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Joint Committee on Children, Equality, Disability, Integration and Youth debate -
Tuesday, 9 Nov 2021

Strengthening Prevention and Early Intervention Supports to Children and Families Post Pandemic: Prevention & Early Intervention Network

We received apologies from Deputy Jennifer Murnane O'Connor, Senator Lynne Ruane and Senator Sharon Keogan. Deputy Jennifer Whitmore is substituting for Deputy Holly Cairns. Before we begin, I need to go through a few housekeeping matters. I ask any member or witness participating remotely who experiences any sound or technical issue, to let us know through the chat function. Otherwise, I will proceed. I advise everybody that as this is a public meeting, the chat function on Microsoft Teams should be used only to advise participants of any technical issue or urgent matter and should not be used to make general comments or statements. I remind members participating remotely to keep your devices on mute until you are invited to speak, and when you are speaking, I ask that, where possible, have your cameras switched on and be mindful we are in public session.

In addition, I remind members of the constitutional requirement that they must be physically present within the confines of the place in which Parliament has chosen to sit, namely, Leinster House, to participate in public meetings. I will not permit a member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate in the meeting from outside the precincts will be refused.

The first session today is with representatives of the Prevention & Early Intervention Network. I would like to welcome Dr. Maria O'Dwyer, national co-ordinator, and Mr. Francis Chance, chairperson of the Prevention & Early Intervention Network. The purpose of our meeting is to engage with you both in relation to strengthening prevention and early intervention supports to children and families post pandemic.

Before I ask you to give your opening statement, I will go through parliamentary privilege. As all of the witnesses are appearing before the committee virtually, I need to point out there is uncertainty if parliamentary privilege will apply to their evidence from a location outside the parliamentary precincts of Leinster House. Therefore, you are directed by me to cease giving evidence about a particular matter, it is imperative you comply with any such direction. You will be allocated three minutes for your opening statement. We have a speaking rota, which has been circulated. Each member will have five minutes for questions and answers. We look forward to engaging with you both today on this very important topic.

I invite Dr. O'Dwyer to give her opening statement.

Dr. Maria O'Dwyer

Thank you very much Chair. We very much welcome the opportunity to engage with members today about how we can invest now to ensure bright lives for children living in Ireland today, tomorrow and every day. The Prevention & Early Intervention Network, PEIN, represents organisations and individuals working in children, family and community services throughout Ireland who are committed to developing a prevention and early intervention-led approach to service planning and delivery. PEIN focuses on the most effective ways of building a protective layer of support to stop difficulties from arising in the first place and providing support at the earliest possible stage when these difficulties occur.

International and Irish research, Government policy and the experience of practitioners on the ground all clearly indicate the social and economic benefits of prioritising prevention and early intervention. However, too often our supports to children and families are too little, too late.

We would like to use today’s opportunity to talk about the impact of the pandemic on children and families, the impact of child poverty and adversity, the national policy environment for prevention and early intervention, the immediate priorities to shift front-line service delivery towards prevention, and the funding strategies needed to achieve this.

There is positive learning from the pandemic in terms of the widespread embracing of public health messages, our combined capacity to make quick changes to how we delivery our services, the adoption of virtual ways of working and the consensus that nobody should be left behind. However, PEIN members tell us that those children who were most disadvantaged before the pandemic have suffered most because of it.

Our members' services are experiencing increased demand, based on pre-existing, new and emerging needs. Anxiety, in particular, is having a debilitating impact on many children and many parents. Adverse childhood experiences, ACEs, including the impact of poverty itself, result in serious physical and mental health issues across the life course.

Both prevention and early intervention are well referenced in a range of Government policy papers, including Better Outcomes, Brighter Futures, First 5 and Sláintecare. However, these policies have yet to be fully implemented and there is a risk that preventive measures could become sidelined, as we continue to deal with onerous national crises such as the pandemic and homelessness.

Children should not wait to access services which are critical to their development. There is a pressing need to ensure that the HSE services that screen children’s development are immediately and fully resumed and that those babies born just before or during the pandemic are fully screened as soon as possible.

We also need to urgently reduce our waiting lists for the full range of early intervention services. In failing to do this, many children may require intensive, long-term and costly interventions later on. These are wholly avoidable.

Clearly, we cannot stop interventions to children with critical needs in order to invest in prevention and early intervention. Instead, we need to reach a point of equilibrium, that delicate balance between crisis response and prevention. We need to front-load and ring-fence funding to preventative services in order to achieve savings on crisis services in future years. For example, PEIN proposes a strategic use of national lottery funding in order to front-load investment in preventative services.

We very much look forward to engaging with members this afternoon on the pivotal role that prevention and early intervention can play in shaping the child of three into the adult of 33. I thank the committee.

Thank you very much Dr. O'Dwyer. We are going to move to questions from members. Senator Seery Kearney, you are first.

Thank you very much Chair. I thank Dr. O'Dwyer for that opening statement, which I really appreciate. I am very struck by the statement that there are good policies in place, but it is about the implementation of those policies. We see reports like yesterday's drug task force report and the research done by the Tallaght drug task force, and it would be mirrored in the one I chair in Dublin 12. Poverty and adversity in childhood set in motion a whole sequence of events that affect aspirations, opportunity, and marginalise children and keep them marginalised. Knowing the current state of affairs, that we are coming out of a pandemic and have much catching up to do as a result of the pandemic and that some services are still lagging behind and waiting lists have increased, what three things would the witnesses pick to prioritise and have us do if they were the Minister?

I call Dr. O'Dwyer.

Dr. Maria O'Dwyer

Thank you very much, Chair, but my colleague, Mr. Chance, will answer.

My apologies. I call Mr. Chance.

Mr. Francis Chance

I thank the Senator for her question. When you are looking at the current environment in terms of policy, the problem is getting from paper policy into action on the ground. As the chair of a drug task force, I am sure the Senator knows that. I know well the situation in Tallaght and the work of the Tallaght drug task force, and that work is replicated around the country.

It is very hard to pick three things because the needs of children and families are multi-factorial. They need integrated strategies across a range of Government environments. I am going to pick three policy areas, which I think are urgent. The first one is the national children's policy. Our current national children's policy, although I should not say current because it is expired, Better Outcomes, Brighter Futures finished at the end of last year. We are currently without a national children's policy, and that is somewhat disturbing. At the same time, I would like to acknowledge the work that has commenced in the Department of Children, Equality, Disability, Integration and Youth on the development of a new national children's policy, but it could well be towards the end of next year before we see that.

It is very important that we put the children with the greatest need and the prevention of need at the centre of that policy. Before we ever had a pandemic, we had child poverty and child inequality, and it has gotten worse. It has gotten worse for the children who were already in the worst position. Therefore, we need to look at the policy and the implementation and at funding in those areas.

The second area would be in relation to Sláintecare. Sláintecare is a really important policy in moving our health service from crisis to prevention. The very first recommendation in Sláintecare is about child health; it is the first thing you come to when you read the Sláintecare report. Yet, it seems Sláintecare is in some crisis at the moment, and we are concerned that the focus is on institutional reform and structural reform, as opposed to direct service delivery reform. We know that due to the pandemic a significant number of children have not been screened for health and development, and we really need to catch up on that, recommence those services immediately and make sure every child who missed his or her screening during the pandemic receives that screening now.

The final point I will talk about is in the area of the First 5 whole-of-government strategy for babies, young children and their families. If we are serious about dealing with the long-term problems of children and their families, we need to start in pregnancy, or even before pregnancy, moving to early childhood. We have a very good roadmap for that in First 5, but we need to invest in the implementation of that. I would point, in particular, to the national model on parenting supports, which we have been privileged to work on with the Department of Children, Equality, Disability, Integration and Youth and which is nearly ready for launching. We need to look at a national strategy where every parent is provided with support in their parenting work, which is the most important work in society. Those families that need extra support should get it, but we should also provide universal supports to each and every parent to every child born in Ireland.

One of the impediments I see is around recruitment and filling gaps and shortages. Where has Mr. Chance seen that manifest itself in terms of what he would like to see prioritised? Does he have any ideas on how to change that?

Mr. Francis Chance

The area of recruitment and the recruitment of specific professionals is a real challenge within our health service as well as within Tusla in terms of social workers. At third level, we need to be looking at what our workforce requirements are in the long term and at investing in additional training places so that we have a home-grown cohort of child health professionals and child well-being professionals coming on stream. We also need to be looking at more creative ways of supporting and encouraging professionals to come from elsewhere to work within our children's services.

I am good for now, Chair.

Thank you, Senator. Dr. O'Dwyer, did you indicate you would like to speak?

Dr. Maria O'Dwyer

I will add to what Mr. Chance said to the Senator in terms of recruitment. In terms of the early years, we were making significant waves at the last budget. The allocation for 4,700 new early years professionals is definitely something to be celebrated and championed. However, we would be very cautious in terms of advising on the quality assurance, the training and the continuous professional development that accompanies that process. To date, the early years have been lagging behind and while it is being addressed, there needs to be a simultaneous process with new recruits and support being put in to protect that cohort because quality, as we know, in terms of early years provision and providers is quality for children on the ground in the service they receive.

From the early years perspective, the Fine Gael Party carried out a body of research recently that showed parents were very happy with the quality of their service providers, but they did not have a diversity of choice. We do not have sport in early childhood, for example. Deputy Dillon, who is here, would be very much into sport and supporting that. We would like to have that diversity where every child's need and the holistic development of the child is supported in early childhood. I hope that when we see the outcomes from professional planning, the joint labour committees, JLC, and so on that we will have a career path in childcare.

Thank you very much. We are moving on to Deputy Ivana Bacik.

Thank you, Chair.

Dr. O'Dwyer and Mr. Chance are very welcome and I thank them for the presentation and the information they have given us. I was very interested to hear their call for new national child policy, but also interested to hear their point that we need to have an emphasis on practical steps to be taken.

I have a few questions. First, they referred to the need for and the importance of Sláintecare, the importance of universal provision of healthcare and of screening for children's welfare and well-being. Will they say a little bit more about how that would look on the ground? For example, how would we screen children, how would public health nurses be assigned and how could we address waiting lists for children in healthcare, which I know has been a hugely topical issue lately?

The Labour Party is also pressing for a universal provision of childcare, for a public, universal free of access childcare scheme, because of all the difficulties parents and families are having accessing childcare at present. The fees are high yet there are low wages for professionals working in the sector. Our childcare system is currently failing all of those involved, and obviously and notably children. Could Dr. O'Dwyer and Mr. Chance say a little more about how universalism might look in a childcare scheme?

Finally, I was very interested in the point that we need to balance crisis response and prevention in our strategies, and the call for the strategic use of national lottery funding, for example, to ensure a longer term approach. Could Dr. O'Dwyer and Mr. Chance say a little more about how that would look in practice, and which prevention and early intervention services are working and what is good practice model?

Finally, I refer the catch up for children fund. Deputy Aodhán Ó Ríordáin and I have been promoting the need for a €100 million catch up for children fund to try to alleviate and address some of the huge adverse impacts on children as a result of the Covid pandemic. There may be a lot there, but they are few of the issues raised in the presentation.

Thank you. Mr. Chance, will you be addressing those questions first?

Mr. Francis Chance

I will take the first and the third question, and I will let my colleague, Dr. O'Dwyer, to pick on the childcare services question. On the first area of Sláintecare, the great strength of Sláintecare is that it is an inter-party agreement on what our health service should look like. Over the last 50 years, since the introduction of the Health Act, we have been restructuring our health service repeatedly, and the health service has gone through a flavour of the current Government approach in terms of constant change. If you are talking about major systems changes within our health service, you need a ten to 20 year strategy, and that can only happen if you have political consensus on that, and the great strength of Sláintecare is that is what it achieved. However, the most recent statements on Sláintecare would indicate that breadth and that vision of Sláintecare is being lost at the moment. The slogan adopted by Sláintecare was "Right Care, Right Place, Right Time" and that is really important in terms of prevention and early intervention. Right care is about providing preventative services. Preventative services will not always succeed, but on many occasions they will. Where they do not succeed, then the earliest possible intervention is required. We should not wait until the problem gets bad enough that intervention is required, which so often happens. The right place is in the community, and ideally even in the family home with home visiting programmes. The right time is as early as possible.

In terms of the current statements made about Sláintecare, my concern is that it is all the right structure. The belief seems to be that if we get the structure right, the other things will follow. We have 50 years of history that show us that has not happened. We need to go back to the original Sláintecare vision, engage with that and move forward on all fronts and in an integrated way.

One of the key areas of Sláintecare would be the investment in child health. The particular suggestion within Sláintecare is about public health nurses. At the moment a public health nurse is responsible for everybody in his or her catchment area from birth until death. It is a cradle-to-grave service which attempts to be all things to all people. We strongly agree with both Sláintecare and First 5 that the time for that approach is long gone. We need a more specialised approach. Older life and end-of-life care need a specialist approach. Equally children and families need a specialist approach. There is a very clear recommendation in both Sláintecare and First 5 that we should have a cohort of public health nurses who are responsible only for the children and families of their catchment area. That is going to provide a better service to those children and families and facilitate greater integration with the work of other agencies such as Tusla, with early years services and with education and other services.

I will talk a little about the national lottery suggestion. One of the key things about prevention and early intervention is that it has the potential to change costs significantly in the longer term, but for that to happen it needs to be front-loaded. The savings that you will create in prevention and early intervention take a number of years to kick in so there needs to be an early investment within that. We are pointing to three different strands within that. One is that every State agency and Government Department that impacts on the life of children and families should be required to identify what its current spend is on prevention and early intervention, and then should work with the Department of Public Expenditure and Reform to incentivise and gradually increase that spend over a ten-year period. For example, a Department or State agency might set out to transfer 2% of its crisis funding into preventative funding on a gradual, slow basis, as obviously we must meet the needs of children in crisis as well as preventing children being in crisis in the future.

The Department of Public Expenditure and Reform had a prevention and early intervention unit in the life of the last Government which has been repurposed for the life of this Government. There was much good background policy work done there and we call for that to be resumed and continued, and that Departments would have an incentive fund from which they could encourage and support Departments to make those kind of moves. There would be a fund they could draw on to support those transitions from crisis towards early intervention.

In regard to the national lottery, we recently had an opportunity to look at some work going on in Northern Ireland and how the national lottery has been used there and throughout the UK in a much more strategic and purposeful manner than we have used it here. The review of the functioning of the national lottery, which is being carried out at the moment under the Department of Public Expenditure and Reform, gives us an opportunity to consider earmarking an amount of funding from the national lottery. If we earmarked one month's income, or €21 million, to invest in prevention and early intervention services each year - once there is a proof of need, the approach is proven and, most importantly, there is a commitment from State agencies that if the approach works, they will pick up on the funding in future years - there could be a real opportunity to use the national lottery in a much more strategic and creative fashion than has the been case to date.

I thank the witnesses for coming in. Their presentation was very interesting and I appreciate the suggestions they are making. They are coming up with relatively simple and feasible solutions to the obvious needs of so many children throughout the country. The fact that we have nearly 200,000 children in poverty is a stain on our society. We will certainly see a greater impact following Covid-19. So many children who were already left behind will now get a double hit because of Covid-19.

Mr. Chance has said that the impacts of poverty include serious physical and mental health issues. Can he give details? What does that mean for children and families in real-life circumstances? What does it look like? I ask him to bring us back to the ground level of what all this really means. What impact is it having on so many families?

The suggestions that have been made by Mr. Chance are very good. Has he had any input to the Department? Has he had consultations with regard to the national childcare policy, which is being developed at the moment? Have there been any consultations with representatives of the Prevention & Early Intervention Network.? Their input is very good.

Mr. Chance suggested that €21 million could be made available from the national lottery. Has he costed up what it would take to provide funding for the early intervention he spoke of? To be honest, €21 million seems a very small amount in the context of such a widespread problem that covers so many different portfolios and regions. Has he costed it? What would €21 million achieve in the context of early intervention?

Dr. Maria O'Dwyer

I will take the Deputy's first question, on what poverty looks like and the kind of impacts it has, and then I will hand over to Mr. Chance. The pandemic has doubly disadvantaged families that were already disadvantaged before it began. As a result, we are starting to see more tangible and evident forms of poverty in regard to fuel poverty and green poverty, etc. I will bring it back to the basics of physical and mental health and start from there. Children who grow up in families where there is responsive caregiving, where their cues are being met and where there is attunement, attachment and security with the parents from the time they are born enjoy a foundation of learning for later in life and positive mental health to be maintained throughout the course of their lives. In families that experience disadvantage on an ongoing basis, on an occasional basis or on an emergency basis as in the case of Covid-19, responsive caregiving is not doable to the full extent. In such cases, parents cannot engage with children in a way that is for the best, optimal development of the child mentally and physically. Small daily caregiving activities like providing opportunities to play and reading to babies do not happen in such families. We see that increasingly as a result of the pandemic. A couple of years ago, there were atrocious pictures of a child in emergency homeless accommodation whose space to play was between the beds. As a result of direct provision and the pandemic, we are seeing more and more of those confined spaces. This has a significant impact on the development of gross and motor development skills. Many children do not have access to play or access to nutrition. We know that food poverty was heightened during the pandemic. Families have always experienced food poverty, but the closure of early years services in schools heightened food poverty, which had an impact on nutrition.

Engagement with services is something we see with families who are experiencing difficulties. It is not as linear. If you have a problem, you know where to go and there is signposting. If there is a whole other plethora of things going on for that family, the access to those services is not as direct as it should be. Nationally we spend a great deal of time thinking about how to unblock referral pathways and uncomplicate the systems we have. Sometimes we unblock those referral pathways more for the service providers than for the families at the end. We really have to start with where the families are. We can get a bit sniffy - I do not know if that is the right word - when we talk about technology. There is a sense that if somebody does not have an iPad or does not have access to such-and-such, it is a very middle-class concern. I would say that prior to the pandemic, in child development we would have thought that having a screen was not essential. The pandemic taught us that we have a significant digital divide in Ireland between those who can access technology and those who cannot. We saw it in such things as homeschooling. It was not even always about the technology itself, but about having a space or an extra device in the house that a parent could use. Parents and families were struggling, which impacted on learning.

In regard to the health and development of children who are experiencing poverty, their outcomes are always impeded by the circumstances they live in, for example if they are on waiting lists. Currently there is a two-year waiting list for early intervention services. If an issue is flagged, the two-year wait sometimes means that the prevention and early intervention window has been missed and the problem is likely to escalate.

We see that with speech and language attainment. Initiatives such as the early based childhood programmes are doing stellar work in community clinical joint interventions where previously something like a speech language deficit or delay was picked up at the seven- to nine-months check-up, and maybe would not have been spotted again until school. We now know in the early years that such deficits are being picked up earlier through the early years community clinical collaborations, such as ABCs, so now there is a chance of prevention and early intervention.

In regard to life opportunities over the life-course, we know children are exposed to things such as domestic violence at home, in which there was a 25% increase over the pandemic, and to levels of aggression. It is very hard for parents who cannot regulate themselves to support regulating their children. That is a cycle. We saw in the pandemic the expectation that all parents can stay calm and guide children through this when in fact half the adult population was panicking.

In regard to prevention and early intervention, the message there is about getting in early enough and learning from the pandemic. For example, mental health services ironically were one of the last to manage to go online effectively. While the business and education sectors pivoted, mental health services which should have been front of stage were a little later to come online, so the impact of that meant that those with high anxiety who were supporting children who probably had high anxiety did not have access to support as and when needed.

The key message about child poverty and disadvantage is we cannot be offering too little, too late. It has to be when they need it, and in most cases for us, before they need it. I will hand over to Mr. Chance.

Mr. Francis Chance

To pick up on Deputy Whitmore's question on policy input, the prevention and early intervention network is made up of individuals and agencies who work at the front line with children and families in providing supports. That is universal supports to all children and families, and targeted supports to children in families with high levels of need. It is that whole continuum. It is important to say that prevention and early intervention is not something that just happens in the State sector or something that happens in the community sector, but it is something that needs to happen in both the voluntary and community sector and the State sector in a joined-up way.

We have had many opportunities to input to policy. We have had inputs to Sláintecare, to First 5 and we are seeking to input into the new children's strategy and we are inputting to the review of the national lottery. A key element of how we do our business is to represent the views of our members. We are launching a paper later on this week on direct provision, looking at how the community and voluntary sector and the State sector can work alongside the Minister and the Department to end direct provision and support the integration of children and families currently in direct provision into local communities. We have a unique offering to bring to that particular table. We are very much engaged in every opportunity and particularly we have been working intensely with the Department of Children, Equality, Disability, Integration and Youth on the development of a national model for parenting supports. This was a very intense piece of work over the past 12 months. We look forward to the Minister launching that hopefully in the very near future and seeing it turn into action.

In regard to costing our proposals I take the point that €21 million is a small amount and our vision by no means stops at that. That is a starting point. The suggestion we were making was that over time we should grow the percentage of lottery funding that is spent on children and families in accordance with the percentage of our population who are under the age of 18. That would over time move that €21 million up to a rolling investment fund of €60 million. That is significant. In terms of costing out the proposals, one of the things we feel is very important is that this needs to be done locally, in local communities and around local need. There needs to be national guidance and national structures which identify what we need in terms of prevention and early intervention, what it looks like and what services should be available to every child and every family no matter where they live in Ireland. Then each local community should work together under the auspices of their children's services committee, State providers and community and voluntary providers with children and families, talking about how that would look in their particular community. The supports that might be needed on an Aran island would be very different from the supports provided in north inner-city Dublin. The key thing is that each child and each family gets the equivalent range of supports no matter where they live.

There is a piece of work to do on costing but we see that as part of the process to identify what our goals are and then cost that, but to have some initial funding ready to invest in it at the earliest possible time.

I welcome our witnesses and thank them for their time. It is a very engaging conversation. I have two questions to follow up on. From reading the literature, I know the witnesses were involved in building new tools to assist delivery of service planning such as outcomes for children data and the information hub. Could they provide the committee with some information on these two initiatives? Also, Mr. Chance spoke about the strategic use of national lottery funding to front-load investment in preventative services. Could we have some additional information on this? In regard to the suite of services that must be delivered through a combination of both statutory and NGO providers, what is their experience to date, both through practice and through international evidence, that provides reliable data to ensure that we have supports around early years care and educational services around health education and also spanning family supports? I would be interested to hear about evidence on the ground in the provision of this suite of services.

Dr. Maria O'Dwyer

I thank Deputy Dillon for those questions. The first question I will pick up on is about outcomes and outcomes measurement. It is an area within the child and family sector where significant strides have been made in the past number of years. What happened in Ireland traditionally in policy development around delivering services was we tended to pilot everything. We would have pilot after pilot, then evaluations of them, and then we started something new. The first national children's policy involved asking what are we looking for and what do we want to do differently. That meant that for the first time we were going to undertake some collective mapping and gathering of collective data. Rather than always looking at individual projects, they were banded together to look at the data that emerged both individually and as a collective. The early based childhood initiative and project would have been the first big attempt at that nationally in terms of a national evaluation on the measurement of child outcomes.

With regard to outcomes frameworks, it can get quite complicated. We look at things quantitatively and we want data and datasets. What we need to do with outcomes frameworks is the balance of both, qualitative and quantitative. At the end, the question is always whether it was value for money. That is wearing the financial hat. The ultimate question is whether it benefited children and families. If it did, how do we do more and how do we learn to do it better? If it did not, how do we change it? There are many tools used and there is an attempt to standardise those as well. In Ireland at the moment, the Centre for Effective Services, CES, currently develops a significant database on outcomes and outcomes gathering. We work closely with the CES on promoting and informing that where we can.

Part of it is ensuring that going forward we are not duplicating the data we are gathering. Another part of it is that we now have enough instrumentation on research to be able to drill down to specific projects so while we can take collective data we also need to know about local context.

When a policy has been implemented nationally, many of its outcomes traditionally have been measured through Dublin. We know that what happens in Dublin and the measurements for it will not be the same as in Kerry and in Donegal. That kind of contextual and geographical element in outcomes frameworks is really important as well.

I refer to the qualitative piece when we are trying to map outcomes for children. We, as well as for many of the members, agencies and partners with whom we work, have honed the focus on the voices of the children for whom the services are provided and of the parents of service users. For long time, services were done onto children and families, instead of being done with them. We are now starting to see children’s voices being incorporated into those outcomes frameworks. It is important to flag there can be much lip service in regard to that. For an effective mapping or any kind of outcomes gathering, however, we want to make sure that those processes are genuine and that they are done in consultation with children and families.

We are lucky to have the kinds of data sets that we have in Ireland at the moment. We can see that, for instance, with the recent ESRI publications. The Growing up in Ireland study has given us a fascinating insight into the longitudinal development of children and into how families are supported and what that looks like. We are starting to see how that started with babies. For instance, in the "Seven Up!" documentary years ago in the UK after the Second World War, they mapped children at longitudinal junctures. We are starting to do that here now. It is creating significant data in understanding what goes on in the home environment. For so long, the kind of data we had gathered on children was reported by parents. What we need is data that has an insight into the home environment, which is obviously formative for child development.

Would there be much in the way of a discrepancy between a regional project or study and an urban or city project or study? Has the Prevention and Early Intervention Network seen any trends in this area, in child poverty or in early intervention?

Dr. Maria O'Dwyer

I thank the Deputy for that good question. We see discrepancies. We see them in relation to rural-urban, as well as related to class. Where we try to implement a project nationally we see that it will not mean the same thing in different places and in the interpretation of it. If one looks aspects such as breastfeeding supports, for example, we take a population approach to how we promote breastfeeding. However, if we gather data in, for example, the Traveller community, that data will be automatically skewed by the information and supports Traveller mothers and parents are given and the traditional inheritance of low uptake of breastfeeding in that community. We are not, therefore, comparing like with like. Often, we look at statistics and think that they are way down when actually we have not looked at the contextual data.

Similarly, some interesting work was done on play and the use or uptake of baby and toddler groups. A survey in the late 1990s looked at play patterns through baby and toddler groups. There was a significant discrepancy between rural and urban, but there should have been. This is because in a rural environment, a baby and toddler group would be held in, for instance, a community hall. That setting is far removed from what they would have in cities. It is important to look at those types of things when looking at trends. It is important that the data allows us to spot those kinds of differences.

The pandemic shone a light on our misconception around play. We have always thought that children in the country played far more outdoors than children in the city but actually they do not. They are pretty much head-to-head at the moment. We are finding that children in country and rural areas spend a significant amount of time in cars, being driven to different places, such as to sports, whereas for children in the city there is a local mobility. We have had perceptions or misconceptions around play and child outcomes, or play as element and indicator of child outcomes. We have to be conscious of nuances around rural-urban, class and culture, and those different nuances and potential divides that exist in how we do things differently.

We have to move on to the next speaker, Deputy Costello.

I apologise that I missed some of the beginning of the meeting because I was speaking in the Chamber. I apologise if I am repeating things.

The witnesses spoke in their opening statement about the national policy environment for prevention and early intervention. One of the things I would like to get their insight into is that over the last few years, Tusla has put much effort into realigning its early intervention. I appreciate that not every adverse childhood experience, or harm caused by poverty that we are looking to prevent, will be the sort of harm that will end up in front of a social worker or on a social worker’s caseload. We need to be careful not to say that every harm needs child protection response. However, Tulsa acknowledges that. It put much effort into the prevention, partnership and family support, PPFS, and the Meitheal. There was concern as these were being set up and rolled out that much of this was an unfunded mandate, so to speak. The work Tusla should have been doing was pushed onto community groups without necessarily putting funding behind them. The family resource centres were often involved in these. Not all the family resource centres were being properly resourced or structured to do this.

I would love to hear the network’s experience of the roll-out of the PPFS and Meitheal. Did it help prevention and family support? Is it a weakness? Where are the weaknesses in it? What do we need to look at?

Generally, what has worked well? We have spoken about a couple of ideas here. The network has spoken about endless piloting, which I must admit, brought a wry smile to my face. However, in regard to the idea of endless piloting, what has worked well? What did we pilot that worked well but which to which we never went back? What are the obvious tricks that we are missing here?

Mr. Francis Chance

I will take that question. I remembered the Deputy’s previous career as he asked the questions. A key issue is that we are not starting from scratch here. There have been 20 years of good work going on in Ireland on prevention and early intervention. Some 20 years ago we started from scratch. However, in particular thanks to Chuck Feeney and Atlantic Philanthropies, there has been a significant investment into children and families services over the last 20 years, with a particular bent to moving these towards prevention and early intervention. That has been within the community and voluntary sector, as well as within the State sector.

In particular, the Deputy spoke about prevention, partnership and family support within Tusla. That programme was funded by Atlantic Philanthropies in order to establish it. A similar programme in which I was engaged with the Health Service Executive on the Nurture programme was about establishing and strengthening preventative services in the Health Service Executive. It developed into what is now the national healthy childhood programme. We are starting with good experience, knowledge, evidence and research within Ireland.

We have to note the departure of the Atlantic funding. Chuck Feeney’s model was giving while living. He has now basically spent down all of his money. Atlantic Philanthropies has now closed its doors. We do not have another Chuck Feeney on the horizon. Yet, we are a relatively wealthy country. Borrowing money at the moment is cheap, as the Ombudsman for Children’s Office has been telling us clearly in some of his recent contributions. The opportunity to invest in early childhood is strongly there, if we can find ways to do that and find what is best to invest in.

A well done piece of research a few years ago asked parents what they found important and helpful in raising their children. It asked them what the gaps were within that. One of the things that came from that was that parents do not understand what services sit under what Departments, silos, and agencies. They do not give a damn about that. If they have a support need, they want the support. The label attached to the person who gives the support is quite irrelevant. We, in our agencies and services in Departments and structures, are all concerned about that but it is important that the supports are there. Many of the families with whom we work - the more complex the family, the more likely this is to be true - require integrated solutions which require the input of more than one State agency, or more than one Department. The role of the community and voluntary sector within that can be crucial as well, because it can been seen as an honest broker or less stigmatising for parents to link with. There are those opportunities there to invest in local service provision.

I want to refer back to Deputy Dillon’s last question about the national lottery.

It is an example of what I am talking about in regard to how we fund services. We suggested eight criteria that should be used for national lottery funding in this area, including that the service must be focused on prevention and early intervention and that there would be a move to multi-annual funding of services or a three to five year period for funding of services. Funding a service for 12 months and it not knowing at a particular time of year if it will be operational on 1 January is not good for children and families. It is also not good for service development.

Services must be new developments and funding should not be used to replace existing statutory funding. We have seen evidence of funding being made available for something dressed up as a new service when it was just a recycling of an existing service. Development money needs to be used on new services, not existing services. There needs to be clear evidence of need for the service, including good local research on the service and why that particular model is appropriate. There must be evidence of the effectiveness of that particular intervention. Services are delivered in partnership with parents. We do not do things to parents; we do things with them. We consult parents and involve them in designing our services. Parents are the key and lead partners in the delivery of services to them. There needs to be strong evidence of integration with other services so that it is not about parachuting a service into a particular community, but about how that service will interact with continuous services in the area and will complement and work with those services in a joined-up way.

Pilot funding is important. There needs to be a commitment from the State agencies that if a pilot is shown to be successful, it will be prioritised for mainstream funding. There is no point in having pilots that run for 25 or 30 years. If a project is running for 25 or 30 years, either it is not working and it should be closed or it is working and it needs to be mainstreamed.

I welcome the witnesses and thank them for their contributions. Many of the topics I wanted to address have been covered, but there is one specific issue troubling me, that is, the public health nurse system and the incredible backlogs in that system as a result of Covid. In my CHO area there are up to 20,000 children who have not had their developmental checks. That is incredibly worrying. I cannot get an answer from the HSE on how it proposes to deal with that backlog.

Reference was made to our public health nurse system being a cradle to the grave system. How can we remedy this system and also address the backlog therein? What are the consequences of us not taking care of all of those children who are clearly missing out on developmental checks? My son is among those who have not been checked. That is what drew my attention to the issue. As I said, my son is awaiting his development check. He is not special; he is just one of the up to 20,000 children in CHO 8 awaiting a developmental check. There is only one CHO in the area.

Mr. Francis Chance

I thank the Senator for the question. It is great to have personal experience coming into this discussion. In recent days, I have heard of two different situations. One case involved a baby born two weeks ago who was discharged from the maternity hospital with a particular health condition but the mother was not given good advice in regard to that condition or breastfeeding. The mother and baby were supposed to get a home visit from a public health nurse within 72 hours of their arrival at home but that did not happen. Instead, the mother received a telephone call asking her to attend the health centre. She had never been there before and had not yet left the house with the baby. She arrived late to the health centre because she could not access parking and she had a very rushed meeting with a public health nurse who suggested that because the baby had lost a little weight, the mother should cease breastfeeding and move to formula feeds immediately. That was not appropriate advice.

In terms of the public health nurse piece, the most immediate priority is that every public health nurse be returned to full public health nursing duties away from any engagement in the Covid supports. Otherwise in six months, 16 months or six years, babies who are being missed now in terms of developmental checks will be appearing in our services with deep-set difficult needs that will cost a lot to address. It is important that we get that screening back in place.

The second piece is a look-back in terms of the pandemic with regard to the children who since March of last year have not been fully screened in relation to their needs. They need to be screened properly now. Last week, a parent told me that her child had just started school and she got a telephone call from the public health nurse asking her if everything was fine and if it was okay to discharge the child. The public health nurse could not get off the phone quick enough. Luckily, everything was fine. If that had not been the case and the family had needed support, that telephone conversation was not one that would have encouraged them to voice their concerns or seek help. Those things need to happen. We need to do that look-back around the children born during the pandemic to identify if they have been fully screened. Otherwise, we are setting ticking time bombs for our healthcare adult services into the future.

The third piece is that we need to immediately start to progress in regard to child and family public health nursing. Again, we are not working in a vacuum. This has been happening extremely successfully for many years now in Longford and Westmeath. A public director of public health nursing in that area many years ago had the foresight and vision to try a different structure within her own area. Nobody stopped her and it has worked. She has good evaluation in terms of care of older people and the care of children, as well as the satisfaction of the staff in that it is working. We need to apply that nationally. It is written in policy. We need to do it. The cost of doing it is clearly laid out in Sláintecare. The cost is €14 million for a phased developed over a five-year timeframe. That should have started in year one of Sláintecare. We are now in year four of Sláintecare, which is a bit wobbly at the moment. We need to bring it back on track and to catch up.

Would Dr. O'Dwyer like to comment?

Dr. Maria O'Dwyer

I would like to make two points. I thank Senator McGreehan for the question. I would like to add to what Mr. Chance said. The Senator will know from her own experience that while we worry about the delays in screening impacting the child and the long-term development, it also increases parental anxiety and stress. The most confident parents in the world, in particular first-time parents, need to be told that the baby is putting on weight, doing great and hitting the milestones. When that does not happen, it causes additional stress that parents do not need in an already fairly stressful time.

The second piece is the structural issue around the public health nursing system. We tend to take a generalist approach to nursing. We do not have dedicated child health nurses, similar to the UK model. In Ireland, there is the possibility for collaboration with the community mothers programme. It is about organisations stepping outside of themselves. We are very tightly bound in terms of our clinical and community public health provision. The community mothers programme has a 30-year history. The community-clinical partnership can support and fill in some of the voids during that critical time.

In terms of screening, more than half of all the babies during the pandemic are currently on a waiting list for a developmental check. That is a significant cohort of children. Home visit programmes such as the community mothers programme, preparing for life programme, parent child home programme and Lifestart can offer critical support a time when there is a gap in other services.

I thank the witnesses and Senator McGreehan. The next speaker is Deputy Ward.

I thank the witnesses for their contributions. I apologise for being late and missing the opening statements but I was in the Dáil Chamber putting questions to the Taoiseach around early intervention in regard to assessments of need and the struggle parents face in getting assessments for their children. Mr. Chance spoke about old services being dressed up as new services.

What is happening is that they are being watered down in the process, going from assessment of needs to a standard operation procedure. The Ombudsman for Children who appeared before this committee stated that it was an old-fashioned three-card trick where kids were being moved from one list to another without receiving the service they need and they are not reaching their developmental milestones as a result of this. There are huge HSE waiting lists for speech and language, assessment of needs, occupational therapy, child psychology. During Covid-19, I know there was an emergency, but we had a bizarre situation where clinicians who were providing these services for which there are huge waiting lists were moved from providing these services to Covid-19 measures. Yet thousands and thousands of people, and I was one of them, answered Ireland's call and offered our services free of charge to fill that gap but our offer was not taken up.

I have a couple of questions. The first is in regard to the post-code lottery whereby, depending on the location a person lives in, the service might be provided more quickly than in another location. The second matter, on which I questioned the Taoiseach today, relates to the response I got to a parliamentary question, where the State now provides a public service to complete assessments of needs, which I was not aware of. Have the witnesses heard of this happening? What are the witnesses' experiences on the ground in regard to the post-code lottery and the waiting times? How can we ensure children get the care they need, when and where they need it, in connection with assessment of needs, occupational therapy, speech and language, child psychology and all the auxiliary services?

Dr. Maria O'Dwyer

I thank Deputy Ward for those questions. We were all nodding along furiously because it is unfortunately a very common story at the minute. Currently there are 2,559 children on the waiting list for CAMHS and that will go nowhere except upwards while we are trying to catch up on the backlog. The idea of a post-code lottery is an awful way to have to think about it but it is the reality, depending on the CHO and availability, of how children are going to be assessed. For us, prevention and early intervention means that when you get in early enough it is not compatible to have an aging-out system which is what we are seeing in many of the assessments of needs. If we intervene before a child is six, for example, we have a window for prevention and early intervention with them whether it is for psychology or speech and language therapy. After six it gets harder and harder and they are in a different place in the system. What we are seeing, and this goes back to the post-codes and differences as well, is there are regional variations. This speaks to the need to standardise the approaches and the protocols we take even around the waiting lists themselves. For example, in different regions there might be a child on a waiting list for psychology who, while on that list, can access other interim therapies such as creative therapies in play, music or art therapy. The child will hold his or her place on the list and progress. In some places there can be up to a three-year waiting list for psychology. In other regions a child may be at the same place on the list but to avail of the same interim therapies he or she must pause his or her position on the list which means others climb up ahead of him or her. That lack of standardisation does not support effective prevention and early intervention because what it means is, depending on where a child lives, his or her access to a service will be quicker or unfortunately will come when the child has aged out of the needs or the appropriateness of that service. I will now pass over to Mr. Chance.

Mr. Francis Chance

To pick up on one issue around the whole area of assessment of need and disability, we had a real problem in recent years about demarcation between State agencies. Going back to my earlier comments, many children and families need the support of more than one agency and it should not be a buck-passing exercise. It should be a partnership exercise. In some of the more extreme cases within Tusla and the HSE there is now a working protocol for how that is planned, but that needs to be applied in the area of prevention and early intervention as well. Both agencies have something to bring to that table and something to offer in that space. It is important they operate both at a national level and a local level co-operatively to develop services and ensure there are proper and effective pathways for families to get to services as quickly as possible. That happens very well in some parts of the country but in other parts of the country, it does not happen at all. One of the phrases we have used in our discussion is the moving family test, which refers to a family who may have their first child while living in one part of the country and for some reason move before having their second child and move again before having their third child; they live in three different parts of the country. We are not suggesting they should receive exactly the same service wherever they are but they should receive an equivalent service. We might structure the service differently in rural west Donegal compared to how it might be structured where my colleague Dr. O'Dwyer is, in Limerick. It is around what services are there already and what is the most logical way to deliver that service in a particular community; nobody should be disadvantaged in accessing a service because of where he or she lives. There has been an assumption in recent years that child disadvantage is something that happens in urban areas, particularly in inner city areas and areas of high deprivation but it happens in all parts of the country.

When the area-based childhood programme was set up, 13 projects were established and 12 out of those 13 projects were based predominantly in cities and large town areas. There is evidence on poverty and child deprivation that there are particular problems in the far west of Ireland and around the Border region. Investing in services in those areas is also important. The original area-based childhood development programme was meant to be phase 1 of a continued roll-out of that programme. We are still waiting for phase 2 to happen, so the notion of investing in another tranche of services in communities in an integrated way looking at the next range of need will be important.

I thank the witnesses for their feedback. One of those heart-breaking things we all do as public representatives is sending back responses from the HSE to say that a person's child is going to be waiting for four years for early intervention, or speech and language, or occupational therapy. Dr. O'Dwyer mentioned standardising the services across the areas but there are discrepancies even within CHO areas. For example in my area, CHO 7, these new children's disability network teams are set up in CHO 7, there are eight of them as far as I know. Two have not had a manager appointed yet. Both of them are in my area, one in Rossecourt and one in Clondalkin. So even within CHO areas, there are discrepancies. For example, in other parts of my constituency a child may get a service quicker in the Palmerstown area but in north Clondalkin or Lucan or other parts of Clondalkin it is not the same service. That is something we need to work on and I wanted to make that point. Also, primary care centres are meant to underpin and have the structures in place to provide these services. Dublin Mid-West is a huge constituency without even one primary care centre at the moment. That is what we are up against.

That concludes our questions. I want to make a few points, not really questions. It was extremely interesting, particularly the issues witnesses raised around play in urban versus rural areas. Is that as a result of the passage of time and different generations? It is that there is a nervousness in a rural area about letting children out to play? In urban areas there might more green spaces or playgrounds in particular areas, although not everywhere. On the matter of transport, as a parent of two living in a rural area when I am not here in work, I am in the car driving to some activity, but that discriminates against many children. I often meet parents or children who say they would love to do an activity but have no way of getting there or no way of collecting the kids. If there was much better public transport in rural areas they might be able to avail of this. My last point is about the value of the public health nurse, which is something I have thought for a very long time. In fairness to them they have to be across everything and it is very different to deal with an elderly community as opposed to new mothers and babies. When it is managed right and done right it can be excellent particularly in situations where mothers potentially have post-natal depression which can be identified. We have all heard very positive stories, but also very negative stories too, so it is about how it is managed. It comes down to resources.

That is a really good recommendation. I know that it is in Sláintecare, but I am glad the witnesses raised that point. Does Dr. O'Dwyer or Mr. Chance wish to make any concluding remarks?

Mr. Francis Chance

I thank the Chairman for those comments which are very appropriate. In many ways we are speaking to the converted here. Nobody is going to argue that prevention is not a good thing in terms of children and families but it is important, in the context of financial decision-making, to stress that prevention is a cost-effective way to work. In our opening statement, we include a graph from Mr. James Heckman, the award-winning US economist, showing that the earlier one invests, the greater the return. Late investment is poor investment in the context of children and families. That is an important element of it. A key requirement now is a new national children's strategy that puts prevention at its centre, one that picks up from where the last strategy left off before the pandemic and also deals with the new and additional challenges that the pandemic has thrown at us. We know that childhood poverty and inequality have grown during the pandemic but if we work together we have an opportunity to address that.

We really appreciate the opportunity to address the committee and would be very happy to engage further with the committee or its individual members in the future. Please feel free to contact us. Finally, we owe it to our children to act now and to act decisively in relation to their development and well-being.

Thank you very much. Does Dr. O'Dwyer have anything to add?

Dr. Maria O'Dwyer

I think Mr. Chance wrapped up very succinctly, but I wish to pick up on the point the Chairman made about play and being in the car. Pre pandemic, the more natural play we saw with children was in areas of disadvantage, which is ironic. Children in those areas would have played in the way children played 40 years ago. Children come home, the street lights are on and the neighbours watch them play. They use green spaces and community facilities. One of the benefits of the pandemic, which I hope we carry forward, is that renewed focus on free play and the use of green and outdoor spaces. The idea of putting children in cars on commutes or having scheduled play dates on rubberised play mats in play parks is starting to be phased out, thankfully. In terms of play being a key process and outcome for child development, we are delighted that there is a positive to take from the pandemic.

Thank you very much to you both. It was a really interesting discussion and I am glad we had the opportunity to engage with Dr. O'Dwyer and Mr. Chance. We will definitely engage with them again in the future. That concludes session one.