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Sure Start: a model for long-term policymaking? – with Naomi Eisenstadt and Donna Molloy

Episode 44 |28 May 2024 |33 mins

About 1 mins to read

More long-term, mission-led policymaking is sorely needed, but how best to do it?

The Sure Start programme was set up with the aim of giving young children the best possible start in life, narrowing gaps in outcomes for disadvantaged children. First announced by the New Labour government in 1998, it has evolved regularly over the past two decades. Recent evaluations have found early versions of Sure Start delivered positive impacts for children – supporting improved educational attainment, employment outcomes and long-term health.   

So what lessons does Sure Start hold for long-term policymaking? How can national policymakers drive long-term change in social outcomes, what pitfalls need to be avoided, and where should any new government be looking if they want to improve children’s lives and health today? 

To discuss, our Chief Executive Jennifer Dixon is joined by:

  • Naomi Eisenstadt, former director for Sure Start and current Chair of Northamptonshire integrated care board (ICB).
  • Donna Molloy, Deputy Chief Executive at Foundations – What Works Centre for Children & Families.

This episode was recorded shortly before the Prime Minister announced a General Election will be held on 4 July. 

Jennifer Dixon:

Long-term mission led policymaking is in the air, but how best to do it? One example to look at is Sure Start, the national programme set up 25 years ago and still running with core services, but local flexibility and user-led design. And the positive impacts accrue to health and education of young people. So what lessons are there for a new government committed to long-term policymaking? How can they do it well? 

Well, with me to discuss all this, I'm delighted to welcome Dr Naomi Eisenstadt. Naomi was the first Director of Sure Start in 1999. And Donna Malloy, who is the Deputy Chief Executive of the What Works Centre for Children and Families. Welcome both. 

From both of your perspectives, could you just outline a bit about Sure Start as a programme, what it was and how it changed over 25 years?

Naomi Eisenstadt:

Sure Start was announced in Parliament in July 1998 and started as a programme in early 1999. The New Labour government had a manifesto commitment to a national childcare strategy and free nursery education for all 4-year-olds, but they were also interested in child poverty. The New Labour government also had something called a Modernising Agenda, which was joined up government and evidence-based policy and user-led not provider-led policy, which I think goes to the heart of what some of the real tensions are in a programme that's meant to be evidence-based. So it was at local level, very small areas, a few streets around 400 to 800 children under 4 with a local board that was set up to include parents local services. And to deliver outcomes that would make children from poorer families school ready to narrow the gap between children from poor families and the rest. It was not targeted by family, it was targeted by area, which is a very important difference. No stigma in being included in Sure Start, it was just where you lived. So that was a very explicit decision not to target by family.

Jennifer Dixon:

So initially, locally led, area based as you say, trying to catch the most disadvantaged children and families. And how did it change over time, Naomi?

Naomi Eisenstadt:

It was targeted initially in the poorest areas of England and it was different for Scotland, Wales and Northern Ireland. And in going to the poorest areas of England, we reckoned that we would get half of the 20% poorest children in England because a lot of poor kids didn't live in poor areas. After 2 years it expanded from 250 programmes to 500 local programmes, and that would get us the half of the children in the 30% lowest incomes. So it's very much about poverty, not other forms of disadvantage. And it was narrowing the gap between poor kids and the rest. Sure Start was immensely popular and it became so popular that every MP wanted one in their constituency. So we went from 500 local programmes in a matter of 3 or 4 years to 3,500 Sure Start centres. But the big problem is that there wasn't the same funding across. So under Labour, they maintained the most intensive funding in the original poor area centres and then spread the others more thinly. When it moved from Labour to the Coalition government, they spread it thinly across and that made a massive difference to impact.

Jennifer Dixon:

So from Sure Start local, it then became Sure Start centres. Were they the same thing or did they take on a different quality as they expanded to 3,500?

Naomi Eisenstadt:

Well, the different quality was the less... A centre was not really different from a local programme because most of the local programmes operated out of buildings. So it was just felt that it was easier the public to understand the language of centre than local programmes. The big difference happened as the Coalition matured and moved into a majority Conservative government. The commitment to integrated and the commitment to open to everybody in the area changed from what was an open access, targeted by area to a social work in localities and became very much targeted towards families with particular disadvantages or particular difficulties. So drop ins, nurseries, all the kinds of things that made it incredibly user-friendly were hollowed out. It wasn't 5 days a week, it was some services on Tuesdays and some other services on Fridays. So the families who most needed an open access, easy and non-stigmatising service lost that. You had to figure out what was on offer when and where to go.

Jennifer Dixon:

And the kinds of services that the users said they wanted at least initially, could you just chart those out for people?

Naomi Eisenstadt:

When you open a programme that is based on what families say they want, they don't ask for evidence-based parenting programmes. They ask for baby massage, they ask for all sorts of things that have virtually no evidence base at all. And what the best Sure Start programmes did is provide people with what they asked for to get trust, and then move on to more evidence-based interventions like parenting programmes. But a lot of them offered cooking, a lot of them offered baby massage, a lot of them offered particular play space for disabled children. So it was a real mix and that mix of what families wanted versus what evidence says helps them, was a fundamental tension in Sure Start, it exactly was the strategy. And the idea that you could work on what people thought would make their lives better, along with what professionals knew made things better for children. My line was always, If they don't like it, they won't come. Just because they like it doesn't mean it helps their kids, so you need it both ends.

Jennifer Dixon:

So Donna, I'd be very interested in your perspective. As a strategy, do you think this worked?

Donna Molloy:

First on why Sure Start was so important, I think there was something about the magnitude of the initiative and the ambition that was really important. The aim of giving children the best possible start in life with a focus on disadvantage areas and narrowing gaps in children's development that we know open up along income lines, felt like such an important moment, I suppose, in the evolution of early years support and really put family support on the map in the UK. And I think the level of ambition of that time still stands out even today when we look back over the last 20 or 30 years, this is one of the biggest moments I think. And also the focus on actively integrating health services, parenting support, early learning, childcare, parental employment support. In that way, I think the strategy was very strong and very sensible.

As Naomi has talked about, where some of this might have fallen down is that there was a very strong emphasis, particularly in the early stages of letting local communities design the services that they want. The language of the time was letting thousands of flowers bloom. And I think we know how we see this all of the time in the work we do at foundations where we look at what works for children and families. Is that what people like is not enough to always the approaches that make the most difference, particularly in terms of shifting some of those very tricky outcomes for disadvantaged children. And so the latest stages of Sure Start where there was a bit more central prescription did try to get clearer about what the consistent offer should be. I think the problem was that point and that coincided with significant reductions of the amount of funding available, and there just wasn't the resource for the sort of suite of evidence-based interventions that we know makes a real difference.

Jennifer Dixon:

So was the core offer more focused because of the money or was it a different kind of philosophy to how to run long-term programmes?

Naomi Eisenstadt:

I would say that it was iterative. So the core offer started to move as we began to learn what was working and what wasn't. And the best example I always give of this is the national evaluation of Sure Start. The first evaluation they did on impact showed that the children of teen parents were doing less well in Sure Start areas than in non-Sure Start areas. And that was a terrible shock for us. That was do no of harm. We were doing harm. And what was good about the programme is that the evaluation design was such that every 2 years we could take stock and see if it was working or if it wasn't. And therefore we could redesign based on that and did assertive outreach for teen mothers. And 2 years later, the next evaluation showed there was no difference between teen mothers and the rest and all we're getting improvements in parenting.

So I think that Donna's right in terms of the movement between completely open-ended into a more focused approach, but still maintaining. And the IFS in their report on educational outcomes makes a real point about the big differences was once local government took over, the requirement for parental involvement went. At the same time funding was cut and therefore results diminished. So the results they get are only from the first 500 that were very well funded and had a tremendous amount of parental involvement. And over those first 3 or 4 years, learning what aspects were the most important thing and what worked and what didn't. So there was a sweet spot of the learning and then the money started flowing away.

Jennifer Dixon:

So it sounds as though from the very beginning there was a sort of enlightened approach to evaluation. And do you think that that kind of flexibility of evaluation is critical in such a long-term programme that would inevitably evolve?

Naomi Eisenstadt:

I think it's absolutely critical and it was very, very contagious at the time in terms of who got the evaluation, the design of it involving people like senior academics. We had an evaluation group. Oddly enough, one of the big arguments was in the design that we had of letting local determination on what was on offer, it meant that you couldn't do a randomised control trial. And when I wrote in my book ‘and a few weeds grew…’ and I was advised to take that out, but naturally that was going to happen and that you'd learn from them. I think the key to my dilemma of Sure Start is that everything it's told us now that it really, really did work for children from very low-income families. And it didn't really work for anyone else. The IFS tells us this definitely worked for non-white children. But on the other hand, if we hadn't expanded it everywhere, I do not believe we would be having this discussion because if it had just stayed with those 500 programmes in poor areas, it would've been cut immediately and nobody would've noticed.

Jennifer Dixon:

The IFS reports were interesting. The ones I've read particularly focus on health and education. And on the health side there seemed to be an increase in hospitalisations actually in the very early years, but a decrease in teenagers later on of injuries, of mental health, admissions and so on. And the educational impact seemed to be higher again about 10 years after the programme had finished, in other words, when people were 12 to 15. Is that your understanding that the bigger impact seemed to happen later rather than earlier?

Naomi Eisenstadt:

On the health side, it's only in the first year that you have hospitalisations and that was I think via more services available and more families were seen. So things were identified earlier. But the changes in terms of health and in education started around eight or nine, it wasn't as late as 16. And there was some very interesting changes that one would not have expected.

Donna Molloy:

What's so striking about the IFS research is that that sort of long-term follow-up per evaluation is just something we so rarely see in this country. And I think that's just highlights how valuable it is. We do have a tendency just to look at short-term effects from many of our government interventions and flagship programme and we just don't stay the course. And it just might be we are missing all of these longer-term outcomes that we so desperately need to know about. And I think one of the really interesting dilemmas about the Sure Start years was the time lag in the evaluation results, and the data inevitably against the fact that there was such interest, such need for information in order to make policy decisions. And the two things were inevitably slightly out of sync. And I think some decisions would've been made when we just didn't have the information about what was being achieved by the programme. And this links into the point about looking ahead and I think just the more we can do to get that long-term tracking and evaluation about some of the key flagship programme in the new government, the better.

Jennifer Dixon:

Because in a sense you've got this large programme in operation, and you need to iterate as you go along to help the programme evolve. So you're looking at shorter term, perhaps some softer measures. But at the same time you've got to put and train this longer term, more traditional summative evaluation, which is the type that IFS did to look at some sort of metrics if you like. So it's a question of double running I guess, is that right?

Donna Molloy:

Yeah, and there's a number of examples along these lines from the last decade or so. The other standard one we often talk about the foundations is the evaluation of family nurse partnership. Obviously very well-evidenced intensive home visiting programme. The original waves of evaluation were disappointing. There was lots of disinvestment, we didn't really hold our nerve. And then 6, 7 years on, we got the data on the impact it made on school readiness for disadvantaged children, which are very hard outcomes to shift. And it remains now one of the best evidence programmes we have in terms of reducing income-related attainment gaps. But we didn't stay the course and I think there were lessons from that, and at Sure Start of course.

Jennifer Dixon:

So just going back to the Sure Start original vision when it was set up, was it set up to be a long-term programme? I know that soon after it formed, there was a 10-year strategy, wasn't there? I think in 2004, but was it really sort of heralded as this is a long-term programme for the zero to fives?

Naomi Eisenstadt:

Well, Norman Glass certainly intended it to be a permanent strategy. The notion that it would be forever is very, very difficult to figure that out in terms of what does that mean because everybody had a different view about what Sure Start was anyway, and what does it mean to be forever? So I think there's something about a branded programme that makes it impossible to be forever because it becomes so politically aligned. The thing that I'm most proud of in terms of Sure Start is that there was a magic about the people who used it absolutely loved it. And I don't think we can underestimate particularly in early years how important it is. And it's the same thing actually with nurse family, nurse partnerships, that the people who get it absolutely love it and enjoy the support. And the culture of it is working with and not for or to.

So there were things about the culture of it that were enormously important to its popularity. And I run into people all the time now who used it when their children were smaller. And I've run into a few adults who were babies in Sure Start. So people's affection for it has not diminished.

Jennifer Dixon:

So if you are a government, if you badged something big like Sure Start, it's inevitable that it's going to change over time whether it's because of a new government wanting to change the wording, or whether it's a new minister who wants to have a different emphasis. So how best to maintain a consistent strategy even if the names and the exact blend of initiatives change underneath that bonnet?

Donna Molloy:

Well, I think you've got to focus on the core components or elements that really matter and we know are most likely to sort of do the heavy lifting in terms of making children's outcomes better. And really what we call these things, the sort of labels matter much less. And it's important just to focus on what really matters at the heart of some of these initiatives. So for me, I would argue that's about carefully targeted high-quality support, thinking about sufficient long-term evaluation, recognising that the value of evidence-based interventions and that the resource needs to be in place to make those interventions widely available. And a lot of the other things that sit around this, I think matter less. And so not getting swayed by the swings and roundabouts of particular language conventions of in a flavour of the month in terms of policies and so on, and just focusing on the stuff that we know makes a difference.

Jennifer Dixon:

And was that the philosophy underpinning the setting up of the What Works Centres? Because in a sense you could say that you are the repository of evidence in this area.

Donna Molloy:

Yes, I think that's right. The view was back nine, 10 years ago when What Works movement was sort of set up at the heart of government, it was felt that there needed to be centres which could develop and maintain repositories of evidence about what makes a difference in terms of whichever particular outcome area or policy area it might be. For us, this is about children's outcomes, be independent, completely impartial, up to date. And make that accessible to either policy makers nationally who are making decisions about new initiatives and policy and so on, or those locally who are designing and commissioning services. For example, we have an online guidebook which has something like 130 different programme and interventions, which have been shown through rigorous high-quality evidence to change a range of children's outcomes.

Naomi Eisenstadt:

I think the most important thing isn't the what works, the most important thing is is their agreement on what you're trying to achieve because [inaudible 00:19:02] immediately assumption of what we're trying to achieve is narrowing the gap in outcomes for children. The example I want to give on that is the current government's childcare strategy, which is a strategy about women's labour market participation. It is not about child outcome. So you need to be very, very clear not to allow policy makers to try to double up or triple up what the aims are because sometimes they're in conflict. And I think this one is particularly in conflict. The other point I would make is that in terms of the Sure Start story, at the same time there were much more generous benefits, there was much more cash transfers and income strategies. And the balance in terms of interventions as opposed to just less poor is completely wrong. So I do think if the problem is the social class gradient on outcomes and poor kids do worse, how about fewer poor kids?

Donna Molloy:

Couldn't agree more with Naomi on outcomes. It's very interesting one of the things that we see in a lot of our work with those who are often developing and designing services, is just that lack of clarity about what they're trying to achieve and for whom. And without that we just get into quite sort of woolly fuzzy intervention design and just impossible to show results. We have to just think ahead as we go forward, as well as thinking about high quality evidence-based support for children and families. We have to also think about reducing economic stress. We know that that significantly affects parents' ability to provide the consistent nurturing environment that their children need. And I think it just feels like only to focus on interventions without tackling child poverty is like trying to operate with one hand tied behind our backs. So it would be great to see a sort of multi-strand focus as we move forward, which is trying to tackle both of those things simultaneously.

Jennifer Dixon:

If you've got a mission, you've got a tight objective to say climate is an example in front of us. Was there any talk on the early years side of having some kind of independent audit of an annual report on the state of children early years, that was independently written a bit like the carbon audit is done these days by the Climate Change Committee? I remember the New Labour government had a kind of how did we do annual report, didn't it? In the early years of its government.

Naomi Eisenstadt:

There is annual reports on children's readiness for school through the early years' foundation stage and on the differences in different groups. I just think that the energies have to be about that dual, how do services work together to improve the circumstances for children and families? And as soon as you do those audit things, they tend to be quite narrow and they don't get this broader service integration or service contribution thing. So I suppose the pig doesn't get better by weighing it and it's so obvious some of the things that we have to do and some of the things I think that we've got wrong. And I suppose that's one of the things I grieve about Sure Start, is that I want to learn from what we did wrong.

Jennifer Dixon:

Let's just turn back then to the national arrangement for this policy. As you pointed out in your IFS lecture presentation, Naomi, it was David Blunkett at education, it was Tessa Jowell and Yvette Cooper at the DH, Department of Health. But their own departmental committees weren't there that were feeding into this sort of assessment. Clearly that's important to have cross-departmental working in this kind of area. But how well did it work and were there any particular mechanisms that any new government should be knowing about to make this work more effectively in future?

Naomi Eisenstadt:

There was a ministerial committee that was represented by six different government departments. But the main departments that were interested was DWP and Health and Education, and quite early on health handed over to DWP. And the other big mistake we made at the time, which I think we're still suffering from and maybe Donna has a view about this as well, and I was all in favour of it at the time, I think was a mistake to take children's social care out of the Department of Health and move it to DfE. And we did it because we were creating a children's department. But as soon as the government changed, we went back to a department for education, not a department for children. And I think it significantly weakened the voice of children in the Department of Health. So I think that no matter how you structure government responsibilities, you need to make sure that you manage and risk assess the new joins and we didn't do that. So I think the health involvement weakened over time, which I think was a great tragedy.

Jennifer Dixon:

So Donna, what are your observations about how this could work better in future, given what Naomi just said?

Donna Molloy:

So we definitely need a new national vision for early years children and families support with the right mechanisms, I think nationally and at local level to drive the direction that we want to see. I would say nationally I was a civil servant for many years and worked with various combinations of central units and task forces and various other structures. I think the crucial things are you need some sort of central vehicle with the right departments round the table with a clear mandate. And whoever is chairing or convening that forum needs to have the authority and direct mandate from number 10 and the Prime Minister to get White Hall working in the way that you might want to. I think a good example, actually I was thinking about this the other day, remembering also another big last Labour government flagship policy, the Teenage Pregnancy Strategy, which again had a central cross-government programme.

There was a ministerial task force in White Hall, but then with clear joined up action at local level through regional and local service coordinators. And so the direction that was set centrally then flowed through those individuals and structures of local level. And there's just something about how it's all very well to set the vision in White Hall that really matters. And we have to do that and assemble the funding and all the rest of it in the direction. But making sure there is the proper funding incentives and levers to drive the change that we want to see locally, I think is equally important.

Jennifer Dixon:

As I understand it, as the programme evolved, local government had more of agency, is that right, over time in Sure Start? And how did that work when we know how local authorities vary enormously in capability and funding and mission and interest in this area how tight-loose was the national local balance and how tight-loose would it need to be in future?

Naomi Eisenstadt:

So the difficulty was that initially these 500 local programme were run from White Hall, which meant that the local committees had an enormous amount of power and did great stuff. And the IFS report shows how the early ones they did the best stuff. The reason that we had to hand over to local government, which again was very, very contentious at the time, was that we had set up this structure called Every Child Matters. That I think was one of the most important things that Labour did for children. I thought it was brilliant. I thought that the five outcomes, I thought the work that was done by Tom Jeffrey and Alvia Finchley and Anne Weissach was absolutely brilliant. The problem is, it was a structural system in terms of having one director of children's services in every local authority who would be responsible for all the children in that area.

And you couldn't then have that director of children's services responsible for all the children in a local government area except the three Sure Start local programmes. It just didn't work. You were sort of creating a different kind of fractured service while we were trying to integrate services for children. Once we handed over to local government, local government was incredibly different from each other in their approaches to the parental involvement role of local programmes. And that's when we started to lose what was that magic about local participation. Some did it very well, some were not interested in it at all. So the principle of why we handed over to local government was completely right. But in practice of course, then you get much more diversity.

Jennifer Dixon:

Donna, your experience of this and how to hang on to these core objectives at the same time as handing down to local government. So how would you get that right, that balance?

Donna Molloy:

It is a tricky balance. I think there has to be central clarity about what types of support or models are likely to make the most difference. And I think we don't always have that in some of the policies we have in this space at the moment. Our argument would be there's often a significant gap between what we know works from high quality studies and what gets commissioned and delivered locally. And we need to be using those things shown to make a difference and not reinventing wheels. And there's sometimes a tendency in White Hall to launch innovation rounds or calling for bids from local authorities and their partners, without any sort of clarity about what it is that we want to see. So I think you need some sort of central menu clearly setting out the types of support that should be available. It's not just enough though to produce guidance from local authorities.

We're seeing time and time again, just producing guidance doesn't shift what happens locally. So that's got to be backed by the right sort of incentives and use of levers in the system. So ring-fence funding that gets specific models delivered. I'm not saying that's the only way of doing it, but it is worth thinking about. We saw just another example again from the Labour years evidence-based parenting models, things like Triple P and incredible years went from being available in a small handful of pilots to being available in every top tier local authority over a four or five year period as a result of funding earmarked for those models with very strict conditions, et cetera. The other thing I think we need to think about is the inspection and obviously the influence inspectors such as Ofsted can have in how they review, scrutinise local authority. But yeah, I don't have all the answers, but I think we need to take a really careful look at what it is we want to do and what architecture we want to put around this.

So we know that as we go forward, the core of interventions that we know are most effective are much more widely available. I find it quite depressing, things like incredible years. I saw something the other day now there's less than 25% of children and young people who could benefit from that type of support actually receive it. And so we've gone backward from having it widely available to now just in a minority of areas. And I'd like us to take that back.

Jennifer Dixon:

For both of you, what would you be advising if you were approached by the new government, a new Labour government perhaps, who wanted to design something which was for the long term and perhaps in this area but maybe even perhaps not? So sort of generic advice based on your experience here.

Naomi Eisenstadt:

I don't disagree with any of the things you've just said. What you think is important in terms of clarity is focus for whom, because Sure Start was very much about the 20% or 30%, not the bottom 3% or 4%. It wasn't about complex families with complex difficulties. It was the families who basically because of low income, had difficulties in providing for their children in the way that we think is the best way to provide for children so that they succeed at school. I find most discourse now is about very, very complex families and that won't shift in child outcomes.

Jennifer Dixon:

And Donna, what would you be saying?

Naomi Eisenstadt:

I would agree with Naomi. We need to first of all work out what it's we want to achieve, and I do think we need a focus on earlier intervention for families as part of that. I think the original objectives of Sure Start remain as necessary today. I would like to see, again, a new focus on providing support for families that we know can mitigate the impact of poverty and disadvantaged, particularly on those crucial educational and other outcome areas. I think there's something about as part of that, what works evidence of the type we provide won't tell you everything about what to do. It's only part of the picture, but it is really important in terms of the things we know are likely to make the most difference. I'd like us to make sure we're using that at the core of whatever it is we develop here.

I think we can't just focus on the near term. And we need to hold our nerve. I think one reflection I have from the last two decades of policy initiatives is that we do have the right ambitions and we do try to do the right things, but just how we go about it sometimes is insufficient or we lose our way mid-course. And I think the new government provides an opportunity to get this right and would like to see a renewed focus on reducing those gaps in outcomes for disadvantaged children.

Jennifer Dixon:

So we must leave it there. A big thank you to Naomi Eisenstadt and Donna Malloy for their first-hand insights. And next month we'll be looking in-depth at what the public really think about the NHS and the pathway for its reform. Until then, many thanks to the team for help producing this podcast, that's Leo and Sean at the Health Foundation and Paddy and team at Malt. And that's all for now from me, Jennifer Dixon.

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