The first five years of life provide the best possible opportunity to lay the foundations for health and well-being. Securing the best possible outcomes for children and young people requires consideration of emotional, behavioural, cognitive and psychological development. Approaches that support individuals, families and communities to develop their potential are more likely to reduce the risk of future health-related problems.

Why the early years are important

The Equally well task force states that ‘... this means continuing to support the full range of preventative services, focusing not only on the early years, but also on areas such as family support, education and learning support, employability services, drugs and alcohol services, community policing and services targeted at vulnerable groups such as looked after children and offenders’.

The healthy development of babies and young children is essential to improving future population health and reducing early deaths from preventable disease [1]. The foundations for future physical, intellectual and emotional development, health and well-being are laid down in the antenatal and early childhood periods. Exposure to positive experiences, social and environmental circumstances can have lifelong effects on an individual’s risk of obesity, heart disease, mental health, educational attainment and economic status [2]. Healthier physical and social environments support and encourage competent and confident individuals and communities to achieve their health potential. To make inroads into the health gap faced by some communities, health, local authority and third sector organisations need to work with local people to implement policies and practices that increase their resilience to deal with adverse events and reduce their exposure to harm. This requires knowledge and understanding to foster health assets and increase capacity for health. Health assets include people’s aspirations and sense of control over their lives within the community. It is a social model that recognises the context in which individuals live their lives, and the various protective, or harmful, interpersonal relationship processes that shape communities. Equal weight should be given to measuring their strengths, abilities and aspirations as well as to the individual’s health needs and their ability to benefit from interventions designed to tackle the specific risks they face [3].

Children require appropriate love and stimulation – provided by parents/carers, nursery and pre-school experiences. Therefore, all universal services should support children so they may realise their potential. Action with individuals and families in the early years requires an environment which supports access to education for child and parent, adequate income for food, fuel, housing and good quality child care. Evidence has identified a clear link between social policy particularly ‘family generosity’ and outcomes for children and their families. This is illustrated by Figure 1.

Figure 1

Family Generosity and infant mortality [9]

Support from the start

A focus on action in the early years, which is preventive, seeks to avoid problems occurring in the first place. It is a more effective use of resources than waiting until crises develop before intervening. Many of the risk factors for poor health outcomes are interlinked, so they should not be addressed in isolation. Effective interventions should foster multi-agency service provision which take account of the whole family and their life circumstances, supporting children, families and carers. Services should help to build capacity and resilience in individuals and families to deal with events rather than be defeated by the challenges of everyday life. This requires public services to work together in preventing health-related problems across society.

It is collective action which is required to achieve comprehensive health improvement and effective partnership working. This is challenging and the types of partnership required to affect populations health are among the most difficult to sustain. Such partnerships require targeted actions over sustained periods so that real change is possible [4].

There are many examples of early years intervention work being taken forward by NHS Lothian in partnership with other agencies, all supporting a multi-faceted approach. Some of these are actions that help to avoid a problem occurring in the first place and some of the interventions address existing behaviours and circumstances which have the potential to cause a health-related problem. The health service, whilst it can make a significant contribution, cannot undertake the work required for the ‘best possible start’ in isolation. Recommendations based on the evidence from the early years intervention work and some of the work being undertaken in Lothian to support those recommendations is described below.

Parenting support

Parenting support should provide a range of opportunities to help parents and prospective parents understand their own social, emotional, psychological and physical needs and those of their children and enhance the relationship between them. Multi-agency parenting strategies exist in all local authority areas [4, 5, 6]. Each is aiming to increase parenting capacity by offering opportunities for staff working with parents and also parents themselves to develop their skills in parenting. The aim is to offer support to parents as need dictates.

The Family Nurse Partnership is also being tested in Edinburgh. This programme, developed by David Olds in the USA, is an intensive home visiting programme for young, vulnerable first-time mothers offering support in their role as parents [8].

Support for good quality early learning

Parents/carers are not the only key contact for children in their early years, nursery nurses and early-years teachers are also essential. High quality opportunities for early learning can minimise the adverse impact of adversity in the early years and improve school readiness. In taking a multi-faceted approach to early intervention for children it is therefore essential to ensure capacity and appropriate workforce skills across relevant agencies. For example, the national Equally Well Sites in East Lothian and Midlothian both focus on improving multi-agency service provision so that all children are best able to make the most of the opportunities for education upon entry into school at the age of five years [10]. The programme is designed to reduce the risk of disadvantage in health outcomes being passed from one generation to the next.

Support for breastfeeding and early nutrition

Supporting an increase in breastfeeding rates and evidence-based practice in infant feeding is an essential part of improving nutrition levels in children. In a developed country like Scotland, similar interventions can be used to reduce the risk of obesity and malnutrition. This should be done by creating an environment which helps women to initiate and maintain successful breastfeeding. Early childhood is also crucial in establishing healthy eating habits to introduce healthy foods as fun before they are required as fuel and to learn a healthy balance between food and physical activity. Example of projects in Lothian include: the NHS Lothian refreshed Breastfeeding and Infant Feeding Strategy; community food projects and support for developing skills in producing healthy family meals [11].

Becoming smoke free

The use of tobacco in pregnancy is one of the most important risk factors for foetal growth and development and whilst many women quit smoking without assistance, support to stop remains important and every opportunity should be taken to provide support and advice, access to services and increase the proportion of homes and cars that are smoke free. NHS Lothian has a comprehensive smoking cessation programme which pregnant women are able to access.

Developing a family-centred-approach

Preventive activities need to be sustained and extended further so that they are core to universal provision, with additional support where need is greatest. Child development is influenced by many factors in the family, community and broader socio-economic environment. Effecting real change requires action at home, at work, and at policy level. The NHS, as an employer of a significant number of parents on lower incomes has a particular responsibility to ensure that its policies and practice support its ambition to contribute to giving every child the best start in life.

Key points


A sustained commitment to multiple interventions in the early years and early responses as problems emerge is required for real change in the health outcomes in our population. Evidence supports action on parenting support, good quality early learning opportunities for all children, increasing breastfeeding rates, reducing smoking in pregnancy and tackling child poverty.

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