 I think that the last meeting in 2014 of the Health and Sport Committee. As usual at this point, I would ask everyone in the room to switch off mobile phones or other wireless devices. They can sometimes interfere with the sound system of course and can also disturb the meeting. I should also ask those attending to know that some members and officials are using tablet devices, which is instead of the hard copies of their papers. I have apologies this morning from the net milling, and I welcome Jackson Carlaw once again as the Conservative Party substitute. Our first item on the agenda today is our inquiry into early years, which is part of a theme work on health inequalities. I welcome to the committee Sir Harry Burns, Professor of Global Public Health University of Stath Clyde. Welcome, once again, and also Professor Michael Marmot, University College London Institute of Health Equity. Welcome to you, both gentlemen. I offer you the opportunity to make a few brief remarks. Professor Marmot. Thank you. Firstly, if Harry Burns is an adequate reflection of what's happening in Scotland on health inequalities, then Scotland leads the world, so you don't really need me because you've got Harry Burns, and certainly his views and mine accord very well. If I could just, by way of introduction, make a few brief points. The first is that when people think about health inequalities, commonly they think about the health of the poor, and indeed the poor do have poor health. That's part of the story, but the real challenge for all of us is the gradient. The fact is that people near the top have worse health than those at the top. People in the middle have worse health than those near the top, and that applies to every marker of good early child development, given that we're talking about children. If you look at children's physical development growth, look at children's cognitive development, linguistic development, social and emotional development, it's a gradient. Look at performance in school by the socioeconomic characteristics of their parents, or the area in which they live. It's a gradient. The lower the socioeconomic level, the worse the performance. I would say that looking at the UK, Scotland and England and Wales and Northern Ireland, we do pretty badly globally among OECD countries in markers of early child development and school performance, which means that if we want to do better globally, we've got to address not just the poor performance of those at the bottom, we've got to address the gradient. I was in Sweden last week, I could probably say that almost any week, the Swedes are very enthusiastic, and a Swedish television interviewer said to me, last time I interviewed you, you told me a story about an economist in Her Majesty's Treasury. When I showed him a graph of the gradient, he said, and the Swedish interviewer remembered this, oh don't come to me with that Scandinavian nonsense, we're Anglo-Saxons here, he said, we focus, in fact he was Irish-Jewish, but never mind. We focus on the worst off, he said, that's the default position of British social policy, we focus on the worst off, and this Scandinavian nonsense is not for us. She said, is that still the case? Well, and this is my second point, we're trying to get the message of proportionate universalism across, and by that I mean, the gradient suggests that we need universalist policies, policies for everybody. A health service for the poor is a poor health service, an education system for the poor is a poor education system. What we want is people to have the entitlements to be part of the mainstream, to bring people in to universalist systems, would be at education, health care or society in general. But we may need to have effort proportionate to need, and hence the proportionate universalism. In the health service we don't spend the same amount of effort on everybody, I'd be perfectly happy if despite paying tax all my life I never used the health service. I feel that would be a great deal because meant I was well, but if I had diabetes and dementia and peripheral vascular disease I'd want a lot of expenditure of the health service, and it's a universal service, we expend proportionate to need. So the first is the gradient, the second is proportionate universalism. The third point I wanted to make is, well what can the health service do? If you're a health and sport committee what can the health service do? Given that the key drivers lie outside the health care system of good early child development and child health. And we produced, my institute of health equity produced a report asking the question of what can health and medical organisations do? And we suggested there were five things education and training, treating the patient in his or her broader context, so you'd have just hand out the pills to the person in front, you recognise the broader context that brought them there. The third is the health service as employer and related to early childhood of course that relates to the work-life balance. The fourth is working with others, partnership working, and again for early childhood that's key, working with other services who have as their main domain early childhood. And the fifth is advocacy. As a doctor, I'm a doctor, I've taken the line going back to Virco in the 19th century, doctors are the natural attorneys of the poor and we in the medical profession should be the advocates for improved conditions that will improve the conditions of the worst off. If I may, the fourth thing I want to say is the importance of monitoring. I think monitoring is absolutely vital and I know in Scotland you understand that very well and are leading the pack in developing good monitoring. We in the institute of health equity for example were commissioned to produce a report on monitoring in early childhood and we said you've got to monitor the children, early child development, parenting, the parents, parents with mental illness with little education themselves and so on that influences their ability for good parenting and fourthly the context in which parenting takes place. I've been looking at child poverty before and after taxes and transfers. If we look at OECD countries in Europe in the United Kingdom we have I think the highest pre-tax child poverty level where poverty is defined as less than 60% median income. Post tax the figures are really very interesting if you look at a country like Sweden and Latvia pre-tax their child poverty levels 35% in Latvia, 32% in Sweden. Post tax Latvia is 25% child poverty Sweden is 12% regrettably the United Kingdom looks more like Latvia than it does like Sweden. Slovenia not a rich country has even lower child poverty levels than Sweden post tax. Ours are above 20% after taxes and transfers so that decision by the Chancellor, Department of Work and Pensions, is affecting the quality of early child development. What the Chancellor does probably has more impact on the quality of early childhood than what the Minister of Health does. And the last thing, if I may, I made a pilgrimage to a finished school. I'm not the first to go and pray at the shrine of finished education. Question is why does Finland always do best at, in the PISA scores, the programme of international student assessment of any European country, not quite as well as Korea and Shanghai, but the best of the European countries. What are they doing? And what they do in the schools is very interesting but one of the key points the head teacher made to me is you cannot divorce what goes on in the school from what goes on in the wider society. She argued that finished schools do really well with relatively small social gradients in outcome of education because this is a reflection of finished society. This is a way of saying that if you want to improve early child development and inequalities in early child development, you need to look to the wider society. It's not a matter simply of having technical interventions. I hadn't intended to make any opening statement because I think that colleagues around the table know exactly where I'm coming from. I've spoken about this before. But just to make a couple of points, the first thing to say is that 20 years ago when I was first appointed director of public health in Glasgow, one of the first people I went to see was Sir Michael because, and ever since then, he's been scientifically the fount of terrific advice for me and I think where I've got to owes a lot to the work that he's done over the years. I think in the last few years where we have moved ahead in Scotland has been in methods for change. I now find myself also going a lot to Scandinavian countries, to Southern European countries because they are really interested in how Scotland is beginning to tackle the problem. The realisation really came from the fact that while lots of studies have shown specific indicated specific issues that needed to be changed, the method for change has always eluded us. We still think in terms of a machine metaphor here that there is a lever you pull here that makes everything all right over there and society ain't like that. It's a complex system and it needs different ways of dealing with it and what we have adopted is a very inclusive approach that we've borrowed from improvement science that has worked so effectively in the patient safety programme. It's not the finished article. I wouldn't claim that what we are doing is absolutely perfect but the point is that it's been co-produced across the whole of the system. Sir Michael has just said that he cannot divorce, he cannot identify a single issue that is the cause of the inequalities problem that we have in early years. We need to be tackling the complex system that is society. That means parenting, it means supporting parents who really don't know how to be parents and helping them understand the way ahead. It means giving young people who become alienated from school. I mean I keep going on about the fact that young people who have difficult early lives have a much higher risk of mental illness, they have a much higher risk of behaviour problems, so what does our school system do? We exclude them from school, completely the wrong thing to do. Alienation throughout life, the young people who become excluded from school have a high risk of going to jail, they have a high risk of never working again and throughout life we need to take a life course view, we need to take a pan societal view that allows younger people to grow and to remain integrated and to be part of society. So we have adopted an approach that seems to allow us to begin to co-produce with other agencies in society and with people themselves and communities the solutions to some of these problems. I know from reading previous minutes of the committee that people are anxious to know is it working, are things moving in the right direction. Well it will take some time, but what we mustn't do is chop and change. If we feel that we're on the right track, we need to stick with it. Some years ago I helped a colleague in Glasgow go off to America for a year with a Heartless Fellowship and he examined a lot of the early years programmes that had been set up under President Johnson who had a big interest in early years. What he said was that the early years produced very significant improvement, early years interventions like preschool education on produce very significant improvements in outcome, but most of those improvements weren't obvious until the children were in their mid teens. By then they were not getting drunk, they were not getting involved in crime, they were staying on at school, they were finishing high school, they were getting into jobs and the return on investment began to rack up at that time. Now again I would argue that economic reasons aren't the prime reasons for doing this, this is an issue of justice and fairness and doing the right thing because it's the right thing to do, but the fact is it makes sense for everybody in society to support this kind of approach. So I would claim that we're ahead of the game in Scotland in terms of our approach to this with things like the early years collaborative. We need to build on that and extend it and the Scottish Prison Service are using some of these techniques in Pullman and so on, where they now call Pullman not a young offenders institution but they're trying to see it as an educational establishment which I think has to be a great leap forward. We need to join up all the good work that's being done and make a movement out of it and I, my previous job in the civil service did not allow me to advocate to be an advocate in the traditional sense of the one but that's what I'm going to do now, advocacy for this kind of approach. Thank you, thank you both. I think our first question is from Richard Lyle. Thank you, good evening, good morning and a welcome handig thee with all the comments you've made at the end of the day. Whilst the state shouldn't be a big brother we could actually start to help people as their children are born and educate them right through the system and in fact I would say what we do for our children today affects their future tomorrow but can I turn to the point and Professor Marmot touched on it and in his six points and basically one of the points you made in regards to child poverty. Child poverty action group has estimated that over 100,000 children in Scotland may be pushed into poverty as a result of UK welfare reforms. You actually said in October last year that the UK was failing too many of our children, women and young people on a grand scale and that in the UK we have chosen to have a relatively high children child poverty rates and you went on about the Chancellor in your opening statement and you said it was a policy choice. What do you believe are the policy choices that have driven this increase in child poverty and what do you expect to happen in the coming years? Well the policy choice, the reason I referred to these comparisons among OECD countries, by saying that some countries are clearly intolerant of high levels of child poverty, I mean there are no countries that get below 10 per cent, I mean that's kind of statistical if it's less than 60 per cent median income it's unlikely that you'll have a distribution of zero with no child poverty so the lowest is Norway with 10 per cent after taxes and transfers but that's a benchmark that's something we could choose to do. We could choose in the United Kingdom in Scotland and England and the other parts we could choose to be more like Slovenia. Well what a name. We should be like one of the fractured bits of the former Yugoslavia in terms of our social and economic policy. Now I mean I won't go into all the details, you probably know them better than I, but I mean if you look at the data from the Institute of Fiscal Studies on the changes to the tax and benefit system by desiles of income the top desile gets a drop because the 50 per cent tax rate kicked in and now it's 45 per cent but gets a drop but for every desile below the top one the lower the starting income the greater the decline in income as a result of the operation of the tax and benefit system that is a political choice that's a political choice so it's a choice that's been made that the worst of should suffer more in terms of percent decline and that the lower you are the greater the drop that's a political choice and I've been very careful never I think to make party political comments in public I analyse the data I analyse the evidence and I point out that's a political choice now if the Chancellor says I'm very happy with that choice that's my choice and that's the way I choose to do it absolutely fine but I feel the responsibility to say that will damage our children and talking in the US I showed them the figures in the US the US after taxes and transfers is worse than Latvia in terms of child poverty and I looked at seven thousand public health people that I was addressing at the American Public Health Association I said you live in a democracy democrat republican I couldn't care less this must be the level of child poverty you want otherwise you'd elect a government that did something different you're damaging the next generation and it's got worse so that's what I mean by political choices this is a political choice when I heard the prime minister say over the floods money is no object and I thought why wouldn't he say that about child poverty floods are terrible but so is child poverty child poverty is like a flood it's like a natural disaster and we could take government action to reduce it and I think arguing from a health point of view we should so you're neither a democrat or a republican um what different policy choices would you make to reverse this change the the theme running through the three reviews that I've done the WHO commission on social determinants of health the marmot review of health inequalities in England and now the european review of social determinants and health divide is to put health equity at the heart of all policy making the filter I would run over all policy making is the impact on health equity people have asked me in a way like you've asked me um what would you do if you were chancellor of the exchequer and I said I think it's a great benefit to the people of Britain that I'm not chancellor of the exchequer and I'm really pleased that I'm not so I can argue that let's put the likely impact on health equity at the heart of all policy making and if something makes child poverty worse I wouldn't do it I would actually run that filter over my policy making and make sure that nothing that I did would make child poverty worse well to absolutely agree with what Sir Michael has said but to make the point that this isn't just about equity in health this is about equity in attainment we've had the publicity about differential attainment at school if we really want a future generation to be delivering intellectually to be innovative to be creative and so on we've got to give them the best start in life and and the damage that is done we know from the studies that we've carried out in Glasgow but have been carried out internationally the damage that is done is physical damage that limits the capacity of young children to learn and to behave appropriately in complex situations very powerful evidence for that the more adversity that young children experience in early life the more likely they are to become alcoholics to become drug addicts to become violent and so on cast iron longitudinal studies why would we not want to prevent that happening so it's it's we're talking about health today but this is across the whole of society that we would benefit and in Victorian times it was often said that that major public health interventions only really occurred when the children of the rich were being damaged you know the damaged by the the infectious diseases and tuberculosis that gave the people at the top of the social tree a reason to be concerned well I think across the whole of society we're all losing out because talent and ability in young children is not being given the opportunity to flourish so we should be concerned thank you we've had quite considerable evidence and you know written evidence to to us about the policy of rich agenda that we have but the poor delivery I think it's you know why haven't we delivered the supposed as a question we we see from the papers and recent news this week that looked after children in Scotland has increased by 49 per cent since 2001 we see that children on the child protection register has flatlined since 2008 in Scotland and the UK has got the worst rates of excess child mortality in western Europe and Scotland is even worse how do we use this proportionate universalism to create action in these areas because you know we're talking about children dying of poverty on the child mortality figures recently just last week you know so you know between that and that gradient you know I hear what you say that there's got to be a broad thrust here but how do we stop and change those figures that have been present since I've raised them in 2009 I was I showed a I gave evidence in in Westminster in the parliament following my English review and I showed a graph we've been monitoring early child development but it would be harder to do for mortality because even though our figures are shockingly bad happily there's still not many child deaths so you can't monitor at local levels because there aren't many child deaths but monitoring early child development looking at the degree of deprivation of the local authority it shows the gradient so you plot 150 local authorities graded by degrees of affluence or deprivation and you see the proportion of children age five classified as having good level of development goes up progressively the more affluent the local authority and some sportsmen in the audience not a member of parliament said the proportion of variants explained in that graph would be quite low and I thought it's just what members of parliament want to hear about a discussion about multiple r squared in correlations so I tried to translate his comment into English what he was saying was that there was spread around the line and the reason I'm making a point of this is it suggests there has to be two strategies the first is flatten the socio-economic gradient the degree of inequality social and economic inequality is very large and child development follows that gradient in social and economic circumstances so bring the social and economic circumstances the worst off up towards the middle and you'll flatten the gradient in early child development but the second strategy given that there's variation around the line it suggests for a given level of deprivation some local areas are doing better than others uh-huh that's very important I went to Birmingham and Birmingham's been a bad news lately early child services but I went to Birmingham because they had they told me six marmot champions one for each of the six domains of recommendations I made in my review and I got out their figures on early child development Birmingham is more deprived than England on average and their early child development scores are worse than England on average and over three years they completely closed the gap between Birmingham and England now they didn't close the gap in deprivation in three years but they closed the gap in early child development so it suggests two strategies one is it's going to be very hard for Scotland or the rest of the united kingdom to catch up as long as we have the level of social and economic inequalities that we have and the getting worse we were talking everywhere I'd been lately I talk about Piketty's book on capital in the 21st century it's getting worse in France it's getting worse in the United States it's getting worse in the UK not in all countries but inequalities are getting worse and it's going to be very hard for Scotland England Wales Northern Island to make progress in the face of that increasing inequalities but there is a second strategy which is take the best evaluated programs and there are good evaluated programs that really do improve early child development and we've not been doing that systematically I don't know the Scottish scene but I do know in England sure start centres have been closing sure start children's centres have been closing local authorities are a strap for cash I was in Newcastle recently they're not despondent they're trying to make do with the hand that they've been dealt but when they're dealing with 24% cuts local authority they said very soon the only things we'll be doing in Newcastle are those things that we for which we have statutory responsibility and nothing else I was in Manchester they're giving me the same story again they're doggedly pushing on but in the face of huge cuts so to start closing sure start children's centres in the face of increasing inequality social and economic inequalities it's not a mystery why we're not doing as well as we might so Professor Bulls yeah I think we are doing a lot through the earlier's collaborative family nurse partnership positive parenting plan very much focused on young teenagers having children and this whole philosophy of nobody wants to be a bad parent they just don't know how to be a good parent is is at the heart of a lot of these interventions so I think we're managing to maintain that at the moment and we will I think in the course of the next year begin to see significant impacts on markers of child development I hope that's the case I think there is a much broader you know you ask why have we not made a difference I think there's a number of reasons the first is that the analysis of inequalities has moved on a lot over the past two or three years if you define inequality in economic terms then you automatically assume that the solutions are economic and it's no doubt part of the solution is but to make sure that you tackle child poverty is necessary but not sufficient on its own there's a whole set of cultural things that we have to do differently Jerry Hasson's new book talks about Scotland's problem as empathy lack of empathy and connectedness and so on the analysis that the Glasgow centre for population health has done in its comparison of Glasgow Liverpool in Manchester the three cities are the same in terms of inequality and average income but they differ significantly in terms of their causes of premature death and the one set of indicators that is completely different between the three cities are indicators of empathy and connectedness Glaswegians are far less likely to trust their neighbours we asked them a thousand people in each city if you lost a purse or a wallet did you think that it would be handed in by your neighbour and you're far less likely to say yes in Glasgow than in Liverpool or Manchester and I went down you know Glaswegians are far less likely to be a member of a club they're far less likely to volunteer they're far less likely to go to church they're far less likely to be part of a community a definable community and I one of my close friends in public health at the time was the director of public health for Liverpool and and then facture lived in Manchester so she knew the two cities well and I presented these figures to an immediately a response was ah well that's easy to understand because people in Liverpool feel well supported there was a fundamental difference in the in the sense of community in Liverpool and since then I spent a lot of time in Liverpool I'm a visiting professor at one of the universities in Liverpool and there is no doubt there is a palpable difference in terms of the sense of community and when you ask them how did that come about amazingly one of the things that they hear often was the leadership produced by the churches particularly archbishop shepherd and archbishop warlock there's a statue in the centre of Liverpool two statues of these two men and they're holding their hands out to each other and there's footsteps in the pavement alongside it and every time you go past it someone is standing in those footsteps with these two men getting their photograph taken the other way it's described to me is well Liverpool and Everton supporters are really good friends actually they don't care who beats Manchester United there is a sense a stronger sense of community down there than there is in some of the parts of Scotland that we see so part of this challenge is not just about pulling a set of policy levers but it's about creating a sense of community and a sense of compassion for people I listened to a marty ascend a well prize winning economist give a lecture a couple of months ago and the lecture was entitled poverty and the toleration of the intolerable and his analysis as to why societies like India and so on tolerate extremes of poverty was not because there was nothing they could do about it there's plenty they can do about it not because they didn't care about it but because the middle classes didn't understand how destructive policy was we lived with people we know they're poor but we don't actually well they get free schools and we get a free health service and all that kind of thing so that can't be that bad well what his argument was yes it is very destructive and we have the evidence that shows extreme poverty changes the way baby's brains develop it's as definable as that we now have evidence that shows that chaotic early life changes the way genes are expressed the whole science of epigenetics is beginning to throw up how the seeds of chronic disease in later life are laid down not just by the your experience as a child but by your parents experience as a child big studies in Scandinavia that show that adverse nutritional circumstances in grandparents at the turn of the 19th to 20th century are still being shown in the grandchildren so the biological consequences of social adversity are defined and profound and the way to deal with that is to deal with the social adversity and we don't just deal with the social adversity by changing the way taxes are distributed necessary but not sufficient we need to go much further and change the ethos in our society you go to places like hollandon no doubt allen will talk about this later you go to places like Scandinavia their attitudes to children are completely different they don't exclude children from school my daughter who spent a year before going to university she spent a year teaching in a school in spain every morning her five and six year old children would line up at the end door of the classroom and give her a kiss and a hug before they went into class culturally teachers would run a mile from that kind of thing here we do not show children care and empathy and it's high time we did i look forward to that future discussion and biology and genetics at the committee here we'll go there but it does seem to to indicate that health is important because we're going to be dealing with mitigation for a long time rather than the game changer you know so the health service runs very hard and fast to deal with the consequences of inadequate investment in children you know we've spoken my last time i was down here it was with the audit committee who were looking at the auditor general's report on the way the health service puts money into health inequalities health services spending tons of money dealing with the consequences we need to spend our money more wisely in early years and that way i mean how i looked after child someone was telling me recently for an academic from england he said that i looked after child will cost society about £2 million by the time he's reached his 20s in terms of a variety of things like the consequences of offending the consequences of mental health and so on we've got far too many looked after children as a result of dysfunctionality in families where the parents don't know how to be parents roda grant followed by bob doros my question i guess follows on quite well from that it's about i mean i'm listening to what you're saying about all the different aspects involved in this but about parenting i suppose is the one where we're talking about kind of social and economic issues being really important but i think it was professor marmot who said that actually you know parenting can be important but then if the curve goes like that is that saying that people with more money are better parents you know where does this all fit in i guess and how do we how do we tackle parenting for people maybe second or third generation who have never had experience within their families of parenting and i suppose added on to that sorry i'm kind of coming out with a load of things things that are successful like the family nurse partnership are targeted at a very small number of people hugely expensive and probably second resources out of other interventions such as health visiting and that supports a wider community how do we i suppose take the benefits of those things without damaging others and and how do we roll that out sorry well if i could start let i like to talk from evidence so when i'm making it up i signal that i'm making it up what i'm about to say now i'm making up no evidence at all but then i'll go back to the evidence what i'm going to make up is i think we are biologically programmed to be good parents the species wouldn't have survived if parents didn't look after their offspring so there's my speculation is that we're biologically programmed to be good parents we get pushed off that track by circumstances that if we weren't pushed off the track by circumstances then we would naturally know how to nurture children that you don't need to teach rhesus macaque monkeys how to be good mothers they just do it it turns out that some rhesus macaques uh are not good mothers and mostly that's because of the way they were reared you can do the experiment and you rear uh rhesus monkeys with peers rather than with their mothers so they don't have the experience of good mothering when they grow up they turn out to be terrible mothers but if you take one of these the offspring of one of these terrible mothers and rear the offspring with a good mother she turns out to be a superman so even if there's some inherited biological program you can get them back on the right track by good circumstances so now coming back to humans and back to where the evidence is i think it's tricky terrain i had one woman stand up and say that man marmot is saying that i'm a bad mother because i'm poor it's a bit confronting i thought she was remarkably well informed i didn't know how poor she really was if she'd been reading my reports but never mind but it's a bit confronting because the evidence shows that if you look at parenting activities reading to children talking to children playing with children singing with children all those parenting activities follow the social gradient the lower the income quintile the less input you get of all those good things from parents but the evidence also shows and evidence from france and it's a nice example of proportionate universalism if you have universally available preschool services the kids from more middle class backgrounds don't benefit very much because they're getting it from home the less they're getting from home the more they benefit from these universally available preschool services so where parents are not playing singing talking reading doing all those things and parents who are depressed parents who are ground down by misery and poverty are less likely to do those things you might think than an unemployed parent what else have they got to do but do those things with their children they do it much less and the famous cancer study on the 30 million words that everybody cites the families on welfare speak to their children less than when two parents are working outside the home somehow they managed to address more words to their children than the families who are not working so being unemployed is not great for child development it is not great for the well-being of the people who are unemployed but services can make a difference and that service may be helping parents be good parents as harry was saying helping parents be good parents it may be making up the lack coming back to harry's point the evidence that we compiled for the european review is if you look by country the greater the proportion of children who spent at least one year in preschool education the better that country performs on pieces schools at age 15 and 16 so in other words good preschool education is not just good for early child development it's actually good for educational performance a dozen years later so i think we can help parents be better parents and i think we can fill in the gap with professional services where that's not possible i would bet you if we looked at the family tree of every person in this room back at one two three generations we would find families in living in poor circumstances in every case something happened that allowed someone in their families to make the leap forward in my case it was my father my grandfather was a minor in Loch Gelly in the 1920s and my father left school aged 15 to go washing bottles in a lemonade factory and he was there for two or three days and a teacher from his school appeared put his arm around him and said you're coming back to school son my father ended up with degrees in physics mechanical engineering biochemical engineering built secret weapons during the war helped build the hydrogen bomb after the war and things like that you know i'm not proud of this but the point was that he did quite significant things in his life starting off from washing bottles in a lemonade factory and a teacher made the difference the point is that poverty does not condemn you to failure and we all know of the positive deviants and one of the interesting things that i think the research community will start look at as we begin to get data sets that allow us to see why some children succeed when many of their fellows will fail that's going to be the really interesting set of studies over the next few years but we know a lot about why some children succeed and it's about that kind of inclusion instead of them drifting off away from a path to success someone sticks their neck out and says we want to help you and and we need to do far more of that that needs to become the culture and i think that this question of the richer you are the more you're likely to succeed well some very wealthy young children are going to be spectacular failures and we see them on the front pages of the newspapers all the time so so it's about events that knock people off course but having said that the key thing is that the wealthier you are the greater control you have over your life and it's that notion of control if you're worrying about being sanctioned by dwp in the bedroom tax and the drug pushers that are trying to lead your children off the straight and narrow and so on other people control your life you're not in control and that lack of control has consequences for your health as well as your children's the more control you have over your life the more likely you are to succeed the more likely you are to be healthier and the richer you are the more control you have over your life i mean i'm thinking about the days when i used to take my children's skiing it was a real trackle you know you flew to wherever it was and you had the skis and you had the passport and all that you know when my son went to oxford one of his friends would go skiing in the private jet and he would fly straight to the ski resort because daddy had fixed up with the passport authorities didn't go you know the rich live a very different life from the poor and the rich live a very different life from the middle classes they are much more in control of their lives and that's the difference yes yes i was just just kind of on the back of some of the things you'd said there about you know people making interventions different i suppose that then comes back to everyone who has a role in a child's life has a parent in role because they can make an intervention and there was also something you said earlier about you know the Spanish school where they all line up and give the teacher a kiss in the morning which to us is absolutely alien but i think it will be alien to most people that work with children because all all of child protection legislation and guidance tells you do not touch a child and i always think looked after children never get any affection from anybody and that must impact on their mental well being it does it does i had a conversation with a a german who worked with looked after children and what he said was he was shocked by our attitude in scotland if someone in a children's home walked past a room one night and heard a child sobbing here he wouldn't be allowed to do anything about it in germany you would go in and you'd come for the child it was natural it was a normal way of doing things and we have to get we have to rethink empathy children learn empathy very early on in their lives and if empathy is what's missing across scottish society the sooner we start to spread that in as prudent a way as possible the better but we can't we're not going to raise a society of people that care for each other if we demonstrate to children that we don't actually care for them i find it really fascinating information on the record sarari i think you'd probably expect me to just say something very briefly about representing glasgo you made a comment about about glasgo what i'd written down it actually written community spirit versus community empowerment in my experience glasgo has community spirit and shovel loads but quite often what it doesn't have is community empowerment and those are two very different dynamics and i could give very detailed public policy decisions at a very local level where communities have felt completely disempowered whether it's school closures or something else but i won't dwell on that i just thought it was important to say in my day-to-day activities in msp in glasgo i see bag loads of community spirit but i don't always see a lot of community empowerment it's but it's there and it's growing i hold a link even though that was important to say for my constituents i wanted to come to that figure about 100 000 children being pushed into poverty because of austerity because of welfare cuts and i don't actually want to dwell on the uk politics of it all i want to look beyond that i think people know what my views of that are i don't think it it's particularly helpful for this committee to elaborate on that any further but but let give you a specific story and i give this story a lot and it is a brief one convener it's about a single parent who was working in a part-time job desperate to work was pushed into unemployment because of tax credit reforms at a uk level so there you have a single parent in a working household now on welfare so whether that person would then count as part of that 100 000 people being pushed into poverty or not i'm not sure but the gradient of poverty that that both professor marmot and sarhari was talking about cuts right across all income groups and those 100 000 people who are if you like falling down that that prosperity scale when becoming more impoverished do they have to be targeted specifically or will they be caught by by universal services when we seek to support them in other words if you're pushed into the same poverty to what will become your new peer group so you weren't poor you are now poor you're in the same poverty as others who have been there intergenerationally should should you just be caught by the same universal service or is the need for targeting there and is there a danger of consigning that family to similar intergenerational poverty and poor health outcomes hope that's not too abstract but i'm just trying to work out how we can identify where these families are who they are and how we can have a useful intervention to benefit their lives or else 100 000 just becomes a number but these are actually individuals and families across scotland well if i could start firstly just to pick up a theme that's been touched on um the implication of what thomas pickett he has said and the reason he's become a rock star uh overnight this is publishing a book by harvard university press it's a bit unusual uh to be a bestseller but never mind is that i think one of the reasons is that what he's saying is that the gap between the one percent and the middle is expanding at a frightening rate it's not just the worst off versus the middle it's the best off versus the middle and in the us for people in for men in full-time employment the bottom 80 percent of the distribution has had virtually no improvement over a 25-year period and between 2010 and 2012 of all the economic improvement that happened in the us 95 percent out of every dollar of the economic improvement 95 cents went to the top 1 percent so we're talking and given that i've been pushing the idea of the gradient for 30 years 35 years uh this is music to my ears the idea that we should stop thinking only about the people at the bottom as i said right at the beginning that's very important that people are missing out but we're all in danger of missing out to a degree all of us below the top 1 percent the gap and talking to doesn't matter who it was but a very prominent doctor in the us who said i'm really worried i'm really worried about social unrest and people are really angry and getting very upset the middle is getting very angry and very upset because it's not delivering for them so to come back then more specifically to your question about should we be targeting or should we be universal well i don't think we should be targeting the bottom 99 percent that's a universal service i don't think we should be targeting the bottom half that's a universal service if the middle are in danger of falling below the poverty line that it seems to me reinforces the idea the need for a proportionate universalism it means that we need universal services and this is part to come back to the original question that you asked me um if you look at uk figures now it's a small majority but the majority of people in poverty are in households where at least one person works and in those households where at least one person works three quarters of the adults are working the problem with poverty is not that people are shirking it's because they're not paid enough they're low paid which means that we taxpayers my taxpayers money is subsidising employers to take on low paid staff it's okay don't pay them very much and we the taxpayer will make up the difference we'll give them housing benefits we'll give them tax credits we'll we'll try and give them enough so they can just about buy enough food or heat the house and as we know the choices between heating and eating and we did a report on fuel poverty and that's the people in work and most people don't think of the people in work as poor they think of the poor as not working but the majority of people who are now below an income threshold of poverty are in work I think we've got to be much more broad dare I say radical in rethinking how we want to organise our affairs as a society what sort of society are we running when people who are working these mythical hardworking families we keep hearing about all the time aren't earning enough to have a healthy life and then we worry about their children will I worry about their children so harry worries about their children but I also worry about the circumstances in which they're raising their children so my response to your question is we really do need not just proportionate universalism we need a much broader approach to how we use our considerable wealth as a society I would absolutely agree with all of that and add to it the need to care for the individual I think that we have this network of services we have this approach that that we would describe as evolving out of a caring society but individuals find themselves in individual difficulties and on top of that we need to be able to mount some kind of connectedness that allows us whether it's through the voluntary sector or whether it's through statutory agencies I mean my bias is always towards the voluntary sector because statutory agencies have rules you know we have child protection rules and all that kind of thing whereas people volunteers are there because they want to be there because they care not because they're paid to be there and people who find specific difficulties who have a specific drug or alcohol problem that's interfering who have a domestic violence problem who have some kind of mental health issue or whatever they're going to need specific help and I mean I'm not about to propose some new set of services or anything that can do this but we need to be more compassionate we need to you know I suggested once to the permanent secretary that perhaps a good way of moving forward would be to allow one day a week for every civil servant to volunteer now maybe one day a week's maybe pushing it a bit far but if we all took some part in volunteering it would show us just how bad the lives of some people are and having recognised that I think it would create a movement it would allow us to move Scotland as a society in a much more caring direction that's what it's going to take you're not going to be able to fix this you can go a long way in this parliament in enacting legislation and policies and so on that will help support it but at the end of the day it's about people looking after each other and we don't do that nearly enough in this society and we've got data to show that okay convener there's lots more questions I want to ask but my fellow committee members want in so hopefully there will be time later for me to pursue some more of this so I can see other members wishing to get in just now okay gil passers I'm going to be a bit confused my mind there's a contradiction I'm getting from your contribution and maybe you can help to clear it up Sir Harry is saying that intervention the prospect intervention can solve the problem that's what I'm hearing but the gradient that Professor Marriott suggests is that the Chancellor his actions can stop the intervention needing to be taking a place in the first place that's what I'm gathering that by his tax methods he can cause the problem to start in the first place no no I didn't I'm sorry if I wasn't clear I said that there are two strategies one is to reduce the level of social and economic inequalities and I said for a given level of deprivation some communities are doing better than others and I cited the example of Birmingham that had closed the gap between Birmingham and England in early child development without reducing the level of poverty or deprivation so I didn't say this is just for the Chancellor and the evidence shows very clearly that good quality parenting good and where good quality parenting is not happening we can support it with good quality services can make a difference so that these are not either or it's not we'll just leave it all to the Chancellor and it'll all be fine children need good quality parenting or support from others in that parenting role no question about it they need that hands on I mean think about reading to children what is reading to children do apart from send the parent to sleep wake up daddy come on wake up what is reading to children do it gives them cognitive stimulation it gives them literary stimulation cuddling warmth care I mean it everything and the Chancellor can't deliver that not even our present Chancellor could deliver that so whatever the Chancellor does doesn't take away from the need for children to be cuddled and read to and loved and played with and all those wonderful things all I'm saying is that's harder if you're in dreadful poverty and it relates to another point I wanted to make it an interesting recent book and scarcity by a Harvard and Princeton economist and psychologist ask the question why is it that the poor seem to make self-defeating decisions why is it they don't take their medicines they don't attend for screening in India they they get a bit of money and instead of buying fertilizer that would improve the crop yield they spend it on their daughter's wedding or whatever it is the poor seem to be making these self-defeating choices and that's why they're poor and they say that's got the causal direction absolutely upside down it's being in poverty that reduces your executive function of the brain and makes it harder to make these longer term decisions if you're worried and we all know this I mean Harry said that everybody in this room would have some experience of poverty in their family if your family's worried about feeding the children they're going to be less concerned with making the long-term strategic decision it's how do I get through the day or the week not what will the next 10 years look like and a wrinkle well it's more than a wrinkle a different approach to that is saying not that they're wrong in scarcity that circumstances of poverty reduce your executive function but that begins in early childhood it relates to what Sahari said about early deprivation sculpting the brain that executive function and empathy the different parts of the prefrontal cortex that temporal lobe the other parts of the brain that are affected by poverty can influence children's executive function influence their ability to make strategic decisions as they get older so by no means am I saying this is just about poverty and what the chancellor does it's about the quality of input that children receive and but that quality of input is affected by the circumstances in which that's happening now people can rise above their poverty as it was put to me in Tower Hamlets in East London the director of education said we tell ourselves every day that poverty is not destiny and we think we can deliver good services despite poverty and I said show me so they sent me the data they've closed the gap in school performance between Tower Hamlets and the English average they're putting it into practice by good services not then they're unable the director of education can't reduce poverty but she can motivate her staff to give good services and they're doing it so I'm sorry if I misled you this when we're on the same page here and could I just before I bring Sahari in but if the chancellor took a different decision earlier on perhaps before the child was born have you data that can point to would it be cheaper to take that decision or is it more expensive to do all the interventions that Sahari outlined which were substantial earlier on that's I very rarely can a point I'm trying to make I very rarely quote Chicago economists I develop a tick when I start to think about Chicago economist but Jim Heckman Nobel Prize winning Chicago economist says that early childhood is a rare example of public policy where equity and efficiency come together and he's I mean I don't believe their models unless I agree with the conclusion um and his conclusion very clear he's got a graph that the earlier in life you spend that dollar the greater the economic benefit um so the earlier in life I don't know if he's taken it back to pre birth but you could to even to preconception um but certainly in utero the earlier in life you spend that dollar the greater the economic benefit now again I agree with Sahari we're not in this for economic benefit we're in this to improve health and well-being of our populations but it turns out there's good economic benefit as well can I just interrupt you again but unfortunately the life of politics is full of politicians who make decisions based on cost rather than improving people's health that's that's for sure and that's what's happening right at this very time Sahari I'm sorry the very children who experience chaotic early lives will turn out to be the adults who have chronic disease who have a long spell of unhealthy life in later life you know it's a no-brainer I many years ago I wrote a paper on program budgeting and marginal analysis in which we we changed a service in Glasgow we saved by working with the clinicians we produced a better service with additional consultants and physiotherapists and so on and saved about a million pounds in the process by seeing that whole programme as a single budgetary entity we were able to move money around and save money at the same time it's high time we began to see the life course in those terms by demonstrating that the costs of chronic disease the costs of keeping people in prison the costs of educational failure are huge that allows you to identify the sum of money that theoretically you can move into early years you can then identify what the margins is movable and begin to make that turn around now finance directors hate that because it stops them doing what finance directors do which is you know move money from one box to another and keep everyone happy it's it imposes a discipline on them that really stops them being able to via money in all sorts of directions but it's the way in which we will transform the economics of this and it can be done and we've started looking at exactly how we can do that and first thing I did in my new job because I understand that that is what that's what will allow politicians to say yes we can do this but as I keep saying all politicians want to do the right thing they just differ slightly in the way in which they want to do it but I have no doubt you guys want to do the right thing and I think our job is to try and show you how you can do that in ways that meet political expediency Richard Simpson Scotland is a long history of trying to improve things for people I mean the lad of parents is an expression which we recognize when I was at university we had meal Monday which allowed poorer people to go back and get their oatmeal supplies for the next few months so we've a long history at that level and we've increased higher and further education to 50 percent it was only 10 percent when I was at university the next stage was that labour when it came in introduced nursery education sure start which is there some evidence has been helpful community schools again coming down to the next level but the group that really I think we haven't explored adequately are they are that is actually that there's the zero the minus one to plus six months I mean I'm old enough to remember balby you know now what 60 70 60 years on Lorenz's original Gosling studies are 80 years on the attachment if you don't have initial attachment no matter what you do in terms of free nursery education in terms of picking up people with problems speech problems at school studying people in schools and seeing where you can improve thing you've had it already surely so you know what should we be doing you know apart from the family nurse partnership which is great but it's only in Edinburgh where there's substantial deprivation massive problems of attachment it's only 120 families what are we doing about that group and can we do it without actually addressing that attachment group I mean you're absolutely right so this is this has been my thing and the whole business about the plasticity of the brain we attribute to different patterns of attachment in very early life different centres of the brain grow more rapidly depending on the attachment experience the early years collaborative has set out you know minus nine months to at the moment five although it's being extended to eight the minus nine months is about beginning to get young women who have had no experience of attachment themselves to understand what that means and to begin to support them and fnp yeah east of scotland has lots of it i mean for those of you that don't understand what it is every teenage girl who becomes pregnant is offered a family nurse regardless of whether or not they live in barnton or western hails the fact is that most teenage pregnancies occur in deprived areas so it tends to be like that but there's no discrimination and that nurse stays with that girl during pregnancy and during the first couple of years of the child's life and when i i went to see this in action and there was a 16 year old girl there the attachment behaviour that she showed with her baby was utterly impressive the father came in he too had learned to attach and then she got in a taxi and went back to school because she had planned a career she was sitting five hires she knew what she wanted to do and i said to the nurse what would you be doing if you weren't here and she said well typically she'd be out with her friends down the shopping centre buying a bottle of vodka and it's utterly transformative of these children's the parents the children who are parents and their children's lives and we need to do far more of that and it is about building empathy there are glasgos using triple p which is a different style of things but you know it seems to be as the evidence-based and the point is that we want local authorities to and community planning partnerships to develop their own style of enhancing attachment behaviour there's been too much directiveness in this business of co-producing it i think is really important the key thing is we want them to collect the data so that they will see what's working and what isn't working and stop doing what isn't working but yeah attachment i couldn't agree with you more it's absolutely central foundation to future success and it builds the kind of biology that we've been talking about it will lead to reduced risk of ill health later life reduced risk of mental ill health in in early adulthood so yeah you're right and we want to do more of it and we will continue to do more of it but in order to afford expansion of this we're going to have to find ways of looking at the programme budget in its entirety do you just the other thing i would add the way you began you know we've been concerned about this for a very long time um things have got better no question but you know that you know that from your own experience apart from the data things have got dramatically better i think what it was to be born in scotland 100 years ago 50 years ago 30 years ago things have got dramatically better babies don't die the way they used to um i mean again i know the english data better than i know the scotish data but um the round tree study in york in 1900 the best off in york the best off group the servant keeping class in york had an infant mortality of 99 zero per thousand live births the worst off now in england is about six i mean you can find single mothers unemployed or something maybe get it up to nine so the best off 100 years ago 90 per thousand live births the worst off now is perhaps nine so it's an order of magnitude different and quality of early child development is presumably although we don't have the good figures over time has presumably improved too the major issue that confronts us are the inequalities the fact that not everybody's benefiting to the same extent and that's the major challenge so some of what we've understood over these years has been put into practice and things have got dramatically better but we're now challenged by the inequalities and the fact particularly in glasgo as i've been quoting all around the world the worst off don't look very respectable in terms of life expectancy in any country in the world the worst off in glasgo i mean it's really shocking so it's the inequalities this is not really relevant to the committee but bulby's son is my neighbour and i was going for a walk and i bumped into and i said something about attachment i had to explain to my wife where i'd been for the last hour because he'd been giving me a lecture about attachment you know his father's theories but and the other group within that if i may supplementary just is is the was mentioned earlier on we've got 16 000 looked after children in scotland i myself was adopted so i was extremely lucky i had a rapid adoption after after birth so you know but i was appalled when i was working in adoption fostering that the first case i had they were looking at placing this this baby in fostering care and when i looked at the papers it had already been placed 17 times in foster placement so linking to my question on attachment you know how do we actually you know we've all you know the sort of philosophy of my generation has been you must always try and get the child back to its natural parents but you know placing a child 17 times what chance has that child got of getting any sort of reasonable attachment any sort of reasonable brain development that will allow it to benefit from the free nursery education good care et cetera so you know what do we do about that in a way that you can well i think we'll have an opportunity later to discuss with colleagues who have a specific interest in this area exactly how we do it one of the interesting things that's taking place in Glasgow is the study of the New Orleans approach to adoption and fostering and and i wouldn't presume to say anything about it other than to say that it seems quite a strongly evidence based pattern of deciding if a child should go back to its natural parents or should be looked after in an adoptive home but you're absolutely right bouncing a child round i mean the the macaque monkeys one of the key determinants of stress and poor outcome in these macaque monkeys is inconsistency in parenting changing patterns of rearing from one day to the next just consistency is really important in all of this and we need to work to do that and it comes back to this point of our attitudes to children you know do we care enough about them you know if a child falls and hurts itself in the playground not to be able to give it a hug and comfort it seems to me to be inhuman to be honest and i said this to the association of directors of social work a few years ago in our gasps of horror in the room this man's a raving lunatic he wants to hug children well we now know that there are epigenetic effects of happiness in children that switch off and switch on certain genes that's not the reason we should do it we should do it because it's the it's our natural instinct to to to nurture people in difficulty and to nurture weaker people weaker than ourselves and all of us in society benefit from demonstrating that we are i mean we are not Anglo-Saxon i don't think the more time i spend in the Nordic countries the more i think we have much more in common with them you know their attitudes to children and to each other that's actually where i would want to be to be honest thank you to harry i certainly found your opening presentations and your contributions and honestly lucid and interesting i've noted it i've agreed with a lot of it surprisingly sometimes to myself i've disagreed with some i shall certainly however having listened reflect i think in a lot and i think the themes that have been explored this morning are almost so broad and so huge that it's impossible to condense anything now into a meaningful question i've had a long-term attachment to the idea of universal health visiting i've noticed what you've said about proportionate universalism and the focus that there might be where that's most needed i wonder in two or three small questions that i might draw out i agree i think with what sir harry was saying about the silos of the financing of this and the inability of some to see where future savings might be assumed now and redirected and the individuality that's needed and i noted what you said to michael about there being a difference in outcomes at certain levels of inequality in different places i wonder if you think how you reconcile that need to be individual in the approach that we have within different authorities and health boards and the difference in the outcomes that we sometimes see and whether we are for want of a better word ruthless enough about trying to ensure that we direct what works rather than always allowing what doesn't to become embedded and entrenched and secondly you were asked if you were chancellor and you said you wouldn't and can i say that at times we've perhaps skirted a utopian ceiling in some of the conversation we've had but given that you have been in scandinavian countries where there is this greater focus on early years what would you say to us if as politicians having to work within an envelope ultimately that you have maybe learned from their health services that they don't spend so much time doing that we spend perhaps too much time doing that could be a source of redirection thank you for those interesting can i start with scandinavia first the nordic countries human nature is alive and living in the nordic countries they're not different from us they're they're not some different species they have i've been to the swedish parliament recognizably i could pick out who's on the left and who's on the right and it's all very recognizable they have the same sort of debates we do interesting what's really inspired me more recently is where the national government has been reluctant to act local government has acted has taken it on so once we said to me you've become a brand name in sweden now there are three reports i was just earlier in the year in malma sorry last year in malma when the swedish city of malma produced a report on a socially sustainable malma so they took my wh o commission on social determinants of health report and said how could we apply this in one city and i said sweden you don't need this and this took me to areas of malma where there's greater than 60 male unemployment in malma so they do need it they have big inequalities right in the city and what they did was get the health service to come back to your question involved but they got the mayor involved in fact the mayor commissioned the review the commission so they got local politicians they got education they got health services they all the main sectors and they owned it and they did something similar in ester gutlunt which is linchirping nor chirping to just south of stock home and i was there last week for a progress report on their big review they got the politicians involved from the beginning as members of the review and they were concerned that they might be too pragmatic the politicians they might say no come on guys let's get feasible what you're saying we're practical people they said that wasn't the case everybody got engaged to the same extent and the advantage of having the politicians involved with the third sector with the civil society people and the academics and local government was that there's more chance of what they come up with being implemented because the politicians own it and i had social democrats come up to me and say you know we're hoping we're going to but had the the right of centre people come up as well and i was trying to get out of their political debate i'm only pleased if they can have the centre right and the centre left engaged at the same time and that seemed to me a very good message now i said there's normal life they don't like each other much but so it's human nature in sweden as well but they've got the centre right and the centre left both engaged in this and i think that's a very important message because they're saying starting right from birth through the life course that these inequalities have to be addressed and they have to be addressed not just through the health care system and i think that's a very important message and if the national government isn't doing it then local and regional government can do it i think it's important that national government do it too but i don't want to get into scottish politics but i think having it at the city level having it at the scottish level and of course having it at the uk level are all important but we know in england three quarters of local authorities have marmot implementation plans so whatever is or isn't happening at the national level we've got local government i've talked to local government association which until very recently was always led by conservative and they're my great allies in england the local government association and i think that's a very important message i think this localism approach is very important and taking bob doris's comment earlier on about community empowerment this is absolutely central to this i am not going to go into detail but working with local authorities across scotland i can see very great difficulties and differences in capacity and willingness to act you do come across the not inventive tear syndrome you know if they're doing it over there we couldn't we'll have to do something different and so on and you know that that's that's fine the critical thing is count what you're doing and if it works do more of it and if it doesn't work stop doing it and be man enough to admit that you've done something wrong and that's at the heart of the earlier's collaborative every five months or so 800 people from across all 32 community planning partnerships get together to look at what they've done and to share the results and beginning we're beginning to see key changes emerge that we need to build upon but you know all of these things are necessary but not sufficient we need to do we need to join it all up and i think it's perfectly possible for really good local authorities um and you know the ones that we you and i are both familiar one you and i are both familiar with are really really good at this kind of thing um it's perfectly possible for really good local authorities to move a long way down this direction but we also need the overarching economic structures that allow us to tackle the lives of people who really really struggle and you know i would invite i'm sure martin johnson wouldn't mind me saying this but to sit with the poverty truth commission and hear the stories of middle class you know people just like us who can't afford to eat for two or three days a week literally they eat nothing for two or three days a week because they can't afford it is very chastening it makes you realise that we need that overarching approach from government that ensures that there is equitable distribution of goods and power and so on in society but also the localism that allows us to support people in difficulty who just don't know how to look after their children and we need to do all of those things and at the heart of it i would say is the culture we need to start looking out for each other i mean i'd just like to quote the violent reduction unit invited clergymen from south los angeles over to glasgo a few months ago who had transformed the gang culture in south los angeles and basically found jobs for them he created social enterprises home by industries and he said in the course of the day he made a statement that really has stuck with me that what we need in society is a compassion that stands in awe at the burdens the poor have to carry rather than stands in judgment at the way they carry them and i think if that's our starting point wow how would we be in similar circumstances if we had to deal with the the lives that these people live and what kind of help and support would we need that i think is a good starting point for transformation of our society good morning i have to say that i've found this absolutely fascinating the six months i've been on the health committee i think it's grabbed me really from the word go from your first words had me thinking all through this about the proportionate universalism and how as soon as you set levels say in taxation and stuff like that the people just above that level tend to get harder and it doesn't the idea of this proportionate aspect really sort of hits through you now we can bring this into perhaps a wider part of society it's got certainly got me thinking i'll be going away with these things in mind but can i perhaps since we're running a little shine time the to go back to what was said about the the stuff sir harry particularly about the empathy that one of the things we always shout about of course the fact we're scots you know we're probably one of the most social minded groups in the world and all this sort of thing some of the things of course you came out with earlier i found quite fascinating the difference between Manchester Liverpool Glasgow for instance when i was wondering and in terms of a lot of this appears to come down to attitude of what we think we are this time and heading backward to the thing about not being able to hug a child or if you are a coach in sports not being able to touch a child and to show them where to put their arm in badminton or something like that and this fear that appears to have been brought through and we've heard about the child protection issues are we getting to the point if we're we're going too far with this and we have to rethink our attitudes on tactile methods of communication such as hugs and whatever within our entire society not necessarily the the the young child crying but this whole thing where it's based on fear you cannot do this is this the sort of thing that's going to drag the idea of the things that you're you've been talking about down yeah i mean i in the talks i give one of the points i make is this notion this thing about the molecular biology of a hug and when i talk about that quite often there's a wee queue of people wanting to give me a hug afterwards and sometimes that's okay but sometimes i'm just not so sure but so it's a kind of yeah it's a difficult um a difficult question and the child protection issue is a really really serious one i mean we can't duck it it's out there and we have we've reacted to it and we've reacted it to it in a way that i think dehumanises us i mean it's it's a small issue but it's a very very serious issue and and damaging a child in any way is you know as to my mind is is a really really serious crime against humanity but we're damaging children by not showing them that kind of empathy as well and we need to rediscover a balance we need to you know we need to realise that that and i'm very conscious about this because my daughter's just had her first grandchild so i'm absolutely obsessed with watching how she interacts with her and how the attachment process is going on we need to realise that that is a very important part of human development and it's not something that is exclusively the province of the parents it's the province of other people who show affection for the child and we need to rediscover that balance i i i would leave it to experts in child protection to comment as to where that balance lies but i would just want to raise the flag that i think the balance is way too far to one side and when a child is crying and looking for comfort it's our responsibility to show them that kind of comfort and you know i just think that the rules and regulations get in the way of us acting like human beings i suppose my next question would have been how how do you do this well i think i think we need to talk to child protection experts about this and not accept the blanket ban on this there has to be a better way of doing that final question for me in terms of the message that i can take away today is that the examples of tower hamlets and birmium is that good services can't close the gap can make a difference the other the other message just let me finish like you can respond to both of them so the other message that we've got continually as well health interventions are important it can't deal with this on its own and that reflects i think all of the evidence that we've had through this whole scoping exercise but it is the the the only portfolio that's got a clear priority for health inequalities and sets out a whole list of targets are they still relevant if they are relevant should similar targets in that principle equity be reflected in the other portfolios does that help very important question and i've been the thing that's given me sleepless nights more than anything else is this question from the time that i started chairing the who commission on social determinants of health the question ministers of education asked is why should i care about health that's not my job that's your job minister of health not my job and the minister of finance says why should i care about health that's your job minister of health not my job and the minister of health says if we take seriously what you're saying about social determinants of health i'll be out of a job so i've had ministers of education and environment and finance say health's not my job and the minister of health saying i don't want to listen to what you're saying because i'll be out of a job if those guys in education environment and finance take health seriously so i've been struggling with this for the last decade and what i can say is i can show you good examples where we've managed to break down those barriers where we've actually managed to get ministers of education realize that what they do in their day job has a positive impact on health i had coming back to the Nordic countries i had a minister of foreign affairs in Norway say i am a health minister because what we do what i do in my day job impacts on health in fact i had a phone call from an official in the ministry of health in Norway saying you know you've been going around the world quoting our foreign minister saying i am a health minister he now is our health minister and he wants to meet you but he came to that portfolio with a rich understanding that he had to work with his colleagues and when i went to norway to meet the minister of health i went to we had a seminar at a table like this with 13 one three different government departments represent they even had the ministry of defense discussing health they had 13 different government departments and when the ministers left the senior officials stayed in the room to keep discussing their cross government strategy i think that health inequalities should be a corporate issue for the whole of government that these should be not a health goal for the ministry of education a health inequalities goal for government it should be for the whole of government and then and i went to a similar meeting in Peru recently where the prime minister shared a meeting and they had a dozen 11 other ministers around the table this was a corporate issue for the whole of government so the whole of government says we've got under five mortality figures that shame us this is a reflection not on the minister of health it's a reflection on the government we've got early child development figures inequalities that shame us we've got pizza scores that shame us this is for the whole of government because these are going to impact on health so that's my way of saying we've got to get health and health equity into the thinking of the whole of government so that it's in whatever government department does my response to that is that when you use the word health lots of people think about illness you know the health service treats illness and it prevents illness and what i've been talking about is well-being inequalities in well-being because that includes inequalities in educational attainment inequalities in offending behaviour inequalities in employment success and so on and i think inequalities in well-being are clearly a matter for a whole of government for the whole of society so i would encourage you to think about positive health as opposed to disease inequalities in disease incidents yeah really important but inequalities in the whole panoply of outcomes i think are very important and i think that we're ahead of the game in scotland historically i mean scotland had two medical officers of health before england had one you know we've had a long history in scotland of concern for public health the first study i can find anywhere in the world of inequalities in health was carried out by the by the city treasurer of glasgo in the mid 19th century when he looked at infant mortality in affluent and measured affluence and deprivation with this very long history of concern we've had a huge tradition of academic research into inequalities in health and you'll hear about more of that later on we know more about it than most places in the world so we've got a good start in scotland and it really we need to push on and just fix it i have you know the the chief medical officer in england is the chief medical officer of the uk government and the uk government is the member of world health organization and so on so when the world health organization wants a chief medical officer they're supposed to go to the chief medical officer in westminster but in fact a lot of the times they come to me because they see scotland as being a leading place for thinking about this countries in the balkan region and in scandinavia and so on really want to know what we're doing we need to build on this and we need to move forward and we have huge opportunity to do so and the fact that you know this committee and the audit committee and so on have taken such an interest in this i think is a terrifically positive sign but you're in a privileged position that you've worked with all shades of government over the devolution process yeah and every politician every health minister i've worked with wanted to do the right thing yes absolutely has the description of other governments across the world taking that wider corporate responsibility do you see did you witness that over the period of devolution it's not evident is it yeah it's very patchy i mean i've been i mean most places that invite you to come and talk about this kind of thing are already there they're already interested they've made the decision but i've been and i want names but i've been to some places recently countries significantly affected by austerity and you talk like this and they just look at is if you're you know how could how could i mean i was that i went to speak to a group of doctors in one country recently and they really thought i was bonkers talking about wellness and well-being rather than talking about treatment of disease we're ahead of the game and the fact that our size makes it accessible meaning we can get 800 people into a room and that reaches into every community planning partnership is a really significant advantage we had evidence on the community planning partnership last week in some gaps there you're working out of time but half local authorities haven't embarked on that journey you know so that there's a barrier you know so there are issues here that we're not applying you know we'll have an opportunity in the next session to maybe discuss some of that but what i'm trying to focus that back to is scottish governments not just the present government but scottish governments over that period of devolution given all of the knowledge the world-leading knowledge the the the studies that have been carried out you as a personality and advocate for all of this is the what more do we need to do to ensure that at a scottish government level that there's that corporate responsibility for health and well-being as it impacts because you're in children itself there are you know there are a number of cabinet secretaries and ministers who represent not one single person but four or five who have all shared responsibility for this and at times over that period of time and being involved in some of these issues and raising some of these children continually fall through the gaps because there doesn't seem to be that corporate responsibility that one line the equity is described by Sir Michael this morning is not embedded into every policy and every decision of government my experience as chief medical officer was that ministers were very accessible civil servants across government saw as their shared responsibility to come together silos were really not in evidence within the civil service everyone continues to come together and i'm still involved in some of the work around inequalities in in young people for the scottish government what i think is could improve is coming together with local authorities and voluntary agencies by working seamlessly not just across the way but at different levels i think that's where the gaps are because some local authorities as i've already mentioned is the not minted here syndrome some local authorities are less willing to take on new ideas than others the voluntary sector is doing fantastic work can we spread that can we join it all up can we learn from the successes lots of small projects going on that are doing good things if we can measure what they're doing if we can count what they're doing and spread it then we will begin to plug the gaps we'll seal the gaps as government can't do this on its own it can create a facilitation but the other levels of action in society need to be involved and it's just a sorry pressure but that's seamless nature that we require from local government is that evident at a scottish government level when one portfolio will make a decision that impacts negatively on the outcomes for certain groups and children on the other my my experience was that government has tried to make sure that there are no unintended adverse consequences of this kind of thing and it just seems to me that if there are some of these adverse consequences emerging then a better dialogue has to be important i'm not just talking about the present government i'm talking about governments over the period i mean the striking thing in my experience with ministers of different governments over the years since 1997 has been the great willingness to do what they need to do to fix the problem and initially it was tell us what to do and since there's no one thing it's about thinking much more about complex systems and how complex system how the interactions within complex systems can make things happen and that's much more difficult but it's much more dynamic change that needs to happen across the whole of society and the collaborative approach it may you know that's evolving but we're the first country in the one to try and make that level of change with that kind of method and to my mind we will see very soon some positive impacts thank you very much for your precious time you've given us this morning all of the evidence and we we will certainly make our discussions as a committee much more interesting thank you very much indeed for your presence here this morning thank you yeah we're going to suspend at this point until we set off for the next session we will now reconvene another table panel in this session on our early years inquiry and in the interest of time i think people can introduce themselves maybe when the committee speak rather than just going through taking more precious time understand it my apologies it's running on a wee bit and there are people already under pressure both committee members and and panel members so um at this point i'll go very quickly then to ailey mcleodd a committee member who will ask her first question and kick us off thanks very much kiviner and obviously we heard earlier this morning from sarahari burns and professor michael marmot and certainly i agree with a lot of the points that they raised and in fact my sarahari burns not mentioned you know that scotland you know is ahead of the game and what we're trying to do in terms of addressing inequalities in health and i suppose for me the concern i have around that extent to which you know progress is being you know affected by you know austerity and welfare reform and one of the comments i was struck by this morning from prism marmot was you know around about the political choices that are made by the chancellor effect in the quality of our early childhood development now we know that for example the scottish government has estimated that welfare benefits will be cut by six billion pounds by 2015 to 16 with over a one billion pound of cuts relating directly to childcare to children sorry in scotland and a number of these have had a direct impact on young families such as the removal of the baby element of child tax credits the abolition of the health and pregnancy grant and the abolition of the child trust fund and cuts to the sure start maternity grants and obviously we have a rising number of the working poor so i'd like to ask around table this morning is how do you think all of this affects the life chances of our children and in the longer term their health and how do you think that we could for example better align our welfare system with our early years priorities and you know so that we can actually improve in the longer term our inequalities and not just health but also in terms of our well-being as well other committee members at this point that the panelist sir you know we've got shorter questions and we'll we'll give the time all the time we have to the to the panelist um professor wilson did you want to come in on that point thank you i apologize for having to leave at 12 um yes i'm from university of albedin and i've been involved in a programme of work looking at assessing the social and emotional and language development of children at various ages in in glasgo and that that works continuing and i'd really like to make a plug if you like for acknowledging the importance of early childhood behaviour and social and emotional development and in particular i'd like to make a case for measuring social and emotional development in children because actually that actually that's the only way that we're going to be able to assess the impact of our services in the early years um it's an important issue we know there are you will have heard earlier um and there's a lot of other evidence supporting the importance of early language development early social development early early development of behavioural regulation and so on um and and long-term health for example the 1958 birth cohort children who were rated by their teachers as being in the top quarter for good behaviour compared with children who were rated by their teachers a very simple old fashion scale who were rated to have bad behaviour the children with good behaviour in the in the the best quarter were half as likely to be dead at age 46 as the children who were rated to have bad behaviour at age seven there are lots and lots and lots of other studies longitudinal studies which demonstrate the relationship between early behavioural emotional social regulation and language development and later health um you'll have seen in the written evidence to the committee that there are differences uh between different economic areas of plazgo we we used a tool called the strength and difficulties questionnaire which measures emotional problems uh conduct problems hyperactivity and attention problems and peer relationship problems very simple questionnaire takes five minutes to complete um we we found that the more deprived areas had on average a score which was half as high again as the as the more affluent areas and you'll have seen if you if you look at my evidence there is a map that we produced uh this was a questionnaire completed by nursery staff for every child in Glasgow there are about 10 000 children represented in that map uh in the preschool year uh and you'll see that the scores in Springburn were twice as high as the scores in Hillhead um now it's that's not the whole story um there is clearly strong social patterning of of scores in the strength and difficulties questionnaire um but it's not just as simple as as finance um for example Govan uh which is economically as badly off as many areas in the east end of Glasgow is doing much better than we might expect and that may be that there are better services a better sense of community cohesion maybe you're more likely to have your granny living around the corner um so there are factors which are beyond just financial factors um and we've started to unpick some of that um and we found for example that the strongest predictor of conduct problems uh in in an area based analysis uh in boys is the crime level uh crime level in local areas seems to be have a very high relationship very strong relationship with with conduct problems it doesn't have the same relationship in girls interestingly enough um so by by analysing data from lots of children geographically we can start to think about what the impact of interventions might be um the other advantage of um measuring uh social emotional language development is uh that you can start to look at trajectories if you can collect the data more than once for the same child then you can start to look at what are the factors indicate whether they're going getting better or getting worse and we've we've um recently done some analyses for children in primary school and we've shown that the big social differentials that exist in the preschool year get much bigger by primary three so children who are in the affluent areas uh who probably start school with advantage get better and children who are in the more deprived areas um who probably have less advantage get worse um so i almost finished the point of trying to collect data i'd like to just make a uh a plea not to forget the importance of general practice uh in uh managing uh early problems in child health like health visitors they're really the only professionals that are in contact with all children uh and they are potentially a very useful resource for identifying vulnerability uh in early childhood do you think anyone else wish to respond dr hill from the university of enmerite to respond to the original question i think i'd reiterate the point that was made by a sir michael marmot about the need for a dual approach to addressing um inequalities in the early years so of course um cuts to benefits is is going to be problematic in terms of increasing the underlying social gradient i do think however there are policies that the scottish government can pursue to try and ameliorate decisions that are made in westminster and that includes measures such as the scottish government's commitment to um try and implement a living wage for example including in its capacity as an employer and i also think that the second um of sir michael's strategy is an important one and obviously that's one where there is much more capacity for the scottish government to take a lead and in particular i would emphasise the role of early childhood education is acting as an ameliorating influence for children who come from disadvantaged backgrounds so i think that um it's important to think of the opportunities that are available for trying to improve the early childhood experience of of children growing up in scotland and that includes not only um the government has taken um steps to improve access to early child care um and i think that that's a really positive move and one that i suspect will be beneficial in economic terms but i think if we want that to um also lead to improvements in terms of both educational and health outcomes we need stronger investment in um the educational aspect of early childhood care so i think not just child care but um early childhood education um qualified uh well supported preschool education i think um offers a really huge opportunity to try and ameliorate some of the more negative impacts of uh cats and benefits i'm here centre of confidence well being but um for many years i'd set up i think called the wise group and heat wise Glasgow which was doing with very long-term unemployed and a lot of that experience i can play into what you're the question you're asking if i can just say this that what we discovered is that we took a couple of thousand long-term unemployed through each year and we got 50 60 percent into jobs but there was a very significant slice of usually young men but also young women who we could not help and the more we analysed and dug into that they were very frequently coming to us and they had virtually no social skills whatsoever um you know homemade tattoos sports clothes um all almost could hardly talk to you and hold your eye and yet we were to get them jobs and there was no chance of them getting the job if if tooth be told actually what we then also discovered that most of this group were parents already two or three times over so there was a major intergenerational issue going on and the tool that we were meant to change that with was on the one hand welfare benefit and then the other one getting my job and actually it was a different category we had to look at because we could not retrofit the soft skills that they needed and in a sense sorry my issue there would then take us in to what we are trying to do on welfare policy what are we trying to do on health policy to actually in get those almost empathetic and language and behavioural skills which happens before you get to school rather than when you get to 21 years of age anyone else Brenda Dunney University of Dundee I just wanted to go back to the point that Sarah made about educating and having care and well-being and education for young children I think it's also important if we're going to do that that we really consider how we educate the practitioners that are looking after these children it isn't just a case of giving children extra hours in a nursery situation or an out of school care or a play group it's really considering who's going to look after these children and we want them to be people who are really well qualified and because what concerns me is quite often it's the most inexperienced and the youngest practitioners who do not have the qualifications that are looking after babies in the baby room so we really do need to consider things like making a difference education Scotland's report on if people are educated practitioners or lead practitioners with perhaps a BA in childhood practice or teachers with an early years qualification they can make a difference and the HMI reports have shown that in a very large way. On that theme can I engage some people on that theme because you know in the written evidence you know this come up in different ways and there's a presumption obviously in those very very early years not to six months or whatever then GPs nurses would be involved but none of the evidence does it say you know how important that those nursery workers care workers who spend an awful amount of time with the children and the young people and you raising the issue so could we have some you know discussion maybe about the work the workforce capacity and the quality what's actually there on the ground and what's important jonathan share thank you i think that i'll leave it to others who are more expert about workforce issues than i am but develop that from if you've no got a workforce issue can i get but none of what the point i do have to make involves the workforce but not just and that is that if there's um one of the very basic messages that i hope the committee will pick up and act on is the the quality of relationships that so much of reducing inequalities whether it's health inequalities or others is down to the nature of and quality of the relationship first and foremost the relationship between a baby and the parent or carer but also the relationship between the parents the relationship between the parents and people like gps and health visitors and nursery staff because it isn't enough to just make this a numbers game the research is absolutely clear that increasing the number of workers only has meaning if what's happened is that there's been the development of healthy trusting two-way relationships of respect and care all the way across the spectrum so to use health visitors as an example increasing the numbers and reducing caseloads absolutely but that's only going to work if health visitors are able to develop the kind of nurturing two-way relationships with parents more health visitors going around and saying this is what you need to do or oh my gosh what a terrible job you're doing somehow that isn't very effective um and so it it it is those relationships across the board that are absolutely crucial and it's not something that we tend to focus on again that the written evidence shows us that there's less health visitors yes professor rose just to make a point in the written evidence I raised the issue that general practitioners are now doing much less preventive child health work than they used to and that's really a largely a result of the 2004 contract so there is no incentive for gps to get involved in preventive child health work and child health surveillance in addition to that there have been a number of well intentions but ultimately I think ineffective policy decisions around health visiting health visitors have ceased to be the experts in normal child development and child development fell out of the syllabus about 10 years ago in health visiting it's an aging workforce there have been a whole series of developments we should demoralise the workforce and there is a big big issue there because they are the major support to parents in the in the pre-nursary years and in addition there have been a very strong managerial push towards so-called skill mix in health visiting teams which means that health visitors themselves the professionals who are educated in this area are not delivering most of the service most of the service has been delivered by much less well trained colleagues and there's been a mentality where continuity of care is not given the importance that it perhaps should have so that people don't know who the health visitor is anymore and this is a big big issue I think for a lot of a lot of families and I think it's something that should be fixed if possible. Hi I'm Ben Farrugia from the University of Strathclyde Center for Excellence for looked after children I would echo Jonathan's words about both the about having the quality of relationships but my day job is working with local authorities and in some cases NHS boards looking at some of the interventions they can provide to looked after children and our experience itself is is that there is a capacity gap and a lot of the solutions that we look to to problems are constricted by the envelope being so small and and when I think about care levers in particular and the world that they're projected into and what we expect in terms of them holding on to relationships with workers whether it's their social workers or three care workers or foster care or a resi worker that is very difficult in the context that we currently have in Scotland a foster care is going to take on new children it's maybe difficult to maintain that in some cases and the resi worker as was said earlier on in the prior session that can be actively frowned upon in some cases but there is a capacity problem that we do see whether it's in schools with support staff and guidance teachers for children who may need them in that context whether it's health visitors and elsewhere and I think that's something which I think it would be helpful with the committee to hold in mind when they're thinking about what are our solutions to the problem. Paul Bradshaw. Paul Bradshaw, Scotland's social research but also project director of the growing up in Scotland study and I really wanted to come back to the point about preschool educators and practitioners working in preschool and really just as a point of information for people on the panel and in the committee that we've got a forthcoming piece of research using growing up in Scotland data where we have information on children's social emotional and behavioural outcomes and on their cognitive ability and we've been following these children from birth and children in our older group are now approaching 10 years old but we also knew know which preschool centre they attended and we've linked that information and extracted details about quality inspections from those preschools and we're now exploding the relationship between aspects of quality that the children of the preschool centre that children attended and the relationship between changes in their behavioural and emotional outcomes and their cognitive ability and we are finding some relationship in particular between specific aspects of quality of the environment intended preschool environment attended by children and some of these outcomes. I can't say any more at the moment that the report will be published next month and it's not an unusual finding because we do have other research particularly in the UK that has found a relationship between the preschool environment particularly the quality of the preschool environment and child outcomes. The point I guess is in the sense of proportionate universalism you know upwards of 95 per cent of children in Scotland eligible for the preschool place take it, they're there, they attend and they mostly go for the time that they're allocated so it is a real opportunity to make a difference on a very broad scale. Thanks Alison Leslie. I work at the University of Dundee in the fatalities investigation and review studies team. I think that the issues that have been raised about workforce are crucial whether we're talking about workforce with young children as Brendan, whether we're talking about the workforce with looks after children, whether we're talking about teachers because to pull in some of the thinking from the earlier session you know in the wake of Bob was work there was this concern that if the attachment bond was broken it could never be repaired and what we've learned since is that even children who've had the most traumatic challenging dreadful experiences can recover and become productive fulfilled members of society with fulfilled relationships and can become productive and caring parents and the thing that makes a difference is one person who nurtures them, who responds to them, who believes in them, who values them and so often when you talk to people who've had that journey it comes down to there was a teacher, there was a dinner lady, I can't tell you how many times over the years people have told me about dinner ladies or janitors or care assistants, people in the school that are sort of as they're doing their sort of work of tidying up and that are talking to a child and making a child feel important and these are the people that we don't invest enough in or we don't recognise and I think one of the things we need to think about is in the areas of Scotland where there are the greatest clusters of children who suffer from that early emotional trauma that can affect their life chances, their health so significantly, we need to ensure that the people working in those areas in the schools in the early care centres are the most qualified, are the most compassionate, the most nurturing because that's where the difference is going to be made. You want to also on that theme, but then they're done. Sorry. No, don't worry. It's something I feel very passionate about. Many years ago I was a primary teacher in Dundee in a very deprived area and there was a thing called educational priority areas, EPAs, and I worked in one of the schools and there was never a longitudinal study or anything done, it was something that we worked in partnership with the parents, we had smaller classes, I had the same class right through primary six and seven and the difference that I know that we made to those children because you were working individually, you empowered them, I mean it did come from a deficit model which I don't really agree with, but you empowered the children, you gave them the goals, the targets, they then set up their own goals and targets, they came to visit me years later when they were in secondary school, it was the first class I had had from that school where they went on to further education, some of them went on to higher education and I was so proud of them and we made a difference and it wasn't just me as a teacher, there were other people in the school equally working with children and classes, why do we just abandon things like that and not do the research over the years to see and it does take a long time to see, did it make a difference because there was things from that that really worked and it's a bit like the high scope approach, there's things that we should be learning from the past that we can take forward and use and make a difference and these children I was working with were primary six and seven, they went on to secondary school full of confidence with I can do but it was about giving them the power and motivating them so that they sort of ran with things. Anyone want to pick up on that continuity and the importance of longer term relationships in education and all those? None of our panel members, I'm going to let Bob take us in another direction. No, we stood in this direction because it was only if none of our witnesses wanted to say anything in terms of preschool provision, they're very passionate about primary six and sevens there, preschool provision can be two and a half hours or three or blocks of early learning and childcare, two or three or four days a week depending on how it's structured. Irrespective of how we get there, there's a growing consensus that has to be a radical significant advancement in early learning and childcare from the age of one onwards has been presupposed as been the best way to do it. Separate from the economic benefit of that and the gender equality switch, I don't want to diminish but I wish to put to one side just for a moment in terms of attachment and relationships. If you've got a young child at one, two or three, developing a relationship with someone in a childcare establishment not for two and a half hours, two or three times a day, but an individual right throughout the week, is that also going to have much more nurturing effect in their development? So not just the fact that you're interacting with other kids but you're going to have an adult role model continuity or right throughout, I suppose, the working week? Has any of that as a research in terms of the piecemeal approach to childcare versus a consolidated earlier childcare approach where you can actually form bonds at the age of two or three with the early learning professionals? Some more on that would be quite helpful. I think that there could be more research into that. I know that, obviously, I work now with childcare practitioners and lead practitioners and they're very aware of attachment theory. There are specific staff who are responsible for specific groups of children but I think that what concerns me is sometimes when a child moves from the baby room into the next room is that that bond may be broken and that they're then having to relate to new people, other practitioners. I think that you've got a really good point there and it's maybe something we should be considering throughout because certainly when I talked about the primary six and seven class that I had for two years, that was attachment, that was a bond that the children and I had and I think for very young children it would be, we should be perhaps thinking about, it's not just about moving them from one room to another but perhaps thinking about the attachment. So I think you've made a really good point and something that's worth considering about and something I'll take into the BA course at the university so thanks. And then Alan Sinclair and Jonathan Shair, do you want back in? No, I'm not. I'm not. You were looking at my direction and I felt under pressure but Professor Frank hasn't contributed so I'll bring you in. My concern about what is best practice in what I think everyone this morning has agreed is the essential investment for Scotland which is better and earlier high quality preschool education combined with care. My concern is you won't know whether you're doing a good job because you're not measuring any outcomes at the present time. So Scotland has no standardized measure of child development collected by everybody in any way that can be analyzed and yet the earliest collaborative asks every local authority to improve early childhood development but doesn't give any guidance on the art stick. So I won't go through our briefing because in it we describe the pilot project we did in East Lothian to just pilot one measure that a teacher can fill out in 20 to 30 minutes for each child in their P1 class after they get to know them around Christmas time. We happen to use an instrument that's used every three years and every P1 student in all of Australia and now most of Canada where it originated 15 or 20 years ago, at least this questionnaire for the teachers. My concern is that in attempting to get people to just hear us present the results, by the way I have no intellectual property rights on this, it's run by a non-profit, it's nothing to do with that. This isn't even my area of interest, I just doing it because I think it's what Scotland needs. We showed the instrument works beautifully, it's very cheap 7P annualized per capita of taxpayers if you like in the local shire but nobody wants to talk about it because of the gridlock between local authorities and the Scottish Government around who would pay for anything new and how much direction can the Scottish Government give to local authorities about anything. So I just want to ask the question to the members. Are we at the point where it's somehow improper to suggest that a standardized measuring stick should be used throughout Scotland for child development at least at school entry so we know how to allocate resources where the need is instead of just giving everybody a proportion of the budget for preschool that's equal to their population, proportionate to their population, that's how we're doing it now. There's no measure of need. I understand that comparisons are odious. I understand that it will reveal massive differences between communities but right now you're not managing by outcomes. I'll just leave you with one thought. A very famous person in health services and policy once said what gets measured gets acted on. Right now nothing's being measured. I don't mind which instrument is used but I'm quite stunned by the inability to even have the conversation in the present climate at intergovernmental relations in Scotland. Measuring need, meeting need, funding need, anyone, any takers? That was certainly one of the things that I had on my list of things to say today and I agree with everything which Philip Wilson has said and both Professor Frank. I suppose for the committee I mean I suppose I wasn't aware if you were aware yourselves of some of the initiatives that the Scottish Government have been trying to pursue through the joint improvement team and some of the relationships with local authorities around doing population-wide surveys of course both in the context of some of the great work which has gone through Gus as well and seeing how that can complement some of that. I would just I suppose one of my reflections is having been close to some of the development of some of those projects we shouldn't lose sight of the fact that there are people in our society who can be quite resistant to some of these things and we should be aware that there is sometimes parental pushback and some of this and I think that's probably a failure in how we communicate the benefits of this and I think sometimes because of that challenge we've gone about it in a way which perhaps could be perceived to be a little bit mischievous and devious and that's not the case and that's not our intention but I think we need to be clear about our intentions and promote the benefits in terms of planning for outcomes. Alan Sinclair, Jonathan Shear, Dr Boston and Dr Sarah Hill. See if I can remember all of that now. Alan. Thank you, thank you. I'm trying to remember the original question here which was one about daycare and I have to tell you I'm getting increasingly concerned that we think daycare is the answer to early years because I think it obfuscates the issues. Daycare normally starts at age three. The big issues in a child's life are from conception to three years of age and the more we talk about daycare the more I think we get ourselves up into our cul-de-sac. Significantly more important is the issue that John Frank has raised which gathers zero attention which is we don't even know how we're doing in Scotland. We haven't got these things measured and unless we do something like that I fear that we will continue to have rather pious and woolly and well intention discussions as a substitute for actually scientifically managed progress or the opposite of progress and we don't know whether we're going that way or this way at the moment but we have a lot of sound and pure. Yes, I'm speaking to you on behalf of Wavetrust and in the written submission there is a document that I commend to you done before I arrived at Wavetrust. There's no pride of authorship called conception to age two, the age of opportunity and some of you have already seen and had a chance to look at that but it contains a great deal of the latest evidence from around the world on what works and what doesn't work whether it's about improving the workforce or enhancing attachment. The crucial part of it is to follow up on Allen's point. It is about the age of opportunity being conception to age two and yet the conversation here continues to be a conversation about early years starting at preschool and I think that the focus needs to shift to pre birth to preschool if we're going to make the great difference and this was shown up in the in the news stories last week where it was where the all the attention was on closing the gap in terms of attain educational attainment. Closing the gap is a great thing to do. We absolutely should do what we can. Even better is preventing the gap from ever opening but we wait around until there's a gap and then try to think how can we close it instead of how do we not have the gap appear in the first place and in order for the gap not to appear in the first place we need to pay very careful attention to pre birth to preschool from our perspective that also means preconception health but I don't want to drag that out. I put it in here but yes there's plasticity and it is never too late to help a child obviously it's also never too early and I think that it is crucial for us to remember and begin to act on the declaration from the Scottish Parliament and the Scottish Government that we value preventative spending because we say that but thus far if you did a hard analysis of where the money is going and where the attention is going it's not on primary prevention and so in a sense I shouldn't have to to tell you what you've already publicly proclaimed it preventive spending could and should be the priority but that means really doing it you can make up for things that went wrong in the first place but there's no such thing as a second chance to make a good first impression and the impression that we make on children's brains on their emotions on their learning on their lives we have one chance to get that foundation right and if we do their trajectory is good if we don't we're going to keep spending extraordinary amounts of time effort and money on trying to catch up and redress what we failed to do in the first place. Dr Boston. Hi I'm an Institute of Health and Wellbeing at Glasgow University it's wonderful today all this talk about prevention but also we need to look more downstream at the more curative things as well and the more specific things in the context of the wider societal things and it was a pleasure to hear Professor Marmot and Sir Harry Burns talk as he did I think daycare yes I'm not an expert on that but also the parents and I couldn't leave here today without putting in a word for the parent attachment and parenting interventions and so on and it ties in with the other issue of reach and being a researcher we do need to look into more who we're reaching with the kinds of interventions that are being implemented and really better understand what kind of effect they're having on the most disadvantaged hardly any research work looks at the most disadvantaged because it's challenging because interventions can't always reach the most disadvantaged and I think that's what we need to think about more and in terms of my own work it's just popped up in my head all the prison work that I've done in the past young fathers empolement was mentioned I think by Harry Burns I mean they're literally a captive audience these guys empolement do a bit of work with them on parenting interventions monitor it see how that's working that's a huge thing that can be done for relatively little spend and I think it's just useful to say that in the context of the wider things that we're talking about also which is wonderful um Dr Hill um yeah just quick to come back to the issue of um thinking about Professor Frank's point about the need to measure and monitor what's going on in terms of early childhood development and also thinking about Ben Feroge's point about the fact there can be resistance from within communities I think it is important to recognise the the role of good parenting and attachment but I think that it's an area that's quite difficult for us to tackle from a policy perspective um certainly where there are interventions that can be offered I'm fully supportive of those but I think those interventions are only ever likely to reach a very small proportion of the population and I think that Professor Marmot made a really good point about the fact that in the end parents from less advantage circumstances struggle to do what they know is a component of good parenting because of all of the other pressures they're subjected to so I think we have to be realistic about the extent to which policy can really um address that while also acknowledging that we should do what we can and for that reason I think that I also think there's some risk if we if we only focus on those people that we regard as poor parents that we are reinforcing a sense of blame for those communities and that's often associated then with resistance to efforts to measure and monitor because those are seen as reinforcing this idea is that these disadvantaged communities are responsible for their own difficulties I think one of the real strengths of the monitoring instrument that Professor Frank is talking about is that it's not the way it's used is not associated with placing blame on specific schools that the point of the instrument is not to measure how those schools are performing it's to measure the capacity of those children when they reach p1 and p2 and that that's primarily used as a marker of need that the point of measuring that is to say which communities have the greatest need in terms of investment in early years education so I think that that's a really positive way that that instrument can be used and to come back to the point about workforce which you were asking us to discuss I think the advantage of looking at early childhood education preschool education is that there's a real opportunity there for policy makers to implement what Sir Michael Marmot refers to as proportionate universalism this as um as Bob Doris mentioned there is early child care provided which for which most all children are eligible at the moment at present the emphasis is on child care what I would be asking for is a shift to seeing that more as an opportunity for early child education and that alongside that we invest in the people that are providing care in those contexts and that we provide them with adequate support both so that they are fully qualified in childhood development and they're able to provide both um uh to help children particularly from disadvantaged backgrounds overcome the disadvantages associated with growing up in an environment where they may not have strong parenting but also so we're investing in supporting those people to provide the most nurturing um caring environment possible in one way there's continuity of care and that that I think is a policy um opportunity that it would be a shame for the government to mess just to add just to add my own it looked after element to some of that as well and during the discussions around the Children Young People Act there was um there was some debate as those proposals were being developed about the impact on children who are looked after at home or with kinship carers with the provision of a basically a full-time carer elsewhere essentially and the building of that attachment relationship rather than with their primary caregiver and I suppose that's just kind of a partial answer to your question and the need to do that and I suppose building on Dr Sarah Hill's point I suppose the in that list of things that perhaps we could wish some of that early years the workforce could do is perhaps working with parents to be able to provide those nurturing qualities that we need to see that they can then build on themselves rather than just providing a different space entirely in which we can build this. But suppose that the point that Professor Frank made is that if the finance and resources are determined by population levels and not necessarily focused on need then how does it how does it impact? How do you get that appropriate universalism Dr Scheer? I hope that my colleague Ellen Sinclair will say something about the experience in the Netherlands because it speaks to this but Sweden was mentioned by by Sir Michael and Sir Harry and one of the things that's different about Sweden is that that there is a universal service for parents of babies and very young children that it has a near universal reach. They don't spend a lot of time talking about hard to reach parents because it's not a concept that resonates there because it's something which is welcome and valued and attractive but what they do is there are opportunities and there's a sort of normal schedule that's just how life is where parents and babies show up 12 times between birth and age two and what's true for them good, bad or indifferent is assessed and when something is found that's a concern there is a transition more or less seamless to getting the support and help that's needed to deal as early as the as the concern is raised and you just do that over and over and over again so the issue of of there being a big gap when they're three years old or going into school at primary doesn't happen and it doesn't happen because it was prevented from happening and I just wanted to use the Swedish example as a very as a very clear one of of how it really works in the real world to to make prevention a normal feature of what government supports and what parents sign up for and participate in freely happily and gratefully. I can partly held back because we've had so much sort of policy tourism going on visiting different countries but I'm trying to find a way of describing why I became a fan of Netherlands in 30 words and it goes on a few things which is when I've talked to you about supporting parents very frequently in Britain people convert that you mean with intervening we're making an intervention we're stepping over the line in Holland I've spent mornings in the most deprived part of Holland where people are coming up to all their regular appointments because they do it from birth right up to school age and they have about 12 14 appointments and they come because this is a help to them and they know the nurse they know the doctor I also do management work in in Holland and without talking about the early years and at this time last year a very successful business person was telling me about who about his family and how the nurses have been helping them with particular issue with their twins it was universal it was there for everyone it was non-stigmatised it was part of what everybody did what worries me about health inequalities and early years is that I fear that we're getting to a position where we think that help with children is what we do for the feckless rather than for the population of people who are suffering and I live in the very leafy part of Glasgow and if I go down my street and I give you the catalogue of problems of middle-class children it would it's terrifying these people are struggling these children have struggled someone we're now dead others are self-harming we have a serious issue here across our society and we are in danger of putting it into a corner where it's about childcare and it's about the feckless actually it's how we operate as a society and if I can disagree with Sarah Hill there are very very clear ways of doing this and the family centres that they have in Holland with the mother and baby wellbeing has been going for a hundred years or more it's well established it's cherished and it's made a very big difference in Holland because on most international indicators those that are doing best on child wellbeing are actually as Holland by a long way. Do families have to access those centres or is it an optional extra I suppose I'm just trying to get to some of the sort of cultural elements that are under pressure. It almost doesn't apply people come because they want to come and they see it as a help but if you do not make a few appointments someone will come and knock at your door to find out why have you not come so there's a long stop but actually it's a long way before you get to the long stop because there is such an overwhelming acceptance that this is this is a help. Richard Simpson I think that the point that Professor Frank's making about monitoring is really you know looking at where we've got to with these early years is very important I mean this is not new I said in the last session we've had family centres sure start home start you know nursery education at three and four we've had that now for some of it to for 10 or 12 years but we don't know actually whether that's really worked there's been some research but not a lot can I ask anyone here to tell us what we should stop measuring so we can measure what's appropriate because we seem to have measured just about everything that moves in terms of process in terms of inputs and throughputs and outputs but not outcomes so you know if people can tell us what we can do that we can then maybe afford to have what is it sounds like a very simple measure at five to say yeah well in this area in this local authority area with that programme this seems to be working with that programme it's not and therefore we stop doing it any takers well Richard I know that you kind of know the answer to this because I know that you are a researcher and a physician but I'll just say that quite a lot of useless hand wringing occurs in Scotland because the annual report on health inequalities which is technically superb by far best in the world technically nothing wrong with it I say that as an epidemiologist but of the 11 health outcomes analysed again and again six years in a row all but one occur far too late in life to be influenced by any policy within five years because they're based on deaths and hospitalizations that are predominantly past age 50 or 60 and not saying that those people shouldn't have the best possible preventive care and clinical care I'm just saying that that will not direct you towards the upstream drivers the determinants of health because you're doing tombstone epidemiology you know and the one measure that it looks at for early life is low birth weight babies the main driver of which prematurity was very carefully reviewed last year by a world class team and published in the Lancet in which they pointed out that we know so little about preventing prematurity that we could only reduce it by five percent of its current levels even if we implemented everything we knew so let's not measure stuff we can't change let's not ring our hands about stuff that's too far gone let's focus on things that we could change in Perth Australia they managed to change the edi scores this is the instrument we were piloted to be piloted and slowly in less than five years they massively shifted the deprived communities edi scores by putting in place reading programs activity programs parent child programs within walking distance of people's homes it's not rocket science this is allison leslie's tombstone figures not you know not not leaders to you know and chill mortality you know some debate there or or indeed you know where we stand out where we have got a high number of of school age children still you know what what can we not use these figures to direct in interesting enough with sort of mortality data it's actually the other way round because the deaths that you can make a difference in are the older children the majority of children who die in scotland are aged under six months half of all children who die in scotland are a year and under and a lot of that are around sort of congenital sort of conditions at birth and so on things that we don't know enough about yet we can't do a lot about the ones that we can actually do things about which are the deaths that where we really sort of are in a sort of shameful position in relation to the rest of Europe are sort of trauma deaths which are sort of you know road traffic accidents suicides deaths from reckless behaviour deaths where there's an element of alcohol or sort of our drugs involved these are the ones that we can do something about these are the modifiable ones that sort of when you you're looking at there and i think again one of the things is if you take for example things like teenage suicide which gets a lot of publicity just now the problem is we don't know enough we don't know what the relationship between the pre-existing and predisposing factors in a child's life and circumstances and the precipitating factors whether it is sort of you know bullying or something in their circumstances we don't know enough about that we don't know what we've not looked careful enough at you know what is happening in other countries where the the rate of teenage suicide is is significantly lower and what's working there that we're not doing here and it's an area which is is really under research and i think we you know is going to be sort of one of the next years we we need to sort of think about as a country get to understand the problem more before we start putting the solution in. The disproportionate number will have been in care a disproportionate number will have been identified on child protection registers we will know we know the number of children who are on child protection registers who are suffering abuse violent abuse etc and i suppose you know where are they how does that trigger a reaction how does that trigger the services are the services there you know to to to help these children children first said in mental health services and child councillors only 10 in scotland and we've got a thousand every year on the child protection register yeah so even we have the information negative if not the outcomes are we acting appropriately appropriately to make a difference in the lives of these children Ben sorry well i was just going to say that i think what what what what i'm hearing sort of slightly implicit in what you were saying there is the issue of thresholds which i think are a reality for lots of communities you know how how bad do things have to get before the intervention is provided and i do use the word intervention consciously Alan because i think that is actually often what it is and and that and that is a concern i think i think mental health is a good example there of where things have been pushed into a sort of cams lens which is a highly specialist service really for for things and and and we have a sense that the people have to reach that threshold when actually mental health services should be if should be about well-being a much lower base so jonathan shear allison lesley is is right that there's a lot that we don't know but there's also a good deal that we do know and i think one of the subjects which hasn't been explicitly stated that connects some of these topics is the issue of child maltreatment meaning abuse and neglect and growing up with domestic violence or in toxic violent environments and and it makes a difference in very long-term health and that there's a whole raft of studies which are are retrospective the that generally are classified as the ace studies at adverse childhood experience studies looking back mostly i have to say from middle class and up people at the at the adverse effects in childhood the maltreatment or other adversity they encountered and the essence of what they've said is that the more adverse childhood experience you've had in your very earliest years the higher the rates of of cancer of heart disease of of early death that that the the connection between what happens in the very earliest time in the first thousand and one days of life has a lifelong effect and if it's negative a life shortening and life debilitating and life illness producing effect so we we do know something about what causes it and but for example one of the things that is rarely mentioned or perhaps because it's not understood is that the majority of child maltreatment abuse neglect domestic violence the children affected by that most um are the children birth to one i mean there's this sort of image of child abuse as being something with a seven year old being smacked around but in fact the that's not where it starts it starts in in those first thousand and one days of life and so if we want to reduce teen suicides and we want to reduce mental health problems and we want to reduce longer term physical health problems and costs the time to do that is those first thousand and one days of life and and even going back to the preconception part um it is important you know one one thing that we do not do in scotland i'd like to say one good thing and one not so good thing one not so good thing is that for all we talk about parenting and are willing to blame parents when things go awry we do not as a society take seriously preparing and supporting the next generation of parents again with it's the same habit we wait until things go wrong and then we react instead of getting it right from the beginning and preparing the next generation in a healthy in a healthy way the good thing i want to say is that attachment i think is indicative of something that's really worked well when i came to scotland nine years ago the only time attachment was ever talked about was when it went horribly wrong and was a psychiatric problem that needed intense special treatment now only nine years later attachment is talked about as and increasingly being dealt with as something that is about everybody as alan said it isn't just some marginal issue for those people over there attachment the basic bond between a baby and parent is something that doesn't respect socioeconomic boundaries if getting it right for any people for any socioeconomic group is crucially important and that's finally been learned and so we are now acting on that understanding not waiting for it to become a psychiatric disorder for a few children and that's commendable as his as is this whole inquiry on early years thank you dr boston and i discover quick mention as well of a study we're doing in my department is a three armed rct called thrive which involves enhanced triple p for babies it involves mellow babies and care as usual and it's not going to be reporting back fully till 2017 which i know isn't great for you guys but the outcomes one of the outcomes is going to be child maltreatment and totally take a point there about parents and inventions and stigma and it's such a hugely political thing but it shouldn't be most parents want to be good parents and if there's help there and you're being recruited during pregnancy then it's important to monitor what is happening and hopefully adapt things so that the women who really feel that they want and need this kind of help can access it and we'll be measuring it you know really thoroughly and properly and so on so it's quite an important trial issue of parenting i wonder if i haven't considered perhaps as in scandinavia countries many parents carers might want to stay at home with the baby for the first two years but they have to return to work because of the poverty side of things because they need to earn a living you know that would be a universal measure that if people could have the choice should they want to to stay at home that they would maybe still have half pay or what have you and that would give them the luxury and the enjoyment of staying at home and bonding with their child and that you know i'm all for the workforce development but i equally think you know many parents would enjoy staying at home and being with their child and you know it links in with the attachment thing as well childcare that to put those two together in finland if you choose to stay at home thanks to the rural party arguing the case then you can get paid the equivalent of what it would cost the state to put you into the child into nursery so that you're staying at home when you get the money for it whereas we think it's a good thing to put children in nursery and put the subsidy is it not a good thing that people look after their own children it just shows you know it's a very strange lot of thinking you know who goes to parenting classes for driving cars and operating television controls now but we don't do it for for people it's not a one to one son right okay richard leogh yes i found this discussion very good and i could cover many points my mother-in-law was dutch went to holland many a time and i found that actually holland was well in front of us in many things and but also their benefit levels were much higher than what they are what they are here daycare zero to three i would say it's first of all it's parents local play groups now it's grandparents my daughter recently had a another baby my grandson was two last friday and his development i put him to sleep by singing to him which is basically a situation but he loves reading books and he loves and doing jigsaws etc and i can see the development in the last couple of months of how he has developed but sometimes i feel as though we we feel that the kids should be put on too fast but again the question i really want to ask to him convening and i think it really it was pointed out the first session but it really wasn't developed we've got a minimum wage we've got 11 wage when i worked when i was self-employed i always believed if i am 10 pound an hour i was making a decent amount of money minimum wage and 11 wage is still under 300 pounds a week i dealt with a case yesterday where the person because of certain income benefit levels there's housing benefit had fallen but the income had went up and down like a yoyo and basically they fall into housing areas and we got it sorted out yesterday but basically a situation i want to ask what would happen if we actually and you see employers on the television and say oh no we can't pay this wage but if we actually raised the wages to a decent level that people could actually afford and also stay at home i actually stopped my wife working many years ago to look after our kids i've got two great kids and two great jobs and basically i think that but i was able to do that because i went out and was able to work i was never unemployed i was lucky that way although i was made redundant twice but if we developed and increased the wages the income for people so that people had a decent wage would that not lift people out of poverty or is that being simplistic that's a question i want to ask professor flank so i think professor marmot said this but i'll say it again you have to do that but it's not enough you have to do that because and there's a great new report um from harvard university you can get it through gram allen's website the english mp um which explains in very plain language how a childhood in poverty changes the way your brain and particularly your stress response functions and it turns it on it can turn it on so in such a fashion that you can't turn it off and it starts a process of chronic disease development prematurely so given that you have no choice if you want to have a humane scotland if you want the kind of scotland that seems everyone in this room wants you have to get rid of child poverty or get it down to the levels that we heard professor marmot describing uh but you will still remain having you still have to deal with elements of culture including elements of the culture as it influences the way parents behave not all but some and you'll have to deal with the fact that communities are not all equally able to support parents and give them opportunities to do things with their kids that are accessible so you got to do that we've got to do that i'm not going anywhere i'm staying here we got to get rid of child poverty just as we need to get rid of pension or poverty that's a dreadful situation but that's not up with here to talk about today but don't think it'll just fix the problem it's like universal health care which we also can in canada enjoy for not quite as long as the UK you've got to do it if you want a humane society but it won't level the entire playing field of life anyone else yes allison can i just come back to a point that was raised in the earlier session about child protection and about the rules and regulations and the way that they affect we react to children because i think it picks up on what Professor Frank was saying about alongside initiatives to sort of redress sort of financial inequalities in society we also need to be looking at you know how we ensure children have the most positive experiences outside the home if they're not getting them in the home and how awful must it be if you are three-year-old and what you learn at your nursery a daycare centre is if you fall over sort of you know no one is going to comfort you you'll we sat down and someone will be sent for to come and put the bandage on your knee or give you a hug or change or whatever because of all the the the sort of you know rules and regulations around sort of you know what's called child protection now i spend the vast majority of my professional life reviewing and investigating the cases where things go terribly wrong and children die as a result of mild treatment and because of the things i've seen over the year there is no one more hawkish about child protection than i am but frankly i think in terms of the the culture and the ethos that's going up around about it you know we have gone completely bonkers as a society it is ridiculous the kind of things we've talked about earlier that people can't hug a child that people can't reach out to a child particularly when a child's in distress and i think that there is something about sort of you know working with sort of you know people who are delivering that valuable job of caring for children whether it's sort of as as sort of extended family whether it's sort of in care settings whether it's sort of daycare nurses or whatever to sort of change the message and i think one of the things that the simplest things we can do is to actually stop talking about child protection if you think of the analogy of data protection as soon as you start to talk about data protection we lost a sense about what legislation was about which the legislation is actually about enabling you to share sort of data in a way that sort of is respectful of people's privacy and the more we talk about child protection what we're creating is this sense of we've got to sort of take children and sort of you know put them someplace sort of safe away from everyone what we're actually should be about is sort of child nurturing and i think we've got to one of the simple things we can do is actually change the language there we're coming to a close of this session and i know that committee members have got pressures elsewhere but i'll give and we've got lots of good written evidence from from the all but obviously unless any committee members are pressing rhoda sorry i was trying to get in earlier but i suppose specifically and it falls on from what Alice and Leslie was saying about submissions we've had about looked after children i mean we've talked about generally about children and their life chances when you take looked after children out of the equation suddenly life chances you know it becomes hugely different and and very very negative and i suppose given time in that what can we do differently about looked after children that actually changes that life chances because it seems to be the moment that badge goes on to them their life changes are kind of disastrously impacted i wish i had a nice simple answer to that question but of course there isn't and i think the the the the parliamentary inquiry into decision making around looked after children that took place in 2013 i think kind of opened up the wide complexity of that of that question of that sort of simple question what can we do and i suppose i would probably echo some of what jonathan and allen have been saying and my fellow colleagues say today which is that actually it's about actually it is about the children and young people of course but it's actually about saying often there is a younger sibling on the way going to be coming and it's about getting in systems in place to make sure that the life for that child who's going to be born and going to be grown up is going to be improved absolutely we need better services i'm a big advocate for better services for looked after children targeted services and a wider sense of universe access to universal services help to support those i mean i'm very conscious of we're thinking just about health that for some looked after children they have access to a lack nurse and some don't and that's not even a matter of whether their placement type is where they are in Scotland and that is perhaps a concern and self-reported by them it's a fantastic service you know it's somebody who they can trust it's an attachment relationship that we've been talking about an important one and somebody who can support them with their health so there are those interventions that i think would be good but you know do we do enough with the families that we know are going to be having more children i might give a very specific response about looked after children which is that what we know is that um care leavers are disproportionately represented among early parents many more care leavers will have children very early than the population as a whole and we know that they're disproportionately represented among parents who will have children who will become looked after themselves there's a non-genetic intergenerational problem here but what we don't do at this point and what we could do is is work much more intensively with looked after children care leavers as prospective parents and do the preconception health things that are needed so that they first of all can make an informed empowered choice about whether they want to become parents at all and if so when and when being contingent upon what's true of them in their lives so that they're ready to become good parents because they want like everybody else they want to have healthy thriving happy babies and they want to have a happy parenting um relationship with those babies but we're not doing anything to prepare them we keep dealing with them as individuals as opposed to understanding that in addition to being individuals they also are parents and prospective parents that's something we could do now that would make an intergenerational difference here simply yep it's the newer lanes pilot in Glasgow which i think mentioned briefly earlier is astoundingly interesting because it simultaneously works with the birth family and works with the fostering family and the child in both settings and simultaneously plans is the child going to move to the foster family to adopt or will they go back because they're trying to put intensive help and support into the birth family to see within a period of time if that can be a safe home because at the moment we are constrained by the nature of law and health care and the decision making that goes on there is not the kind of decision making that goes on in the child's life and attachment and what the pilot is doing basing on very good work that's going on in the States is trying to put that into Glasgow just now i think is astounding we have come to the end but i'm happy if people want to leave us with a thought you know that you know much do or whatever then i'll give you that opportunity now i ask you to see this as a live process so what you've heard today and what you've discussed today can be followed up by email and we'd be happy to receive additional you know does does anyone want to leave us with a final thought or i'm not going to encourage you Jonathan you see you're looking over it i'm seeing me raising it well can i on behalf of the committee thank you all for your the the time you've given us this morning and we'll look forward to engaging with you in the future on on these difficult and challenging issues thank you very much for your team this morning coming along thank you thank you thanks