Archive for the 'Health' Category

Challenging the politics of early intervention

Nicola Horsley

Ros Edwards

Val Gillies

The past decade has seen a rash of early intervention programmes targeting mothers of young children.

Reports by the World Health Organisation and UNICEF, and early years policy and service provision in the UK and internationally, are now characterised by an emphasis on early intervention in the belief that pregnancy and the earliest years of life are most important for development. It has become the orthodoxy in a whole range of professional practice fields.

The idea of being able to intervene in parenting to ensure better life chances for children feels constructive and positive, but there is little evidence to suggest that it works. Moreover, early intervention doctrine ultimately holds mothers accountable for poverty and other social ills.

“…there is little evidence to suggest that it works.”

Pressure on mothers

Early intervention is directed at mothers as the core mediators of their children’s development. The significance of mother-child relationships in the early years often is underlined through reference to the developing brain. For example, the website of the influential Harvard Center on the Developing Child refers to mothers as ‘buffers’ between their children and adversity. As buffers, they are held personally responsible for inculcating what the Harvard Center terms ‘a biological resistance to adversity’ in their children.

The quality of mother-child relationships is posed as a decisive lever in building children’s brains, and is a core principle structuring the everyday work of many early years intervention programmes. In one UK early years intervention initiative that targets young and marginalised first time mothers, the Family Nurse Partnership programme, practitioners provide mothers with a sheet headed ‘How to build your baby’s brain’ featuring a list of activities claimed to enrich neural connectivity, such as reading books, singing rhymes, and playing on the floor.

“The deprivation facing poor working class families is posed as a result of poor mothering.”

The responsibility loaded onto mothers is especially pronounced in relation to low income, working class mothers and Black and minority ethnic mothers, as both cause of and solution to their children’s marginalisation and poverty.

The deprivation facing poor working class families is posed as a result of poor mothering and consequently the stunted brains of their offspring, at the same time as they are positioned as buffers who can mitigate against and overcome the effects of a harsh wider environment for their children. Early intervention programmes such as the UK’s Family Nurse Partnership, the Solihull Approach, and Parent-Infant Partnerships, overwhelmingly are delivered in areas of deprivation to poor mothers.

Ideas about brain science are used to legitimise interventions in the child rearing habits of working class families, protecting children brought up in poverty from any effects of their disadvantage and promote their social mobility. The social and structural causes of hardship and need that are being experienced by these families in the present are effectively masked, placing mothers as hidden buffers against the effects of privation on their children.

The developing world

Globally, UNICEF brings together early years development and parenting to offset children experiencing war and hunger on the basis of the speed of new neural connections formed in the brain in the early years, asserting that good parenting will help children overcome multiple adversities such as violence, disaster, and poverty. Despite the overall paucity of evidence that early years intervention works, initiatives are being rolled out across the developing world, in the belief that improved mothering will surely benefit the state of the nation.

For example, the ‘Fine Brains’ (Family-Inclusive Early Brain Stimulation) programme seeks to promote parental stimulation and interaction to improve children’s brain architecture in sub-Sahara. It asserts that mothers in these countries are ill-equipped to maximise the benefits of interaction, need to be trained, and then to train their husbands to parent properly. The complex and diverse historical, economic, political, social and religious contexts of sub-Saharan Africa are obscured in favour of a focus on individual mothers as able to overcome poverty, conflict and post-conflict, engrained gendered inequalities, and so on, through improving their knowledge of child development and home engagement practices.

“Despite the overall paucity of evidence that early years intervention works, initiatives are being rolled out across the developing world.”

 

A meritocratic construction

The policy and practice preoccupation with how poor mothers and deprived families bring up and nurture their children relies on a meritocratic construction of the wealthy and privileged as having better developed brains. This is a statement that many of us might find offensive. But within the confluence of brain science and early years intervention, success is naturalised and unproblematically correlated with brain structure and intelligence. From this perspective, the solution to poverty is to make people smarter. Working class mothers, black and minority ethnic mothers, and mothers in the global South can enable their children to think their way out of their predicament.

The idea that hardship and discrimination is to do with how much attention of the right sort that mothers give to their children, and the notion of countering global traumas and inequalities through parenting, is jaw-dropping. It demonstrates why early intervention policy and practice deserves more critical scrutiny.

 

Challenging the politics of early intervention by Val Gillies, Rosalind Edwards and Nicola Horsley is available with 20% discount on the Policy Press website.  Order here for just £18.39.

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What effect do sanctions & conditionality have on disabled people?

Guest editor Ben Baumberg Geiger introduces the new Journal of Poverty and Social Justice special issue, focusing on disability and conditional social security benefits.

 

Ben Baumberg Geiger

“There are times that policy runs ahead of academic knowledge.

Indeed, this is often the case, for policies must first be introduced before social scientists can study them – and if policy makers were restricted to policies that had been tried and tested, then policy innovation would be impossible.

Yet such innovation can come with considerable risks, as new policies can be introduced and widely imitated, only for social scientists – after some delay – to show that such policies are difficult to implement, can fail to achieve some of their aims, and may even have unforeseen and harmful consequences.

In a new special issue of the Journal of Poverty and Social Justice, we focus on one area where this might be happening: conditionality for sick and disabled social security claimants. While, historically, disabled benefit claimants were largely exempt from seeking work, high-income countries from Australia to Norway have increasingly required disabled claimants to take steps towards finding work, under the threat of financial penalties.

“…high-income countries from Australia to Norway have increasingly required disabled claimants to take steps towards finding work, under the threat of financial penalties.”

The conventional wisdom repeated by bodies such as the OECD is that this is a necessary step towards reducing high benefit claim rates, and, moreover, helps improve the finances, health, and social inclusion of disabled people themselves.

However, there are several challenges to this story. By any principle of justice, claimants cannot reasonably be required to perform actions that they are incapable of doing, but it is difficult for benefits agencies to know exactly what someone can or can’t do. If they get this wrong, conditionality for disabled people can create injustices, and inflict considerable stress on disabled people. Moreover, conditionality may move disabled people further away from work, by both undermining their relationship with their employment support caseworker, and making them less willing to take risks in performing tasks that they are not sure they are capable of doing.

 

Two conflicting stories – but what does the evidence say?

Until now, there has been very little published research trying to establish which of these accounts is correct. This is the aim of the special issue, which includes four research papers looking at experiences from around the world. In the UK, Aaron Reeves looks at on the impacts of conditionality for disabled people claiming unemployment benefit. In Denmark and Sweden, Sara Hultqvist & Iben Nørup look at the different forms of conditionality implemented for young disability benefit claimants. In Germany, Patrizia Aurich-Beerheide & Martin Brussig look at the (failed) implementation of conditionality for disabled people in Germany. And my own paper (see below) brings together these papers with a wider review of evidence and practice, to come to some initial conclusions about what we know so far.

“It is crucial for the wellbeing of disabled people around the world that deeper knowledge and more informed policy go hand-in-hand.”

The special issue also includes four further, slightly more unusual papers about the UK, perhaps the country where these issues have become most hotly contested. Indeed, conditionality for disabled people has been the subject of an award-winning film (I, Daniel Blake) and an award-winning play (Wish List), both of which are reviewed in the special issue (by Alison Wilde and Kim Allen respectively). Jed Meers covers a recent Supreme Court judgement about the ‘bedroom tax’ in the Supreme Court. And we felt it was important to convey the lived experience of conditionality, so a team from the Welfare Conditionality project describe two real-life stories of people who took part in their research.

So at the end of this, what do we know? In my (open access) review paper, I summarise the evidence into four ‘stylized facts’:

1. Requirements for disability benefit claimants are common, but sanctioning is rare (particularly outside of the UK and Australia).

2. Assessment and support are critical in making conditionality work on the ground, and can be combined into ‘passive’, ‘supportive’, ‘demanding’ or ‘compliance-based’ systems.

3. The limited but robust existing evidence suggests that sanctioning may have zero or even negative impacts on work-related outcomes for disabled people.

4. Individual case studies in ‘compliance-based’ systems suggest that sanctioning in the absence of other support can lead to destitution, and that conditionality can harm mental health.

While we need to know more, it is already clear that we cannot assume that conditionality for disabled benefit claimants is easy to implement, nor that it will have purely positive consequences. Policy may have run ahead, but research is now starting to catch up. It is crucial for the wellbeing of disabled people around the world that deeper knowledge and more informed policy go hand-in-hand from this point.

This is an edited version of the (free) introduction to the special issue, and is simultaneously being posted on the Policy Press blog and my own Rethinking Incapacity blog. The full special issue can be accessed here.

 

You can read the Disability and Conditional Social Security Benefits’ special issue of the Journal of Poverty and Social Justice here. 

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Election focus: Avoiding Another Failed NHS Experiment

In the next post in our Election Focus series, David Hunter, author of The health debate, explains that the election must not become an excuse for shelving much needed health system transformation.

David Hunter

“A possible unwanted side effect of this most avoidable of unnecessary general elections, and the accompanying purdah into which everyone has slumped, is the impact on the NHS reforms initiated by the NHS Five Year Forward View published in 2014 and its update in the Next Steps delivery plan published last month.

One can only hope the NHS Chief Executive, Simon Stevens, is correct when he asserts that ‘there is no version of reality’ in which his changes will not be needed and actively pursued. Even if he is proved right there could still be disruption if a new health secretary replaces the current post-holder, Jeremy Hunt.

Or if the all-consuming Brexit negotiations divert the government’s focus and slow down the pace of change as seems likely. Or if a new administration decides to replace Stevens. As the chief architect and champion of the changes, he is critical to their success, especially at such a delicate stage in their evolution and before they have been fully embedded.

New Care Models and Sustainability and Transformation Plans

The election comes at a pivotal time in regard to progress with the New Care Models (NCM) nested in the Vanguards initiative and the evolving Sustainability and Transformation Plans (or Programmes if you prefer) (STPs) agenda.

“…opens up the prospect of further stalemate and a failure once again to get to grips with long overdue changes to reshape the NHS for the new challenges it faces.”

In the case of STPs, Labour has stepped back from its rather foolish pledge announced in the leaked manifesto to impose an immediate moratorium on them if elected. But while the final manifesto now states that Labour will merely ‘halt and review’ STPs, the move still heralds a return to heavy-handed ministerial meddling from the centre.

As a way of running the NHS, it has rarely if ever been desirable or worked. Moreover, it opens up the prospect of further stalemate and risks failing once again to get to grips with long overdue changes to reshape the NHS for the urgent and complex challenges it faces.

What’s needed?

For the changes to succeed requires sensible resourcing and sustained commitment over a reasonable time period, both of which are already fragile under the current government. If re-elected with a larger majority it is unlikely much will change which could leave the changes in a precarious state, especially when coupled with the desperate pressures the NHS is already under both in terms of financing and staff recruitment.

So, while perhaps not putting the changes at risk in the way Labour’s proposals seem destined to do, a Conservative government with a fresh mandate need not axiomatically be good news for the NHS.

If the political outlook for the NHS changes presently being implemented looks potentially bleak or risky whoever wins, it will be incumbent on senior managers and clinicians, perhaps with the support of the Royal Colleges and others, including local government, to lead and drive the changes.

An opportunity

The Vanguards and STPs represent a chance of a lifetime opportunity to transform the NHS as it approaches its 70th birthday in July 2018. Too often in the past resistance to change has won out and the result has been an NHS which in many respects has become ossified and no longer fit for purpose given the changes in demography, lifestyles and the evidence of growing inequalities.

“Too often in the past resistance to change has won out.”

Successive inquiries and critiques of the NHS have pointed to the repeated failure to take prevention and public health seriously, to integrate health and social care, and to rebalance the health system away from costly, acute hospital care. The Vanguards initiative and STPs are confronting head-on all these deep-seated systemic problems that have persisted in the NHS for decades.

Drawing conclusions from the NCMs is premature and inconclusive. Generalising from very complex and different models and contexts is a hazardous business. But, putting these health warnings to one side, the early evidence emerging shows a passion, enthusiasm and high level of commitment to make the changes work. They are also felt to be the right way to go in terms of patient care.

Once the evidence from the local evaluations starts to appear later this year, there will almost certainly be a mix of likely successes and failures although it will take longer to assess how far the changes have actually impacted on health outcomes. It is also the case that, as the Public Accounts Committee concluded recently, STPs are a mixed bag and of variable quality. In most places, engaging local government and the public should have assumed a much higher priority at an earlier stage.

But when all is said and done, the unprecedented transformation journey on which the NHS has embarked has given permission to local areas to chart their own destinies within a national framework providing support and development know-how. It is not perfect and tendencies for old-style, command-and control behaviour to surface have to be resisted. Nor is the overall financial climate helpful or sustainable although, if one is honest, resource pressures have been an important stimulus for change.

If the changes underway can be maintained post-election and the NHS becomes a genuine health service rather than a sickness one, which it has been since its inception, then that must be the goal of all those who want the NHS to survive and should be embraced enthusiastically.

Warts and all, we should not squander this opportunity to transform the NHS so it can meet the 21st century challenges confronting it. Surely that has to be a 70th birthday present to remember.

 

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Care and caring: challenge, crisis or opportunity?

SusanMYeandle

Sue Yeandle

As the first issue of the International Journal of Care and Caring publishes, Sue Yeandle, Editor-in-Chief, highlights the global space that care now occupies and introduces the journal as a new forum where world-class knowledge about care, caring and carers can be shared.

Issue 1 of the International Journal of Care and Caring is free to access on Ingenta until 30 April.

“From Nairobi to Tokyo, Sydney to Bogota, Montreal to Stockholm and Gdansk to Glasgow – and beyond – care is more visible than ever, and an issue of growing importance all over the world. It is central to human life and relations. It underpins the world’s health, employment and welfare systems. It affects every family and human being on the planet.

“In all its horror, glory and daily realities, care touches us at every level.”

Continue reading ‘Care and caring: challenge, crisis or opportunity?’

Blinded by science: when biology meets policy

Sue White and David Wastell, authors of Blinded by science out today, explain the rise of neuroscience and genetics and their influence and impact on social policy.

David Wastell

Sue White

“Biological sciences, particularly neuroscience and genomics, are currently in the ascent. These new ‘techno-sciences’ are increasingly seen to promise a theory of everything in the psychosocial realm.

Social policy has not been slow to conscript technological biology, and is making significant use of neuroscientific evidence to support particular claims about both the soaring potentialities and irreversible vulnerabilities of early childhood, and the proper responses of the state.

The far reaching implications of epigenetics

The last decades have also seen a profound shift in our understanding of biological processes and life itself.

Whereas genetics has conventionally focused on examining the DNA sequence (the genotype), the burgeoning field of epigenetics examines additional mechanisms for modifying gene expression in manifest behaviours, physical features, health status and so on (the phenotype).

It provides a conduit mediating the interaction of the environment on an otherwise immutable DNA blueprint, and invites a natural interest in the impact of adverse conditions, such as deprivation or ‘suboptimal’ parenting. The implications of this for social policy are far reaching.

Continue reading ‘Blinded by science: when biology meets policy’

It’s not just about the money: 5 dilemmas underpinning health and social care reform

Following on from the publication of the third edition of Understanding health and social care, Jon Glasby looks at what’s needed for long-term, successful health and social care reform.

jon-glasby-pic-2

Jon Glasby

Open any national newspaper or turn on the news and (Trump and Brexit aside) there is likely to be coverage of the intense pressures facing the NHS.

Throughout the winter, there have been stories of hospitals at breaking point, an ambulance service struggling to cope, major problems in general practice and significant financial challenges.

For many commentators, this is one of the significant crises the NHS has faced for many years, and quite possibly the longest period of sustained disinvestment in its history.

“Draconian funding cuts have decimated services at the very time that need is increasing.”

Continue reading ‘It’s not just about the money: 5 dilemmas underpinning health and social care reform’

Get social care right and the NHS will benefit

How can we improve access to and quality of social care? Catherine Needham, co-author of Micro-enterprise and personalisation, discusses how micro-enterprises and micro providers could improve care services. 

catherine-needham-head-shot-b

Catherine Needham

At a time when the Red Cross is warning of a ‘Humanitarian Crisis’ in the NHS, there is a growing recognition that pressure on NHS services will not be alleviated unless we get social care right.

Social care services support frail older people and people with disabilities. They are run by local government and have borne the brunt of the local authority cuts in recent years, with around 26 per cent fewer people now getting help than did in the past.

Many care providers have gone bust due to downward pressures on fees and in many parts of the country it is very hard to recruit trained staff to work in care when the pay rates are higher at the local supermarket.

“It is very hard to recruit trained staff to work in care when the pay rates are higher at the local supermarket.”

Together these pressures contribute to older people being stuck in hospitals, unable to be discharged into the community because the support is not available to them.

Fixing social care

Getting social care right is not a quick fix. Access to good quality, affordable care for people with disabilities and older people is a challenging issue.

Continue reading ‘Get social care right and the NHS will benefit’


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