Annex 2 – York-Nesta discovery project summary report

During the last four months of ‘trial partnership’, our work has focused on understanding barriers to families accessing services for two year olds with a specific focus on the two year health review delivered by the Healthy Child Service and a secondary focus on uptake of two year old funded education places. During the course of this work we have:

1. Engaged with families – via interviews and a text messaging survey - to better understand barriers and facilitators to accessing services

Our approach

We conducted in-depth semi-structured interviews with 8 parents, to better understand their experiences and perceptions of early education and of the 2 year Health Review, and to understand more about the barriers and enablers to accessing services. This qualitative research was complemented by interviews with 5 frontline professionals working in the York early years system, to hear their perspectives on barriers facing families.

We then conducted a survey via a text messaging platform to find out more about parents’ perceptions of services and what key messages appealed to them. We recruited participants for this survey via multiple channels (including online forums and through practitioners working in targeted services), and successfully engaged 46 respondents for the survey.

Key findings

● Common barriers facing parents in accessing services:

○ Lack of confidence, especially among new parents

○ Feelings of anxiety or guilt (childcare)

○ Fear of being judged (both health review & childcare)

○ Lack of awareness of available services & the benefits of services

○ Logistical barriers

● Major influences on parents’ views and decisions about whether or not to take up services:

● Social networks: family and friends, and through social media.

● Relationship with health visitors: positive, trusting relationships with a health visitor often encouraged parents to take up services (health review, childcare, and other support), but a negative experience with a health visitor often meant parents were less likely to engage in future.

● What parents value from the health review and childcare, and messaging which they found helpful and encouraging:

○ Childcare:

■ Educational, social and emotional development for their children. The opportunity for their child to play, be imaginative, have fun, and make friends

■ Parents emphasised the benefits for their children more than benefits to themselves - eg. enabling them to go back to work.

■ Few expressed concerns about putting their children in childcare besides cost.

○ Health review

■ Reassurance & practical advice from a professional on key developmental milestones & concerns

■ Key issues they wanted advice from their health visitor on included potty training, weaning and speech development

○ These learnings could be applied to communications around these services to try and improve uptake.

Moving forward, we are keen to continue to engage with and understand the needs of communities in York, and to systematically gather and monitor feedback from parents on their experiences and views of services. We also intend to focus on more targeted engagement of families in communities or areas associated with low take-up, to learn about the particular barriers they face in greater depth.

2. Used data in new ways to better understand our communities and the needs they have

Our approach

We conducted quantitative analysis of Health Review data to understand patterns of take-up across York. Data categories included whether the child was brought or not to their Health Review, ward & Children’s Centre area, and demographic information (gender, ethnicity, religion, single or two-parent household, number of siblings). Analysis was conducted to identify any associations between these categories and attendance of the Health Review. We also analysed data on take-up of the 2 year old childcare offer, although this was much less granular than the Health Review data, only showing percentage take-up by Children’s Centre Area.

Key findings (click here to visit interactive plots)

Geographic area: The most striking difference in terms of take-up rates of the Health Review in York was by geographic area. Where a child is born in York seems to be a key indicator of how likely they are to receive the Health Review. The highest non-attendance rates were found to be in the city centre, as well as some key wards in the North & East Children’s Centre areas (Fishergate and Guildhall, and Strensall and Fulford & Heslington).

We also looked at ward-level deprivation levels and child health outcomes. While some of the lowest take-up areas also had higher levels of deprivation, there did not seem to be a clear pattern, so further work is needed to understand these trends. We also wanted to compare this geographical picture of the Health Review take-up with the 2 year old childcare offer data - however, more granular childcare data is required to determine if there is correlation between take-up of these two services.

Ethnicity: Demographic categories such as gender, number of siblings, and single or two-parent household did not seem to be associated with differences in take-up rates. However, ethnicity seems potentially associated with rates of attendance. From the data we analysed, white British children in York have a higher attendance rate of the Health Review than all other ethnicities. However, a caveat to this is that the actual numbers of children in the dataset from non-white British ethnicities were comparatively very small, so more work needs to be done to explore the significance of this finding.

Graph showing comparative proportions of take-up rates between different ethnicity groups - the non-attendance rate is in purple and attendance rate is in orange.

3. Used both of the above to work with professionals to design a more responsive and targeted service

Using these insights from our qualitative research with parents and our quantitative data work, we worked with professionals from across York to design a service delivery model for the 2 year Health Review which aims to overcome some of the barriers to take-up and to be more engaging, responsive and targeted. We shared findings and discussed potential solutions at a workshop with a range of early years professionals and practitioners, and worked closely with the Healthy Child Service team over a number of dedicated sessions to design the service changes. 

These changes to delivery include:

● Changing the default for the 2-year-old health check appointment to an ‘opt-out’ rather than an ‘opt-in’ model

○ Opt-out models have a strong basis in behavioural science - they increase simplicity, remove hassle and create a friction cost in cancelling the appointment. 

● Updating the language of the appointment invitation letter to reflect what we learned parents value from the service

○ We used insights from our qualitative research to consider how to communicate with parents about the Health Review in order to encourage uptake. We incorporated messaging about the benefits of the Health Review based on what parents had told us they found valuable and helpful.

● Phone calls before follow-up home visits to families where the child is not brought, to talk to parents and save health visitor time

● Using data and evidence to screen children not brought to their appointment for risk of poorer outcomes, to target resource and focus efforts. These risk factors include:

○ Ward - families living in wards with the highest levels of deprivation and the poorest child health outcomes (see York Ward Profiles)

○ Ethnicity - those identified from a non-white British background. This is because our data analysis showed that all other ethnicities have lower take-up rates than white British children in York; and also because nationally, children from non-white British backgrounds have poorer outcomes on a range of health indicators

○ Non-take up of 1 year review

○ Eligibility for 2 year old childcare offer.

The rationale behind this approach is that there will be benefits for:

● For children & families:

○ Hopefully a positive impact on take-up rates by switching the default to make it simpler to attend the appointment

○ Ensure targeted support is provided for children at risk of poor outcomes

● For Healthy Child Service staff and practitioners:

○ Save time and administrative burden

○ Focus resource on highest need

To achieve:

● Better identification of children at risk of poorer outcomes

● Opportunity for early intervention through proactive, evidence-based and personalised approach

4. Developed systems for ongoing use of real time data (both quantitative and qualitative) to allow service delivery to be more community responsive in the future

Alongside redesigning the service delivery model, we built a data dashboard into which real-time, granular quantitative and qualitative data on the 2 Year Health Review can be fed. This dashboard aims to improve understanding of York’s communities, and allow service improvements and targeted interventions to be more responsive and community-led, by enabling York services to:

● Monitor need by showing take-up across areas and demographic groups over time

● Update risk factors

● Target resource

● Systematically aggregate and monitor feedback from families about their service experience

The data dashboard is designed to be accessible and easy to use. Data is presented in various ways including:

● Bar charts

● Heat maps to show geographical variation

● Word clouds to show common themes in families’ feedback

And can be broken down by different categories of interest such as:

● Geographic scale (ward/Children’s Centre Area/LSOA)

● Time period

● Ethnicity

● Gender

Next steps for this work are to:

● Build capacity to enable York staff use the dashboard in their day-to-day work

○ This may include supporting York’s Business Intelligence Unit to build their own data dashboard using York’s software systems

● Integrate other databases into the dashboard, such as take-up of the 2 year childcare offer, to get a more holistic and nuanced view of need in communities across York.

5. Started the delivery of a small-scale pilot to test out the new ways of working. This is showing signs of promise.

In collaboration with the North Children’s Centre Area Healthy Child Service team, we launched a small-scale pilot to test out these changes in service delivery of the 2 Year Health Review (as outlined in Sections 3 and 4 above).

The June cohort of children invited to their 2 Year Health Review in the North CC Area received the adapted service model: their letter invited them to an opt-out set appointment time, and the language of the letter communicated the benefits of the Health Review. Children who were not brought for their set appointment time were followed up with a phone call - if the family had simply forgotten then the appointment was rebooked; if the HCS team still could not reach the family, the child was screened for risk of poor outcomes (as per criteria in Section 3 above). If the child was flagged as being at risk of poor outcomes, then a follow-up home visit was arranged. Feedback from families on their service experience was collected and fed into the data dashboard, along with data on which children were and were not brought to their appointment.

Results from this pilot were promising:

● While no claims to causation can be made from this small-scale pilot, giving families a default appointment time looks like it may accelerate the pace of take-up. 68% of children in the June cohort in the North CC Area had already already been seen for their Review within a month, compared with 42% of children in the West and 18% in the East - the majority of appointments in these two areas, where the service was being delivered as usual, were booked for a couple of months in the future (with no guarantee that the child will be brought to these appointments). There are real benefits to seeing children for their Review earlier as it allows more time to identify needs and put additional support in place.

● The ‘screening’ process seems to be valuable.  There were only 4 children in the North cohort not brought to their default appointment and whom the health visiting team could not reach to rebook a new appointment. These children were screened for risk of poor outcomes and all were flagged under the criteria outlined in Section 3, so were then followed up with a home visit. Having this process in place potentially means more rapid identification of and follow-up with vulnerable children.

● The feedback from families about their service experience was excellent.

Aside from signs of promise for increasing families’ uptake and engagement with the service, the pilot was also an opportunity to try out a new way of working with a service delivery team: co-designing an evidence-based intervention to tackle an issue, testing out the intervention, and iterating to make improvements based on learning from the operational experience. We held two sessions with the North CC Area HCS team to work together to design the process, and following the pilot we conducted interviews with 3 individual members of the team and held a reflection session with the whole team, to hear views on how the pilot went, and discuss which procedural aspects should be refined for the next iteration in order to improve consistency and ensure sustainability.

          The success of the pilot was due to the excellent engagement from the HCS team (including health visitors, managers, and business support), who offered valuable feedback, and were enthusiastic and willing to try out new ways of working. The input from the team has been both operational (smoothing over some of the early bumps in the process) and strategic (making sure that these changes feed into being able to offer families better and appropriate support by increasing take up).

We are continuing the pilot in the North CC area and providing ongoing support for refining and continued delivery, to enable us to gather further results and embed the process before considering scaling up to other CC areas. Plans for future action discussed with the HCS team include:

● Using SMS reminders before appointments to minimise the number of families who forget their Health Review slot

● Continuing to refine communication to engage families - for example, including some of the positive feedback from families who have had the Health Review in the invitation letters

● Using the data dashboard to understand in greater depth where there are low levels of engagement,

● Adopting a more targeted and responsive approach based on increased understanding of need in different areas and communities

● Linking up with other services to provide more holistic support for families which are harder to reach and improve children’s outcomes.