healthy eating including Healthy Start, physical activity, accident prevention, improving parents’ confidence in managing minor illnesses and reducing unnecessary antibiotic use, sun safety and skin cancer prevention, oral health, promotion of smoke free homes and cars, responsive parenting, behaviour management including sleep, promotion of development, play and a language-rich home learning environment, and the promotion of free early years childcare offer for eligible families.

Age 2 to 2 and a half is a crucial stage when concerns such as speech and language delay, tooth decay or behavioural issues become visible. Early identification and good quality evidence-based early interventions improve outcomes for children. If a child is already attending an early years service, the health review may be integrated with the Early Years Progress Check carried out at age 2.

Speech, language and communication development

Early language impacts on many areas of child development. It contributes to a child’s ability to manage emotions and communicate feelings, to establish and maintain relationships, to think symbolically, and to learn to read and write. It’s important that any deficits in language development are identified early and support is given to children to achieve their full potential.

Recent evidence sets out a case for language as a primary indicator of a child’s wellbeing. Early language impacts on children’s social, emotional and learning outcomes. Almost all children learn to communicate through language, yet there are strong and persistent differences in their ability to do so, with a child’s socio-economic background an important factor. Approximately 10% of all children have long-term speech, language and communication needs. In some areas of deprivation, more than 50% of children start school with speech, language and communication needs. Meeting the needs of children and reducing inequality requires a system-wide approach, as currently, needs are frequently unidentified. Further evidence and guidance to help improve speech, language and communication in the early years, including an Early Language Identification Measure and intervention tool for use with children aged 2 to 2 and a half years, have been produced.

While the reasons behind the word gap in the early years are complex, exposure to a breadth and depth of vocabulary and a rich home learning environment, supported by high-quality early years provision, can have a significant impact on children’s speech, language and communication development.

Language-related social inequalities are not inevitable and health visitors are ideally placed to support parents and caregivers by:

• providing information on ways to promote early language acquisition, such as the home learning environment
• early identification of children with signs of speech and language delay
• ensuring uptake of appropriate early intervention strategies or specialist support and referral

At 2 to 2 and a half years of age, a parent or carer will be able to actively participate in their child’s developmental review through the use of the Ages and stages questionnaire. Alongside this, a new early language identification measure and intervention for use by health visitors at the 2 to 2 and a half year review aims to improve early identification of need and enable parents or carers to support their children’s language development. This will form part of a holistic assessment designed to focus on a child’s strengths and identify any barriers to a child’s developmental progress. Information gathered from the review will inform discussions with parents about their child’s progress, to identify any problems or delay and find solutions or make referrals to more specialist services.

An integrated health and early education review acknowledge that a holistic approach is important to good health and development and multi-agency or partnership working is essential.

The purpose of the integrated review is to support a collaborative approach to a child’s developmental review, combining health and education information. The purpose of the integrated review is to:

• identify the child’s progress, strengths and needs at this age in order to promote positive outcomes in health and wellbeing, learning and behaviour, and to promote school readiness
• facilitate appropriate early intervention and support for children and their families where developmental delay or additional needs are identified
• generate information which can be used to plan services and contribute to the reduction of inequalities in children’s outcomes

The review will draw on the content of existing health and educational reviews, focussing on the child in:

• speech, language and communication
• personal, social and emotional development
• physical development, including a review of growth and the promotion of healthy weight and physical activity
• learning or cognitive development
• physical health, including oral health and bladder and bowel health to prevent such problems as constipation and urinary tract infections

These align with the Early years foundation stage prime areas of learning.

Early parenting matters. Some children do not experience positive parenting, which may impact on their future life chances. Health visitors are well placed to assess and identify risk early as part of their universal and targeted contacts with families, having extensive knowledge of child development and wider parenting risk factors.

Health visitors can intervene to address additional need, providing evidence-based support, promote uptake of the 2 year offer for eligible children and work with early years services, school nurses and other community resources to support children to be ready for school.

A focus on preventing child maltreatment is essential and the need to identify and work with vulnerable families paramount. Evidence-based prevention and early intervention can make a difference to life-long health and wellbeing, educational achievement, employment prospects, economic productivity and responsible citizenship throughout life and achieve significant cost savings. Furthermore, they help to break the cycle of disadvantage, setting up the next generation to enjoy better health outcomes than the last.

The Early years foundation stage profile results highlight that too many children currently start school with poor communication skills and personal care skills such as not being toilet trained, and are not emotionally ready to learn, with avoidable national variations. The health visiting service aims to support every child to achieve their potential and contribute to reductions in inequality by levelling up this gap.

Education and lifestyle choices begin at an early age. The health visitor may work in partnership with the learning disability nurse to help the child with additional needs reach their full potential and reduce the health inequalities faced by children with a learning disability.

The role of health visitors

Health visitors, as public health nurses, use strength-based approaches, building non-dependent relationships to enable efficient and effective working with parents and families to support behaviour change, promote health protection and to keep children safe.

Health visitors also undertake a holistic assessment in partnership with the family, which builds on their strengths as well as identifying any difficulties. It includes the parents’ capacity to meet their infant’s needs, the impact and influence of wider family, community and environmental circumstances. This period is an important opportunity for health promotion, prevention and early intervention approaches to be delivered. Working with parents and families, health visitors identify the most appropriate level of support and intervention for their individual needs.

Healthy Child Programme

The Healthy Child Programme offers every family a programme of screening tests, immunisations, developmental reviews, information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.

The Healthy Child Programme is universal in reach. It sets out a range of public health support in local places to build healthy communities and to reduce inequalities. It also includes a schedule of interventions, which range from services for all through extra help to intensive support.

The Healthy Child Programme is personalised in response. All services and interventions need to be personalised to respond to families’ needs across time. For many families this will be met by the universal offer. More targeted, intensive or specialised support and evidence-based interventions should be provided early to meet ‘predicted, assessed and expressed need’ to improve outcomes.

Improving health and wellbeing

The high impact areas will focus on interventions at the following levels and will use a place-based approach:

• individual and family
• community
• population

The place-based approach offers new opportunities to help meet the challenges public health and the health and social care system face. This impacts on the whole community and aims to address issues that exist at the community level, such as poor housing, social isolation, poor or fragmented services, or duplication or gaps in service provision. Health visitors as leaders in public health and the Healthy Child Programme: Pregnancy and the first 5 years of life are well placed to support families and communities to engage in this approach. They are essential to the leadership and delivery of integrated services for individuals, communities and population to provide RightCare that maximises place-based systems of care.

Individual and family

Health visitors have a vital role to play in school readiness and preparing families for school. This will include improving families’ knowledge on the importance of hygiene, particularly after toileting, before eating or preparing food and when children or family members are unwell so that illnesses are not spread through the family. They also play an important role in education of families and children about health protection issues such as immunisation, screening, using antibiotics appropriately and not when they have viral illnesses such as coughs and colds.

The health visitor can coordinate appropriate early intervention support before the child starts school. This will ensure local authorities are aware of any additional support needs required prior to a child starting school.

Two years of age is a key time for the development of speech, language and communication skills, as well as social, emotional and cognitive development. Health visitors assess children in their family context, which builds on their strengths as well as identifying any difficulties, including taking account of:

• parenting capacity
• child development and the home learning environment
• family circumstances
• social or community and environmental circumstances
• health and wellbeing, including the immunisation status of the child

Where a child is assessed as needing support from another agency, or risks to the child’s welfare or safety are identified, the health visitor will make a timely referral to the appropriate service and contribute to multi-agency support packages including early help, the Troubled Families Programme, safeguarding, or multi-disciplinary meetings for children with a disability and, or complex health needs. Where a child has been identified to have a learning disability and, or with complex health care needs, the health visitor will work in partnership with the learning disability nurse and, or allied health professionals working with families within the home or as part of a multi-disciplinary team.

Where a child already has an identified disability or developmental delay, health visiting teams will need to agree with parents whether they wish to complete the ASQ-3TM questionnaire as part of their child’s 2 year review. Much rests on the professional judgement of health visitors and their skill in working sensitively and collaboratively with families to agree on the best approach.

The review provides a population measure of child development at age 2, building a picture of how children are developing at age 2 across the country.

Parents are experts in their child’s development and are key players in the review, sharing information about their children’s development with their health visitor or community nursery nurse by completing a short questionnaire. Combined with the clinical judgement of the health professional, a rounded picture of a child’s development can be made to identify the child’s progress, strengths and needs, with an agreed plan to address any needs going forward.

Where a child has a special educational need or disability, the health visitor may work with the family and the children’s learning disability nurse in order to positively plan to address the health care needs of the child and, or identify any additional support they might require enabling the child to achieve their full potential. Where the parent opts not to use an Ages and stages questionnaire, health visiting teams may wish to use an alternative tool to help assess a child’s development as part of their 2-year review. It is up to local areas to choose the most appropriate tool, but we would expect this to be an evidence-based, standardised tool, as set out in the Healthy Child Programme 2 year review guidance document.

During the review, the health visitor should check whether the child has an integrated Education, Health and Care plan or if work is underway to develop one. Where a child does not have an Education, Health and Care plan, the health visitor may want to discuss with the family whether they should request one. Where a plan exists, it should provide a comprehensive source of information that can inform the integrated review process.

Community

The remit for improving school readiness does not rest with a single agency, and health visitors work in partnership with other key stakeholders, including local government, early years services, children’s centres, education settings, school nurses and voluntary organisations. Health visitors play a key role in promoting early language acquisition and signposting parents to early years services and community groups.

Health visitors can also promote the uptake of free early education and childcare for eligible children who have not taken up this offer. They can also signpost to libraries to promote reading and language skills and encourage parents to register the child at the local library.

Population

To promote a smooth transition between health visiting and school nursing services, PHE has produced a pathway for supporting health visitor and school nurse interface and improved partnership working.

A health and development review is offered to all families with a child aged 2 to 2 and a half, which should also include anticipatory guidance, for example advice about toilet training and oral health.

At a population level, this data will provide a measure of children’s development and wellbeing as part of the Public Health Outcomes Framework and generate information which can be used to plan services and contribute to the reduction of inequalities in children’s outcomes.

Using evidence to support delivery

A place-based or community-centred approach aims to develop local solutions that draw on all the assets and resources of an area, integrating services and building resilience in communities so that people can take control of their health and wellbeing, and have more influence on the factors that underpin good health.

The All Our Health framework brings together resources and evidence that will help to support evidence-based practice and service delivery, Making Every Contact Count and building on the specialist public health skills of health visitors.

Most health and care professionals focus on interventions that tend to be delivered on an individual basis. However, health visitors and school nurses focus on individuals, families and communities’ approaches. It is critical that all professionals consider the importance of population health as an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population.

Social prescribing complements such approaches, enabling public health nurses and other health and care professionals to refer people to a range of local, non-clinical services. Health visitors recognise that children’s health is determined primarily by a range of social, economic and environmental factors. Social prescribing seeks to address individuals needs in a holistic way, taking greater control of their own health.

Measures of success or outcome

High quality data, analysis tools and resources are available for all public health professionals to identify the health of the local population. This contributes to the decision making process for the commissioning of services and future plans to improve people’s health and reduce inequalities in their area including child and maternal health profiles, measures of access and service experience. Health visitors and wider stakeholders need to demonstrate impact of improved outcomes. This can be achieved by using local measures.

Access

Measures include:

• percentage of 2 to 2 and a half year health visitor reviews completed is reported through the Community services data set (CSDS) each month – it’s published in the Early years profiles
• percentage of 2 to 2 and a half year health visitor reviews completed using ASQ-3, is reported through the CSDS each month – it’s published in the Early years profiles

Effective delivery

Measures include:

• collection of scores using the Ages and stages questionnaire (ASQ-3™-British English), which produces a score for 5 separate areas of development: communication, gross motor, fine motor, problem solving and personal-social

Measuring impact

Measures include:

• percentage of children who were at or above the expected level of development in communication skills is reported through the CSDS each month, and is published in the Public Health Outcomes Framework and Early years profiles
• percentage of children who were at or above the expected level of development in gross motor skills is reported through the CSDS each month, and is published in the Early years profiles
• percentage of children who were at or above the expected level of development in fine motor skills is reported through the CSDS each month, and is published in the Early years profiles
• percentage of children who were at or above the expected level of development in problem solving skills is reported through the CSDS each month, and is published in the Early years profiles
• percentage of children who were at or above the expected level of development in personal-social skills is reported through the CSDS each month, and is published in the Public Health Outcomes Framework and Early years profiles
• percentage of children who were at or above the expected level of development in all 5 areas of development is reported through the CSDS each month – it’s also currently collected and reported on a quarterly basis through the PHE interim reporting mechanism while the CSDS becomes established and is published in the Public Health Outcomes Framework and Early years profiles.
• dental attendance of 0 to 2-year olds
• number of children with developmental delays detected and receiving appropriate support – this may include health visiting universal plus or universal partnership plus interventions (including monitoring), or referral to early intervention by a partner agency, or further assessment
• number of children starting school with unrecognised developmental delay or special educational needs

User experience

Measures include:

• feedback from NHS Friends and Family Test and health visitor service user experience questionnaire on satisfaction with 2 to 2 and a half year review or integrated review via local commissioner and provider data
• uptake of child immunisation, for example, measles, mumps and rubella

Other measures can be developed locally and could include measures such as initiatives within health visitors’ building community capacity role, such as developing peer support, engaging fathers, joint developments with parent volunteers and early years services.

Connection with other areas

The high impact area documents support delivery of the Healthy Child Programme and 0 to 5 agenda, and highlight the link with a number of other interconnecting policy areas such as the maternity transformation programme, childhood obesity, speech, language and communication, immunisations, troubled families, mental health and social mobility action plan. The importance of effective outcomes relies on strong partnership authority including early years services, and voluntary sector services.

Best Start in Life has been identified as a priority as part of PHE’s 5-year strategy, which runs from 2020 to 2025. Best start in life is a priority for the government and as such is included the Prevention Green Paper.

Improving services for children and young people is part of the NHS Long Term Plan. The Child Digital Strategy and Maternity Programme are currently developing and implementing infrastructure to improve access and timeliness of data with the aim to know where every child is and how well they are. This includes the development and implementation of a Digital Parent Child Health Record. This programme supports the ambitions and modernisation of the Healthy Child Programme.

Collaborative working

Early years services play a key role in supporting improved outcomes for children and families as part of the integrated planning, delivery, monitoring and reviewing approaches. Partnerships can use information from Joint Strategic Needs Assessments (including early years foundation stage profile data, public health data, information about families, communities and the quality of local services and outcomes from integrated reviews) to identify need and respond to agreed joint priorities:

• Public Health Outcomes Framework measure of child development at age 2 to 2 and a half – data will be collected via the children and young people’s health services data set
• PHE’s 0 to 19 health visiting and school nursing commissioning guidance
• information-sharing agreements in place across all agencies
• health visiting and early years services to offer integrated reviews at age 2, bringing together the early years foundation stage progress check and the Healthy Child Programme (0 to 5) health review – data for the outcome measure will be collected during the 2 year Healthy Child Programme review
• NHS Outcomes Framework 2016: tooth extractions due to decay in children admitted to hospital, aged 10 years and under
• demonstrating value for money and return on investment

Improvements

These include:

• improved uptake of the mandated 2 year health review for all children, to ensure accessibility for vulnerable groups
• use of early identification measure and intervention to support children’s speech, language and communication
• improved levels of oral health in 2 year olds
• reduction in tooth decay aged 5 years and hospital admissions for tooth extraction
• integrated IT systems and information sharing across agencies
• development and use of integrated pathways
• systematic collection of user experience, for example, NHS Friends and Family Test to inform service delivery
• increased use of evidence-based interventions with incorporated local evaluation methods and links to other early years performance indicators
• improved partnership working as described in the health visiting and school nursing partnership pathway: Supporting health visitor and school nursing interface and improved partnership working
• consistent, culturally relevant, information for parents and carers
• standardised measure of child development: Ages and stages questionnaire (ASQ-3 British English™) and ASQ SE-2
• appropriate services to address identified needs
• reduction of the percentage of children with unknown needs identified at school entry
• increased uptake of free early years education and childcare for eligible children

Professional or partnership mobilisation

These include:

• access to multi-agency training programmes
• understanding tools
• multi-agency working
• use of IT systems
• information sharing
• safeguarding
• how to support parents to improve the learning environment
• effective delivery of evidence-based universal prevention and early intervention programmes, with clear evaluation methods
• improved understanding of data within the Joint Strategic Needs Assessment and at the local health and wellbeing board to better support integrated working of health visiting services with existing local authority arrangements to provide a holistic, joined up and improved service for young children, parents and families
• identification of skills and competencies to inform integrated working and skill mix
• approaches to enrich home learning environments from pregnancy through to early years

Associated tools and guidance

Policy

Child oral health: Applying All Our Health, PHE, 2018

Childhood Obesity: Applying All Our Health, PHE, 2019

Children and Young People’s Health Benchmarking tool, PHE, 2014

Delivering better oral health: An evidence-based toolkit for protection, PHE, 2014

Early years foundation stage profile: 2018 handbook, Standards and Testing Agency, 2017

Early years foundation stage profile: Exemplification materials, Department for Education (DfE) and Standards Testing Agency, 2014

Early years (under 5s) foundation stage framework, DfE, 2014

Fair society, healthy lives (The Marmot review), UCL Institute of Health Equity, 2010

Health matters: child dental health, PHE, 2017

Healthy Child Programme: Pregnancy and the first 5 years of life, Department of Health and Social Care (DHSC), 2009

Improving oral health: An evidence-informed toolkit for local authorities, PHE, 2014

Improving oral health: A toolkit to support commissioning of supervised toothbrushing programmes in early years and school settings, PHE, 2016

Language as a child wellbeing indicator, Law J, Charlton J and Asmussen K., London: The Early Intervention Foundation, 2017

Rapid review to update evidence for the Healthy Child Programme 0 to 5, PHE, 2015

The 5 year forward view for mental health, NHS England, 2016

Universal Health visitor reviews: Advice for local authorities in delivery of the mandated universal health visitor reviews from 1 October 2015, DHSC, 2015

Working Together to safeguard children, HM Government, 2018

Child oral health: Applying All Our Health, PHE, 2019

Research

1001 Critical days: The importance of the conception to age 2 period, WAVE Trust, 2014

Ages and stages questionnaires

Child and Maternal Health, PHE

Early Language Development: Needs, provision, and intervention for preschool children from socio-economically disadvantaged backgrounds, The Education Endowment Foundation, 2017

Early years foundation stage profile results: 2014 to 2015, DfE, 2015

Factsheet on developing a public health outcome measure of child development at age 2, DHSC

Place-based systems of care: A way forward for the NHS in England, Ham, C., Alderwick, NHS England, 2015

Healthy Child Programme, e-Learning for Healthcare, 2016

Health for All Children (revised 4th edition), Hall D and Elliman D, Oxford University Press, 2016

Help paying for childcare

Integrated review FAQs, Foundation years

Language as a child wellbeing indicator, The Early Intervention Foundation, 2017

Leading Change Adding Value, NHS England, 2016

Public Health Outcomes Framework 2013 to 2016, DHSC, 2015

SAFER Communication Guidelines, DHSC, 2013

The Best Start at Home, Early Intervention Foundation, 2015

Guidance

Speech, language and communication pathway, PHE, DfE, DHSC, 2020

Early years foundation stage, National Statistics, 2018

A framework for supporting teenage mothers and young fathers, PHE and Local Government Association (LGA), 2016 (updated 2019)

Health visiting and school nursing partnership: Pathways for supporting health visitor and school nurse interface and improved partnership working, DHSC and PHE, 2015

Healthy child programme 0 to 19: health visitor and school nurse commissioning, PHE, 2016

Healthy Child Programme: review of children aged 2, DHSC, 2009

Improving oral health for children and young people infographic, PHE, 2016

NICE guidance

Health visiting, NICE local government briefing [LGB22], 2014

Maternal and child nutrition, NICE quality standard [QS98], 2015

Oral health: Local authorities and partners, NICE public health guideline [PH55], 2014

Oral health promotion, general dental practice, NICE guideline [NG30], 2015