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5. SMARTER SCOTLAND: EARLY YEARS AND YOUNG PEOPLE

REDUCING HEALTH INEQUALITIES IN THE EARLY YEARS

Note: This paper was written and considered in advance of the publication of a joint policy statement by the Scottish Government and COSLA on early years and early intervention.

Overview

This paper considers the opportunities for reducing health inequalities that originate in the period from pre-conception to age 8. Inequalities that appear in this age range often have a significant bearing on outcomes in later life or are markers for later inequalities. This is one of the reasons the Task Force has taken a strong interest in early years.

Note that the paper refers to a number of specific projects or programmes. A Glossary is attached which explains the main features of these.

The Evidence

Biomedical research has progressed hugely in recent years and makes clear connections between stresses in the pre-birth period and during the early years and a range of health inequalities. A recent research review from the Harvard University Centre for the Developing Child states "science has shown that toxic stress in early childhood can result in a lifetime of greater susceptibility to physical illness … as well as mental health problems … and substance abuse". Such stresses can arise from a range of sources - poverty, neglect, inconsistent parenting, disease, violence, poor diet, poor housing, debt and exposure to harmful substances such as alcohol, tobacco and drugs.

At the same time, we have a developing body of UK and Scottish social research that provides some stark evidence of the early experiences of Scotland's children. Research tells us that young parents and those from deprived backgrounds in Scotland are much less likely to breastfeed or access antenatal care and that their children are more likely to have asthma, be subjected to tobacco smoke in the home and to have accidental injuries. The Millennium Cohort Study has shown differences in development of up to a year at age 3 and that this is closely linked to deprivation. There is strong evidence of inequalities being transmitted from one generation to the next.

Early Years Framework

In early years, health inequalities are closely linked to social and educational inequalities. The root causes of a range of inequalities are often common, as are possible approaches to improvement. This is the rationale behind the Government's plan to develop an early years framework that considers early intervention in a joined-up way. The themes for the framework have been agreed by Cabinet and were launched by Ministers during a debate on 31 October. The four themes are:

• Building parenting and family capacity.

• Creating communities that provide a supportive environment for children and their families.

• Meeting the needs of children and families in a holistic way.

• Developing workforce models to deliver this.

The Cabinet Secretary announced on 31 October that the framework would be taken forward in "full partnership" with local government and other partners. This has become a specific commitment in the concordat with COSLA that accompanies the spending review announcements. The thinking in this paper needs to be seen, in this context, as seeking views on the range of issues that might form the basis for initial discussions with our partners.

There is a strong evidence base that argues that early intervention is likely to have the best outcomes for children. A key principle in our approach is therefore that working in a preventative way to build resilience is more effective than intervening later once problems are already apparent. Indeed, some of the biomedical research would suggest that it is difficult if not impossible to overcome some types of inequality that appear in the first few years of life and that later interventions are often a form of managing problems rather than solving them.

The early years framework has a time horizon of 10 years in recognition of the scale of the change that is likely to be required to turn around some of the problems we currently face.

Current Policy

The bulk of children's services are delivered through the universal health and education systems. The universality of antenatal care, home visiting, immunisation and education services is a strength in that they have very broad reach and are generally non-stigmatising to vulnerable parents. It is important, though, that we consider how effective these services are at engaging some groups of parents and delivering the intensity of support that families with higher needs require.

At the other end of the spectrum, there are some very targeted services such as children and families social work, drug rehabilitation and services for looked after children that focus on families in greatest need. Such highly targeted services often have some stigma associated with them and can find it difficult to secure full engagement from parents.

Sitting somewhere in between is Sure Start Scotland, which provides a mix of universal and highly targeted services that often operate in a multi-agency way, with health often in the lead in the programmes that are regarded as most effective. The reach of Sure Start services can be fairly limited i.e. the services it provides tend to be based on small scale local projects that vary from area to area.

Our philosophy is therefore to build on the strengths of universal services in terms of their reach and relative lack of stigma, but to build into that system much better risk identification and more targeted support for those with higher needs. There is still very much a role for targeted services, but if we can create pathways to them via universal services then we can hope to improve engagement and uptake of additional support.

Some aspects of current policy are already moving in this direction. Health for all Children (Hall 4) is a surveillance, assessment and need identification tool which NHS Boards have been asked to implement as part of the universal service they provide to young children. If used properly, the expectation is that it will deliver access to more intensive support for those with greater needs, and one of our priorities must be to build on the progress made to date to make sure this is properly implemented.

A further development in a similar direction has been Starting Well, the national health demonstration project for early years. It aimed to demonstrate that child health in Glasgow, particularly in deprived areas, could be improved by a programme of activities that both supported families and provided them with access to enhanced community-based resources. It has been independently evaluated and showed some small positive effects to date, although the full impact can only be realistically evaluated in the longer term. There has also been a range of broader learning that has emerged from the project around home visiting, skills mix, operating in a multi-agency environment and the role of the voluntary sector. The demonstration period has now ended and a version of the approach mainstreamed in the form of local Parent and Child Together ( PACT) teams across Glasgow.

What Works In Reducing Health Inequalities

The Harvard research review identifies a number of approaches that can be effective in reducing inequalities in early years:

• High quality, evidence-based antenatal care that identifies risks early and takes effective action to deal with them.

• Schemes to improve maternal nutrition during pregnancy - there is a specific manifesto commitment in this area.

• Measures to alleviate poverty in families with young children e.g. tax credits, benefits, employability support, free or subsidised childcare. There is a manifesto commitment to increase the availability of high quality, flexible childcare.

• Measures to improve the quality of interaction between parents/carers and children in the very early years. High quality home visiting services and parenting programmes are a particular focus here, but reserved areas such as maternity leave and pay are also relevant.

• High quality, centre-based pre-school provision - there is a manifesto commitment to increase pre-school provision by 50% for 3 and 4 year olds.

• There is evidence that school education and the level of attainment is important in health outcomes.

• Targeted interventions/programmes for children at particularly high risk and effective risk management.

• Reducing environmental hazards.

There are also other areas such as immunisation against common preventable diseases where we can look to reduce inequalities. Overall immunisation rates in Scotland are adequate but there is scope to improve the rate amongst families in more deprived circumstances

Research reviews make clear that no single policy or approach has been shown to be a complete solution. We need to make progress in all these areas if we are to make a real impact on health inequalities and wider outcomes, and even then we should be wary of regarding early intervention as some kind of magic bullet.

There is good evidence that quality matters. For example the Nurse Family Partnership research closely links outcomes to qualifications of the home visiting staff. Similarly, the UK Effective Provision of Pre-School Education ( EPPE) study provided evidence of the link between the quality of pre-school provision and outcomes achieved. Poor quality services have reduced impact or can even make things worse.

Area-based programmes such as the Sure Start programme in England have struggled to help the most vulnerable, with more motivated parents at the top end of the income and educational scales benefiting most from services. In some cases, the relative position of the most disadvantaged became worse. The conclusion we draw is that area-based programmes are not a solution on their own, and that approaches based around individuals and families are probably the bigger part of the way forward.

The children's services reforms being taken forward through Getting it Right for Every Child are a critical component in joining up the many individual strands of policy that we can consider. This is because GIRFEC provides a unifying approach based around identifying and then meeting the needs of the individual child which will be critical in making a multi-agency approach to children's services work on the ground.

While universal services, and some health services in particular, are not regarded as threatening by vulnerable families, there is fairly clear evidence that there is plenty of room to improve engagement with families with higher needs. The evidence on the degree to which such services fail to engage parents suggest this should be an initial priority, as it would seem likely that there is a strong connection between this and lower rates of breastfeeding and other inequalities amongst younger mothers and those from more deprived backgrounds. There is also likely to be scope for improvement in the way services such as pre-school support and build capacity in families with higher needs, and for education services to promote parenting skills as children develop into young adults i.e. the parents of the future.

Finally, we need parts of the system that focus on specific age groups to work together to provide a continuum of care for children and families and to ensure key transitions are appropriately managed. There is strong evidence that we need to sustain the intervention for many families beyond early years. While we can hope to build capacity in some families to the point where it will be self-sustaining, for others the benefits will quickly fade out if we do not offer continuing support.

Children and families with higher needs

The groups that need particular attention if we are to address health inequalities that originate in early years are substance-misusing parents, parents who are in or have been in prison, mothers with mental health problems or learning disabilities, mothers suffering from domestic violence and mothers who have been in care. Child-related factors that would point to increased need of support include low birth weight, disabilities and being looked after. Poverty is often a pressing issue for many parents and children with higher needs. Some families suffer from a complex combination of these factors and others that are strongly associated with them, such as debt, unemployment and poor housing. It is often only by addressing these wider stresses that we can hope to build capacity and make a real difference to the quality of interaction between parents and young children.

There is evidence that outcomes for children of teenage mothers are markedly poorer and that these inequalities appear in pregnancy and the early years. Young mothers experience multiple source of disadvantage - they are more likely to live in low income households and more likely to live in the most deprived areas of Scotland. Young and poorer mothers were less likely to attend ante-natal classes, breastfeed, attend baby or mother and toddler groups, and more likely to find it difficult to know who to ask for help and to actually ask for such help. It appears that these inequalities are related more to deprivation and to education than to age i.e. it is not being young that leads to poor outcomes but that teenagers who become mothers tend to live in poverty and have poor educational attainment and it is these factors that are strongly associated with poor outcomes.

Nevertheless, if we take the preventative approach to its logical conclusion, we need to reduce the numbers of young women becoming pregnant, whilst supporting those who become teenage parents to maintain links with education and their local communities in an attempt to break the cycle of deprivation which teenage parenthood can lead to.

Priority Action

Based on the above analysis, the key actions would appear to be as discussed below. There are some important caveats to note here. In some areas the research evidence comes from the United States, where the health, welfare and education systems are very different. For example, there is no universal home visiting service in most of the US and pre-school entitlement also tends to be limited. Evidence from the US regarding the quality of services also needs to be treated with care as workforce structures and qualifications are not necessarily directly comparable.

There is therefore a need to test some of the evidence and assumptions in a Scottish context. Part of that process will be engaging a wide range of stakeholders in the debate through the process for developing the early years framework. It is also likely that further evidence and ideas will emerge through that process that we will want to incorporate into the framework. Until we have gone through that process, which will take place during the first half of 2008, the following priorities need to be considered as provisional.

First and foremost, we need a continuing focus on children's services reform through Getting it Right for Every Child. GIRFEC is the foundation for multi-agency working at the level of the individual child and the driving force behind a culture shift to see meeting the needs of the child in a holistic way as the key to effective service delivery. Given the impact of parenting and parental stresses on the quality of care and interaction with children, we should also start examining the practicality of moving GIRFEC to the family level. This will be extremely challenging as it implies adult services shifting their outlook to focus more on the impact on young children.

Closely related to this is the need for the different agencies that work with children and families to operate more closely in partnership. No single agency or programme can deliver on its own and some of the biggest challenges from pilot projects and other initiatives in this area are finding effective structures within which many public and voluntary sector partners can work effectively together. Without making progress on this at local level, chances of success are very low. It is possible to go further, as the early years framework will, to see meeting the needs of children and families as also involving a strong community dimension where there is a sense of collective responsibility for the welfare of young children.

Improving the ability of antenatal services to reach higher risk groups and improving the use of evidence-based approaches to identify and manage risks during pregnancy would seem to be an obvious initial focus. In 2004, an NHS Health Scotland audit found that the evidence of effective interventions to support the transition to parenthood was limited and uncoordinated. There is now a recognised need to maximise the potential for all maternity care episodes (face to face or otherwise) to be used as teaching and support opportunities for all women but especially those in the most vulnerable groups.

In addition, there is Scottish-based evidence that younger and more vulnerable women begin maternity care later and are much less likely to attend antenatal classes. This probably means much more use of outreach and one-to-one support for vulnerable women during pregnancy. There is a clear opportunity to link this to other initiatives such as improving nutrition during pregnancy and improving support for breastfeeding.

Implementing or piloting evidence-based parenting interventions such as nurse-family partnership ( NFP), Triple P, Webster Stratton or mellow parenting would also seem to be an area we should look at, as there is some evidence from studies in the US and elsewhere that these programmes can have positive benefits for parents and children. This might also look at combined parent and child programmes such as the Perry pre-school or Early Head Start models. NFP is being piloted in England and it may be that we can use evidence from that to make progress quickly. Similarly, Triple P and mellow parenting are being delivered in various places in Scotland, mostly through local Surestart programmes. What we need to decide here is whether to scale up one approach or, possibly more likely, set some national expectation that local partners will make available one or more evidence-based programmes from this list to families who meet certain criteria.

Given the role that wider issues such as housing, debt, poverty etc play in the stresses that impact on families with young children, we should examine whether we can create a holistic family support service that can deal with a wide range of issues that families face. A particular focus should be on providing a coherent set of supports for families with higher needs and especially those whose needs are multiple and complex. There may be a role for more children and family centres to provide a hub for a range of services that families need. There are a variety of different models of family centre and we need to look carefully at those, as well as whether co-location or more effective joint working using a more distributed model is the better approach. For the most complex cases, we may want to consider models based on the Dundee Families Project where families are assigned a key worker who provides often daily intensive support to the whole family and works to build a set of wider supports around them.

We need to make progress with implementing the commitment to extending pre-school entitlement but also examine earlier entry to pre-school for high risk groups. There is evidence from EPPE that an earlier start and longer duration of pre-school has benefits for disadvantaged children and we are running pilots in three local authority areas (Glasgow, Dundee and North Ayrshire) at present. Initial outputs from the evaluation study are unlikely to be available before Autumn 2008.

Looking at the early school age years, plans are currently being developed to increase the healthcare capacity in schools, harness existing skills and shape new roles. The approach here needs to be appropriate across the wider age range that school education provides for.

Perhaps the biggest shift we need to make is in the outlook of children's and relevant adult services. We need to move away from an old-fashioned view of delivering services to children and their families towards one that is focused on working alongside parents and children to build capacity.

Finally, we need to maintain a focus on reducing child poverty. This will partly involve working with and lobbying Whitehall departments on issues such as employment rights and tax credits. In terms of issues under devolved control, we need to continue to improve employability services for parents and underlying enablers such as affordable and accessible childcare. The Government will bring these issues together in a new anti-poverty framework for Scotland.

Resource Implications

There is likely to be considerable scope to change existing roles to achieve more in terms of health inequality, but some actions that we could consider would involve significant new capacity.

Some approaches such as group parenting programmes e.g. Triple P have relatively modest costs associated with them of a few hundred pounds per family (low thousands if delivered on an individual basis). Other options based on intensive one-to-one support from highly skilled practitioners such as NFP cost in the region of £5000 per family. Expanding pre-school services for two year olds costs £2500-3000 per child. Creating joint infrastructure such as family centres also involves significant costs, with evidence from England that the public funding for a typical family centre is around £400,000 per annum on top of initial start-up costs. We will be developing more sophisticated cost models as part of the early years framework, and all the above figures are based on historic costs that will increase over time.

There is evidence of a positive rate of return on some types of early years investment, for example the Perry Pre-school project showed a rate of return of 7 to 1 at age 27 when reductions in welfare payments, criminal justice costs and wider social costs in later life were examined. The Nurse Family Partnership model claims a 4 to 1 payback ratio but Early Head Start shows a rate of return of just 1.23 to 1. There is less evidence from a UK perspective of a positive rate of return from more generalised early intervention programmes, to some extent because fewer UK evaluations make that sort of calculation. It is important to reinforce one point here - prevention approaches will almost certainly not pay for themselves in the short run and will only do so in the long term through effective targeting and delivering high quality services.

A key issue will be the extent to which existing spend can be redirected in the short term and how high a priority early intervention is in comparison to other pressures.

Measures of Success

There is a range of measures that we could consider in the short term to measure progress. For example, we can track the degree to which higher risk parents access antenatal support, breastfeeding rates, admissions to A&E, infant mortality, low birth weight, childhood obesity, dental decay at age five and many more relevant indicators. The Growing Up in Scotland ( GUS) study provides a particular opportunity to track the developing health of a range of Scottish children and see the links between different behaviours, circumstances and child health. There are also options to develop sophisticated cross-sectional analysis through GUS.

The Chief Medical Officer has also suggested some more innovative measures based on stress hormone levels that are worthy of consideration.

In the longer term, measures of success are likely to be similar to those for health inequalities more generally.

Workforce Implications

The workforce implications of some of the priority actions identified above are potentially profound. Perhaps the biggest implications flow from two areas:

• Delivering a more holistic service.

• Moving to working alongside families and supporting the role of parents.

In moving towards delivering a more holistic service, there are a variety of workforce models we can consider. For families with higher needs, we may look towards key worker models, or an enhanced lead professional role. There may well also be merit in looking at a family care worker role at practitioner level which can work across health, education and social care services and which has particular expertise in supporting parents. A possible extension to this would be a Scandinavian-style pedagogue role at graduate level. We will still need to retain specialist roles in a number of areas, but they will need to be able to work within a multi-agency environment as enhancing the role of multi-disciplinary teams is also likely to be part of the picture.

The second point regarding moving to working alongside families is also challenging. In part, this could be about broadening the skills base of some key practitioners such as nursery nurses so that they are better equipped to support parents and parenting. It also suggest a much higher focus on skills related to engaging parents, particularly those with higher needs, across many parts of the workforce.

There may also be an enhanced role for the voluntary sector here, which has a good track record in engaging families with higher needs. They also have a good track record in delivering holistic models of support through the Dundee Families Project and a range of other projects. We need to think hard about our relationship with the voluntary sector if we are to give them a greater role.

External Views

We are at the beginning of a process of developing an early years framework which will give key external stakeholders the opportunity to work in partnership with the Scottish Government to refine our understanding of what works and what the priority actions should be.

The broad scope of the early years framework means that the process will encompass a very wide range of stakeholders, including all of those that would be considered stakeholders in health inequalities in early years.

Engaging with service users will be a particular priority in the coming months. Meeting their needs more effectively is central to the approach set out here.

December 2007

GLOSSARY

Sure Start

Sure Start Scotland is an early intervention programme for children in the 0-5 age range. It is managed by local authorities alongside partners in health and other services and the Grant-Aided Expenditure assessment is around £60m in 2007-08. It funds a range of projects including family centres, parenting programmes, early entry to pre-school and a range of other supports for young children with a focus on integrated multi-agency approaches. Two mapping exercises have been carried out but there has never been an outcome-based evaluation done on the programme because of various factors including the lack of a baseline.

Sure Start in England is constructed as an area-based intervention for young children, with more centrally-directed elements. It is the subject of a very large evaluation study that to date has found that the programme's impact has been quite limited, with some of the most vulnerable families actually finding themselves relatively worse off.

Bookstart

Bookstart was the first national baby-book-gifting scheme in the world when it began in 1992. Bookstart works with libraries, health visitors and early years professionals to give the gift of free books to every child at around 2 months, 18 months and 3 years old, along with guidance materials for parents and carers. Bookstart seeks to promote the importance of books and the benefits of early book-sharing, such as parental bonding and promoting emotional intelligence, as well as building good communication and listening skills, and helping to lay the foundations of early literacy. The Scottish Government provides £1,050,000 to Bookstart in Scotland for financial year 2007-08.

Starting Well

Starting Well is the national health demonstration project for early years. Phase one of the project (2000-2004) focused on intensive home visiting support to all families with new-born babies in two deprived communities in Glasgow. In Phase 2 (2005-6) the universal service provided in the two areas moved to a targeted approach to those most likely to gain from the interventions. Support was provided by a skill mix team comprising health visitors, lay health support workers, nursery nurses and a bilingual worker and included a parenting education programme (Triple P). The strengths of the programme include the use of home visiting as this is convenient for families and creates a "power shift" between parent and professionals. Health Visitor-led skill-mix teams were valued by families and professional teams. The employment of health support workers from the local community through a voluntary organisation led to many benefits, for example then families greatly valuesd the contribution of these lay workers to their emotional and practical support.

Nurse Family Partnership (also known as the Olds Model)

NFP is a home visiting programme set up by Professor David Olds at the University of Colorado. It targets low income, first-time parents and their children. The home visitors are highly educated registered nurses who receive more than 60 hours of specialised training. The visiting programme starts no later than the 28th week of pregnancy and goes on for a total of 2_ years involving 64 visits to each family. Visits last, on average, 75-90 minutes and nurses have a case load of around 25. Published research findings show that NFP mothers are less likely to abuse or neglect their children, have subsequent unintended pregnancies, misuse alcohol or drugs; and are more likely to maintain stable employment and reduce dependency on welfare. 15 year follow-up studies show 50% lower arrests, 80% fewer convictions and significantly lower substance abuse and sexual activity.

Triple P

The Positive Parenting Programme is a family intervention model developed in Australia. It is used by a number of public agencies in Scotland, usually as part of health or Sure Start programmes. It is a multi-level programme with 5 levels of intervention based on the needs of the family. These interventions include a universal population-level media strategy targeting all parents, two levels of brief primary care consultations targeting mild behaviour problems and two more intensive parent training and family intervention programs for children at risk for more severe behavioural problems. Triple P has a strong research base covering a variety of variations on the core model including self-directed versions for use in remote areas.
http://www.triplep.net/files/pdf/Parenting_Research_and_Practice_Monograph_No.1.pdf

Solihull/Mellow Parenting

The Solihull Approach is an integrated model of working for professionals who work with families with emotional and behavioural difficulties. It has been successfully used by a wide range of professionals around the UK in their individual and group work with families. The model brings together three well developed concepts, which are Containment from Psychoanalytic theory, Reciprocity from Child Development and Behaviour Management from Learning Theory. The mellow parenting course which is based on the Solihull approach has a good research base and is used by several local authorities in Scotland.

Webster Stratton

This is a parenting programme that teaches positive parenting skills such as anger management and which teaches children key social skills such as empathy and conflict management. Delivery is via group work modelling, including discussion and role play, bolstered by home-based activities and support for parents. It includes several individual programmes. Rigorous evaluation has shown effectiveness in addressing a number of parent and child outcomes but that these are less effective when individual elements are used in isolation. A UK-based study of the Incredible Years part of the Webster Stratton programme found reduced antisocial behaviour but that children were still experiencing peer relationship difficulties.

Perry Pre-School

This was a US programme from the late 1960s that combined high quality pre-school education for 3 and 4 year olds with weekly home visits to families by trained teachers. These visits reinforced the curriculum and provided support for parents to engage with their children in cognitively and socially enriching activities. Although the programme could not establish the unique contribution of the parent component, it demonstrated long term benefits in school performance, fewer special education placements, higher rates of qualification, reduced teen pregnancy, higher rates of employment, and lower rates of juvenile crime and adult arrests.

Early Head Start

Several different models of Early Head Start have been trialled in the US. A national evaluation looked at a model that combined intensive family support services with centre-based childcare and education from birth to 3 years. It found small effects on cognitive, social and emotional development, as well as several areas of parenting and economic self-sufficiency. Some individual programmes performed better by enrolling parents earlier and implementing rigorous performance standards.

Dundee Families Project

The Dundee Families Project is operated by NCH Scotland with funding from Dundee City Council and works with families who have lost or are about to lose their tenancy as a result of anti-social behaviour. Many families have a complex combination of problems and are supported by a key worker who builds a range of supports around the family, looking at the various stresses that may be having an impact in a holistic way. Some families are housed in a core block where they are in close proximity to their key workers while others are supported in their existing home. Case loads are very low - around 4 families to each worker - and the support lasts for an average of around 2 years. Evaluation to date has been relatively informal but has shown a range of positive outcomes. A version of the project opened recently in Aberdeen and several sites using a similar model are now operating in England.

Child and Family Centres

Child and family centres are community-based centres which provide a range of services for parents and young children in the 0-5 age range. Services often include pre-school, childcare, parenting groups and classes, healthcare and advice services. They are usually targeted at disadvantaged families and located in areas of concentrated deprivation. They are normally operated by local authority education or social work departments. There are approximately 120 child and family centres in Scotland. In England, there is a massive programme of investment in Sure Start Children's Centres, with a target of 3500 centres by 2010.

REDUCING HEALTH INEQUALITIES AMONG YOUNG PEOPLE

Context

1. The recent OECD report on the quality and equity of schooling in Scotland found Scottish education to have many strengths. Scotland performs at a consistently very high standard in the Programme for International Student Assessment ( PISA). Few countries can be said with confidence to outperform it in mathematics, reading and science. Scotland also has one of the most equitable school systems in the OECD. Only a very small proportion of Scottish 15 year olds are assessed in the lowest bands of performance. Headteachers are amongst the most positive of school principals in the OECD in judging the adequacy of staffing and teaching resources, and students are generally very positive about their schools. Underpinning the impressive international performance of Scottish schools is a system of near-universal and high quality pre-school education.

2. However, the report also recognised challenges. One major challenge facing Scottish schools is to reduce the achievement gap that opens up about Primary 5 and continues to widen throughout the junior secondary years (S1 to S4). Children from poorer communities and low socio-economic status homes are more likely than others to under-achieve, while the gap associated with poverty and deprivation in local government areas appears to be very wide.

3. Little of the variation in student achievement in Scotland is associated with the ways in which schools differ. Most of it is connected with how children differ. Who you are in Scotland is far more important than what school you attend, so far as achievement differences on international tests are concerned. Socio-economic status is the most important difference between individuals. Family cultural capital, life-style, and aspirations influence student outcomes through the nature of the cognitive and cultural demands of the curriculum, teacher values, the programme emphasis in schools, and peer effects. The geographical perspective that national data afford also show that deprivation intensifies the effects of family socio-economic status and of a predominantly academic culture in schools through the concentration of multiple disadvantages in schools serving poor communities.

4. The Task Force's approach is to get behind the causes of health inequalities and as such they are interested in reducing inequalities in life circumstances and addressing underlying issues of poverty and deprivation. In this context, education plays a key role in building capacity and resilience in individuals and communities and preventing future health inequalities. This paper outlines relevant current policy and action and identifies routes forward.

Current Policy and Action With an Impact on Health Inequalities

5. Current work to develop a strategic approach to young people and in particular Getting it Right for Every Child ( GIRFEC), the More Choices, More Chances Strategy, the reform of education from 3 to 18 under the Curriculum for Excellence programme and the Early Years Strategy should act to address underlying issues of poverty and deprivation and thereby health inequalities.

6.GIRFEC provides the framework within which all services will deliver a personalised, effective response to young people. In bringing together GIRFEC, Curriculum for Excellence and other key strategies we will: improve the delivery of opportunities and support to all young people, identifying priorities and gaps and working with partners to fill them; promote awareness and understanding of the rights of children and young people and encourage them to take individual responsibility for ensuring the best outcomes for all young people; and ensure young people at risk can access the support and opportunities they need.

7. In terms of health inequalities the most significant policy is the reform of Scottish education from age 3 to 18 under Curriculum for Excellence. The outcomes that are being sought through this programme are very much in line with the approach that is being taken by the Task Force and also reflect one of the fifteen national outcomes agreed by the Scottish Government and COSLA in November 2007. Specifically, Curriculum for Excellence is about providing the best possible education for all our children and young people, wherever they are being educated, to help them become successful learners, confident individuals, responsible citizens and effective contributors.

8. It is important to note that Curriculum for Excellence is not about a national curriculum that is imposed through central guidance. It is about changes to learning and teaching, being less prescriptive in terms of content but having a strong focus on understanding and transferability of skills. In particular Curriculum for Excellence will ensure a focus on literacy and numeracy and skills for life, skills for work and skills for learning. It will also have Health and Wellbeing as one of eight groupings of experiences and outcomes.

9. In terms of literacy and numeracy, there will be separate curriculum outcomes in these areas and reinforcement across the curriculum with every teacher having the responsibility of promoting numeracy and literacy from age 3-18.

10. Young people need skills for life, skills for work and skills for learning to play their part in a global economy where the prevalent constant is rapid unpredictable economic and technological change. An ever increasing proportion of jobs are likely to be found in highly skilled areas so there is a focus on raising the bar in terms of academic attainment. Education also has a role in helping to engender a culture of resilience, self-reliance and inquiry founded on an expectation of lifelong learning and retraining. Individuals need to be equipped to move between jobs and industries and this is also reflected in the skills strategy to "place the individual at the heart of learning and skills development". Skills for life, skills for work and skills for learning will be delivered across the curriculum.

11. The Schools (Health Promotion and Nutrition) (Scotland) Act places a legal duty on Scottish Ministers and education authorities to endeavour to ensure that schools are health promoting. This new duty is a key driver for change in health inequalities. It places health promotion at the centre of school education, with a whole-school approach to promoting the physical, social, mental and emotional wellbeing of all pupils. The guidance for the health promotion duty will/has be/been released at the same time as the draft outcomes and experiences for Health and wellbeing, one of eight groupings of experiences and outcomes in CfE. They cover learning in mental, social, emotional and physical health to promote resilience, confidence, independent thinking and positive attitudes and dispositions. The framework for curriculum design will make it clear that health and wellbeing is both a whole-school issue and a curriculum area its own right and because of this a range of people will be involved in the delivery of the experiences and outcomes. Taken together, the Health and Wellbeing outcomes and experiences, and the Health Promotion Guidance will describe the expectations for promoting the health and wellbeing of children in school.

12. The Act also places duties on Local Authorities to: ensure that food in schools complies with nutritional regulations; promote the uptake of school lunches and free school lunches; and protect the identity of pupils receiving free school lunches. These duties will commence in August 2008.

13. There is a dedicated More Choices More Chances project within Curriculum for Excellence which provides a rigorous challenge and proofing role across the programme to ensure that proposals will meet the needs of all young people, including those in need of 'more choices more chances'. In this way we are proofing the programme in relation to underlying issues of poverty and deprivation.

14. The transformation of the education system through Curriculum for Excellence therefore provides a strong vehicle for improving life outcomes for ALL young people, increasingly enabling schools to work effectively with partners, including young people and families, to provide more engaging and personalized learning both in and out of school, for example through youth work and volunteering and to provide the support that may be required to engage with learning. In doing this, it will help us to meet the concerns raised in the recent OECD report on quality and equity in schooling in Scotland.

15. In addition there are a number of other key policies relevant to reducing health inequalities. The Additional Support for Learning Act (2004) supports early intervention and a personalised, approach to additional support needs, in order to address inequality and promote positive outcomes for children and young people. Under the Additional Support for Learning Act education authorities have a duty to establish procedures for identifying and meeting the additional support needs of every child for whose education they are responsible. Other agencies such as Health Boards are under a duty to help an education authority meet their duties under the Act if requested to do so, unless of course it would be incompatible with their own statutory duties or unduly prejudice their ability to carry out their functions. A child may require additional support for a variety of reasons. These may include those who are being bullied, are living with parents who are abusing substances, are living with parents with mental health problems, are on the child protection register, are young carers have experienced a bereavement, or are not attending school regularly, as well as those who have behavioural or learning difficulties, mental health problems, or specific disabilities such as deafness or blindness.

16. Home-school link workers play a valuable role in supporting vulnerable and hard to reach families to engage with education services. They promote Inclusion and Social Justice by providing specific services such as home visiting, individual support and advocacy to vulnerable families. For example, home-school link workers provide workshops for pre-5 centres and primary schools in literacy and numeracy and provide packages of support for family literacy and numeracy which support engagement with education and link with the school health resource, with family planning services, and community health services to ensure that those at risk get continuity of support from family to community to school.

17. The Scottish Schools (Parental Involvement) Act 2006 introduced a new framework to assist parents to support their children's learning at home and in school, to strengthen home-school partnerships and to give parents a stronger voice in school education. Education authorities are required to prepare a strategy that sets out how they will support all parents to be involved in their children's learning. The Scottish Government has provided a practical toolkit which includes examples and activities to help schools and parents strengthen home-school links and to make the most of their community. The Parentzone website also provides information for parents aimed at promoting healthy eating, fitness and emotional health and wellbeing.

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