Background
Methods
Study design and setting
Sampling and data collection
Phase 1: Shallow dive interviews
Phase 2: Semi-structured interviews
Interview guides
Data analysis
Validation of themes
Results
Participant profile
Stakeholder group | Local | National |
---|---|---|
Parentsa | 59 | N/A |
Local Authority staff (managers and frontline) | 19 | N/A |
Health professionals | 8 | 2 |
NGOs/advocacy groups | 5 | 8 |
Retailers | 3 | 8 |
Sub-total | 94 | 18 |
Total | 112 |
Aim 1: To examine stakeholders’ perspectives and experiences of HS in England
HS is wanted and needed, especially now
“Having the digital card now is so much better, I have more flexibility as to where to spend the money, it makes a huge difference. There are no problems using the card and I have much less anxiety.” Mother, ID6005Although communications about the scheme’s changes were issued directly to families, many struggled to sign up successfully due to lack of digital access or skills, not appreciating the need to reapply, or other problems with transition to the digital system.“We have high levels of digital exclusion in the two most deprived wards where we work. This was a major issue when the scheme went digital, we have a cohort of families that are particularly hard to reach. They don’t come into the children’s centres, so it was difficult to let them know they needed to reapply and a lot of them probably haven’t done that.” Local Authority, ID5038
“My children’s diets improved as a direct result of Healthy Start because I always knew I had that extra bit of money each week to get just fruits and milk. Without Healthy Start you have to think ‘maybe this week I can do without’.” Mother, ID6003Many stakeholders recognised that HS also offers wider benefits for families.“Healthy Start is not only about food, healthy diet impacts on everything, including mental health and it’s about so much more than food.” Local Authority, ID5008
“I like to give them fruit and milk every day but some of that will come to an end [now Healthy Start has stopped]. I am thinking carefully about what foods to give each day as now I can’t afford milk and fruit every day. But how do I explain that to my 4‐year‐old?” Mother, ID6005“The upper age limit should be increased to dovetail with FSM because nutrient requirements don’t end when a child turns 4.” National Health Professional, ID5004
“I don’t want to be ungrateful for the help but after buying enough milk for the baby there is only £3‐4 left over in the month, so I buy veg with the rest. Due to rising cost of milk the value of the card goes a lot less far than before.” Mother, ID6004“The money is good, but it doesn’t go very far with food inflation and prices as they are now.” National retailer, ID5010
Raising uptake is about more than just awareness
“People hear about HS and think ‘that’s not for me’ and we need to do more to understand why that is and what those barriers are for some families.” National NGO, ID5040.“HS is the white people’s thing, that’s not for us.” Local Authority, ID5033.“Often it’s the male partner who does the benefits applications and the woman is not involved, so even though she may hear about HS she thinks he is taking care of that side of things.” Local Health Professional, ID5029.
“I’m afraid it might make me lose other benefits or I might be asked to pay it back if it turns out I’m not eligible.” Mother, ID6005.
“When I first applied for HS [in Summer 2022] NHSBSA asked me for the same information more than ten times, and I was asked to send the same documents again and again. I started to worry where all this data about me and my kids was going as they kept asking for it.” Mother, ID6004.“I don’t want people to know my circumstances and personal details. I don’t really trust anyone.” Mother, ID7037.
“People’s circumstances change, and they might need to take benefits, they should not feel ashamed, but they feel other people think ‘I am lazy because I’m on benefits’.” Mother, ID6004.“Can we reword things so that people understand this is for them to help feed their children and they are entitled to it.” Local Authority, ID5008.
“The application is too long or too difficult for some people. They think it’s too much information they have to put in, usually doing it on their phone and it’s such a small screen, they think it’s formal and it puts them off; some of our families don’t have the literacy or the digital skills and they get put off very easily.” Local Authority, ID5032.“They need to give an advice line so someone can help explain the reasons [if you are unsuccessful].” Mother, ID7028.
It is not always clear who can apply
“I would have given up if the midwife I happened to meet at a local baby event had not intervened on my behalf. The refuge workers tried, the Sure Start centre people tried, but no one could help me until there was a personal contact at NHSBSA via this midwife. This is definitely not a robust or fair system.” Mother, ID6004.“It’s just too complicated, it should be much simpler criteria. Frontline staff are so swamped they shouldn’t have to be struggling with this. We are constantly trying to demystify Healthy Start to frontline staff.” Local Authority, ID5028.“The income limit is appalling, I do think it’s appalling, even the real living wage is more than that.” Local Authority, ID5033.
“There are so many young parents being denied HS and they are entitled to it, the paper application system for them is not working.” Local Health Professional, ID5013.“There is not a clear understanding about the criteria for asylum seekers and those with no recourse to public funds (NRPF). I get so many queries from frontline staff. Everyone is confused and it’s so complicated—people just apply to flag the desperate need to government for this group.” Local Health Professional, ID5025.
“The biggest barrier to accessing Healthy Start is having to apply in the first place. It’s unnecessary and wastes a huge amount of everyone’s time, energy and resources that could be better spent elsewhere.” Local Authority, ID5028.“The idea of Healthy Start is fantastic, but we would prefer our families to get automatic access instead of having to apply for it because we have a lot of digital exclusion, a lot of our families live chaotic lives, they have not great literacy. For the families we work with it’s just a step too far for them.” Local Health Professional, ID5039.
There is a disconnection of services at local and national levels
“We need a BSA regional point of contact who can troubleshoot individual cases, someone who knows the system and works with us to get claims through.” Local Health Professional, ID5013.“There is much less support now compared with back in 2008, there is a lot less contact with health professionals and especially after the birth they didn’t help enough, you need that support [for schemes like HS] but it is not there.” Mother, ID6003.“Since the pandemic everything has become a bit faceless.” Local Authority, ID5008.
“Why can’t the Job Centre use the Universal Credit journal to tell people about HS?” National NGO, ID5004.“Why can’t new parents be told about HS when they register the birth of a child?” Local Authority, ID5005.“Families come into contact with different services many times from pregnancy to when a child turns 2 years old, if these touchpoints were mapped and coordinated families would not miss out.” Local Authority, ID5017.
“All the government organisations are working in isolation and if they would work together more we could probably pick up all the people that are missing out.” Local Authority, ID5032.“Why can’t DWP send us a list of those eligible for HS just like DfE sends us a list of the eligible 2 s, that would allow us to get everyone signed up so easily.” Local Authority, ID5034.
Capacity and resources are lacking
“The drop off in uptake can be tracked to the reduction in resourcing for early years services through austerity.” National NGO, ID5002.“There have been extensive cuts and nationally there are not enough health visitors, we had a big call for action about 10 years ago, 1000s were trained and recruited, but we now have fewer health visitors than we had then due to cuts, changing structures, retirement, changed workload after Covid etc.” National Health Professional, ID5004.“Voluntary sector organisations themselves are feeling very vulnerable due to rising energy costs and other increases. They tell us they might not be able to survive, and this really worries us because we have such a vibrant and dynamic voluntary sector in the city. This is a huge risk to families and could affect them significantly.” Local Authority, ID5009.
“Everybody is struggling with capacity, so it needs to be everybody’s business and not one person’s responsibility.” National Health Professional, ID5003.“We can’t expect the midwife to be all singing, all dancing, knowing about everything, because we haven’t got the capacity to do that, even though we would love to be able to do that, we just don’t have the capacity.” Local Health Professional, ID5013.
“We want to do better but we have to look at what is the highest priority with any family that comes in the door. The Healthy Start application is a huge task – maybe we do short promotions, say 3 per year in order to really focus on getting families signed up.” Local Authority, ID5018.
Stronger leadership and accountability are needed
“Healthy Start should be everybody’s business, there are many professionals that come into contact with families, if it was on everyone’s KPIs then we would all be accountable.” Local Authority, ID5008.
“Currently there is no accountability for getting a family onto HS because it’s not clear whose job it is and I might think the midwife will do it but she might think I’m doing it, because it’s not anyone’s actual responsibility.” Local Health Professional, ID5039.
“Targeted promotion of the scheme in certain geographic areas where uptake is low – this is an easy ask to retailers. If we all act together in a specific postcode or local authority, everyone would be up for that.” National Retailer, ID5021.“HS don’t provide promotional resources or materials for free. We don’t have a budget for printing, we don’t have colour printers either. A digital promotional pack is not good enough.” Local Authority ID5017.“It was hard to engage with the team running HS and I don’t think they understood clearly the reach that we have as retailers, that was a bit of a barrier to the digitalisation which was a shame.” National Retailer, ID5050.
Aim 2: To identify stakeholder recommendations to improve effectiveness and take-up of HS in England
Policy recommendation | Illustrative quote |
---|---|
1. Continue to offer Healthy Start to families and assess how much the current value enables families to purchase | |
Healthy Start is an extremely valuable government food policy, unanimously supported by all stakeholders. The overall value is seen to offer less than in the past due to increasing food prices | “My view of Healthy Start is overwhelming positive, make no mistake, this scheme makes a real, tangible and significant difference to household food budgets, as well as to the dietary intake of young children.” National NGO, ID5040 |
“It’s a fantastic benefit and if only it could be in line with inflation. Nowadays it doesn’t even come close to covering the cost of formula or enough fruit and veg for a week.” Local Authority, ID5036 | |
“Healthy Start is a life saver, but since the cost of living it just doesn’t cover anything anymore” Mother, ID7016 | |
2. Establish a solution-driven, cross departmental Healthy Start specific working group | |
Develop a solution-driven cross departmental working group for HS (including DHSC, NHSBSA, DWP, DLUHC, HMRC, His Majesty’s Treasury, Cabinet Office) to explore and coordinate activities such as data sharing, touchpoints across statutory services to flag the scheme to eligible families, options for opt-out implementation and extending provision until a child starts school | “All the work that is done like training local professionals and HS Champions, the impact on uptake is marginal. It is smaller than we would like. This is the key point to Government, here we are putting all the blood, sweat and tears into promoting Healthy Start and helping families to apply, but still there is only a marginal increase, because local action is no substitute for national policy and coordination.” National NGO, ID5040 |
“Healthy Start should continue until the child starts school, it’s a no brainer in terms of childhood development and where is the evidence that nutrient requirements change when a child turns 4?" Local NGO, ID5044 | |
“It should not be a fighting battle to get Healthy Start. It should be automatic via auto-enrolment for eligible families.” Local Authority, ID5028 | |
3. Reframe the language surrounding Healthy Start to co-create appropriate and inclusive wording | |
It is important to work with a wide range of families to develop wording to promote and describe Healthy Start that is inclusive, empowering and enables everyone to feel comfortable talking about the right for children to access a healthy diet and develop well | “It’s all part of the messaging campaign, it’s about how it is framed, you know, 'You have a right to this, to feed your children, it won’t affect your other payments, you meet the eligibility criteria.’ Some clarity around this message is needed.” National NGO, ID5040 |
“White British families are accessing this support much more than ethnic community populations. We need to work better with community leaders and groups to talk about HS more, through trusted relationships, to move families forward with it. Find out what the barriers are for those communities.” Local Authority, ID5008 | |
“People feel they don’t want to take more from the government who have already given so much and therefore they don’t apply out of shame or pride.” Local Authority, ID5028 | |
“Parent champions are essential for taking the Healthy Start message back to the Bangladeshi and Chinese communities.” Local NGO, ID5044 | |
4. Provide national leadership on a Healthy Start promotional campaign, ensuring coordinated activity and adequate resourcing for providing families with a helping hand to complete the application | |
National leadership on a promotional campaign is needed to coordinate action by public, private and voluntary sector stakeholders. Adequate resources are needed for local services to provide a helping hand to family through the application process and resource promotional activities | “National leadership and investment in promotional campaigns are needed, to bring together all the local stakeholders including the public, private and voluntary sectors.” Local health professional, ID5013 |
“We know hand-holding works well for a lot of our complex families but we don’t have the resources to do that.” Local Authority ID5034 | |
“Job centre staff don’t have capacity to help people fill out the application form, they would ideally signpost families to local services that can help with that, but unfortunately due to lack of capacity in local statutory and voluntary sector there is limited support to do this.” Local Authority ID5053 | |
“Our workers come from the communities that they work in. They are having conversations with families all the time in many different settings including local parks.” Local Authority ID5036 | |
5. Hold regular and coordinated three-way communications between national, regional and local services | |
Regular communication between national, regional and local services would assist the flow of information, concerns and successes top down and bottom up. OHID regional teams could coordinate communication between stakeholders including local DWP teams, Local Authority teams such as Early Years, Children and Young People, 0–19 services, local voluntary sector organisations, and NHSBSA and national DHSC policymakers. Additional resource for these activities may be necessary | “Let’s not reinvent the wheel, let’s use existing structures like OHID regional teams to communicate about Healthy Start in a bottom up as well as top-down manner.” Local Authority, ID5012 |
“We need regular meetings with NHSBSA to start up again with open dialogue between us and them. We don’t always understand what the application problems are so if they could share more about that then we would know what to do to fix them.” Local Health professional, ID5013 | |
“The people at NHSBSA are very helpful and friendly but are clearly hugely under-resourced.” Local Authority, ID5038 | |
6. Coordinate local action, potentially through Health and Wellbeing Boards | |
Health and Wellbeing boards offer one mechanism for ensuring coordinated local action, monitoring and accountability, particularly if made statutory | “Local Health and Well-being Boards or their equivalent could lead a Healthy Start Steering Group with all relevant services as members including health, housing, education and others, to develop action plans, coordinate activities and monitor progress.” Local Health professional, ID5013 |
“Our research locally showed that no one had Healthy Start in their job role, so that was one of our main recommendations and now it is officially in the job role of a member of the local public health team. She coordinates the HS working group and is the focus point for coordinating action across the city, but we need more leadership and accountability to make a real difference.” Local NGO, ID5044 | |
“Give Healthy Start dedicated Council time in the debating chamber once a year perhaps to report on progress and debate why haven’t we achieved our target?” National NGO, ID5040 | |
7. Develop local “one-stop-shops” that are adequately resourced to support all families holistically | |
Families want a single place to go in their local communities where they can access a range of services, including a helping hand with Healthy Start applications. Community centres which are universal and recruit local people have been life-changing for some parents and families. Outreach facilities are necessary in rural areas and to reach the most vulnerable families not opening mainstream services | “We need more community-based spaces for families to access, and they must be open to all families, because if targeted then the intended families don’t go. These spaces are also important for modelling behaviour, e.g. how to read with your child, how to cook healthy foods.” Local Authority ID5008 |
“My daughter is going to uni now which I would never have believed ten years ago, but because of Sure Start I was able to deal with a lot of my mental health issues [….] and the help I got made me into the person I am now, working here and helping others like me.” Mother, ID6006 | |
“We have been able to work together with our local DWP Partnerships Manager to make sure all Job Centre staff know about HS and are able to talk to new suitable UC claimants about it in their Commitments Meeting. Thanks to this partnership working, all local DWP Work Coaches should understand what HS is and be able to advise families if they might be eligible or not.” Local Authority ID5053 | |
There are some families and some communities we just can’t reach, it’s about more than just awareness and training professionals, we need outreach workers, we need resources to do that, we need people from the community to reach out because of the trust issue. Local Authority ID5038 |