Promoting, protecting and advocating for the Healthy Start scheme in the UK

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Welcome to our blog


The main contributer to the blog is Georgia Machell. Much of the blog content stems from research conducted as part of a PhD thesis that Georgia completed at the Centre for Food Policy, City University London entitled Food Welfare for Low-income Women and Children in the UK: A Policy Analysis of the Healthy Start Scheme. We welcome comments and feedback and hope that you’ll find the blog interesting and useful.

By Georgia Machell, Apr 13 2015 04:46PM

Healthy Start beneficiaries can access free vitamins through the programme for both mums and children. The Healthy Start maternal vitamins contain vitamins D, C and folic acid, the children’s vitamins contain vitamins A, C and D, Vitamin D is the vitamin that has received most attention in recent years, andthe CMO even made a statement encouraging Healthy Start vitamin promotion and take-up to specifically address concerns around growing levels of vitamin D deficiencies.

NICE are conducting an economic analysis examining the cost effectiveness of moving the Healthy Start Vitamin programme from a targeted to a universal approach. Although growing numbers of local areas are choosing to make Healthy Start vitamins universal, this analysis will assess whether there is an economic case to change the policy centrally, making it mandatory that all women and young children receive Healthy Start vitamins.

The discussions around vitamin D and Healthy Start raise issues about who Healthy Start is for. It is not only low-income women and their young children at risk of vitamin D insufficiencies, also people with dark skin, those who cover-up and the elderly are at risk. If Healthy Start vitamins do become universally available, the nature of one aspect of the nutritional safety net will change from one which originally had a targeted approach to address health risks in low-income communities, to a general population approach. This may positively impact population averages for nutrient intakes, but will not necessarily impact the health of vulnerable populations or address health inequalities. Thus, as the shifting history of welfare foods has illustrated and the changing policy context for Healthy Start indicates, the focus and shape of welfare food provision may continually change in response to new evidence and concerns. The benefit of having vague objectives, is that the policy can be manoeuvered to fit as a policy response to a range of issues.

The focus on vitamin D as an area of policy concern and Healthy Start vitamins being hailed as a solution, highlights the fluidity of welfare food policy. Healthy Start, which began as a scheme to promote breastfeeding and counteract the negative connotations with the Welfare Food Scheme, today appears to be largely regarded as a system for distributing vitamin D. The recommendation from the CMO and the economic assessment being undertaken by NICE are valuable, however the food aspect of Healthy Start is getting overshadowed, perhaps because it is unclear what the impact of the food vouchers is intended to be and the lack of data collection or monitoring on how families choose to spend their Healthy Start vouchers.

By Georgia Machell, Mar 2 2015 01:33PM

Did you know that the Welfare Food Scheme, which operated in the UK between 1940 and 2006 was never formally evaluated? It is hard to imagine that such a long running, nationally funded programme was never investigated to find out if was effective, but in some ways this may reflect the ‘duty of care’ aspect of the scheme. The strong belief that vulnerable women and children should be supported nutritionally, regardless of whether an outcome could be measured, may well have carried the scheme through many years of its life. One of the criticisms of the COMA review of the Welfare Food Scheme that was undertaken in the early 2000s was that there was very little data on the programme for them to evaluate, and without data how do we know a policy is actually doing what it set-out to do? My research also found that any evaluation of the new Healthy Start was also considered a little late in the day. Most evaluation experts will tell you that the time to consider evaluation and monitoring of any programme is before the programme rolls out, that way evaluators can collect any baseline data and be clear on what information is needed and how it can be collected. A report from 2007, outlines options for evaluating Healthy Start (note: Healthy Start rolled out in 2006). Never the less, the Department of Health commissioned two evaluations of Healthy Start that reported in 2013. This post gives an overview (but for more information I strongly recommended reading both reports which are available here). This is a longer post than usual, but I can’t emphasise enough how important these evaluations are in terms of adding to the understanding of Healthy Start, so here goes...

Both evaluations published in 2013 broadly address how Healthy Start operates on the ground, however they have slightly different, yet corresponding remits. Specifically, Lucas et al. (2013) undertook a process evaluation of Healthy Start across 13 Primary Care Trusts (PCTs). The objective was to gather experiences of beneficiaries, frontline staff and staff employed at small independent retailers. Methods comprised of qualitative research to glean the views of beneficiaries (n=107), frontline staff (n=65) and staff employed in small independent retailers (n=20). Like Hills (2006), Lucas et al.’s (2013) evaluation does not engage with large numbers of participants, thus findings are not generalizable. Rather findings are considered as indicators of issues emerging in practice.

McFadden et al. (2013) undertook a larger multi-method evaluation to look at voucher and vitamin use in Healthy Start and consider the feasibility of economic impact evaluation. This evaluation includes:

· systematic review of qualitative and economic literature

· qualitative research with Healthy Start participants in London and Yorkshire and the Humber (n=113) and practitioners (n=49)

· Participant demographic questionnaire (n=109)

· national electronic consultation with health professionals (n=620)

· cross-sectoral workshops (n=56)

· consideration of both commercial and public data sets.

· consideration of the first purposeful sample in 2010 Infant Feeding Survey

The methodology draws on range of methods, however the number of beneficiaries interviewed remains relatively low. This reflects a similarity between this evaluation and the former evaluations and studies on Healthy Start.

It is unclear why the Department of Health commissioned two evaluations simultaneously. Neither evaluation makes reference to the other. Despite this, many of the recommendations and implications were similar or the same, thus the benefit of having two evaluations is that they reinforce some of each other’s findings. McFadden et al. provide almost 55 recommendations based on their research, whereas Lucas et al. (2013) provide 26 implications of research. Despite the issues that emerged across the evaluations, in both reports there is a general belief that Healthy Start is an important scheme that should remain in place. Key general recommendations that both evaluations make are:

· Universalising vitamins

· Support local areas to make better links with local services such as children’s centres

· Raise awareness of Healthy Start in general

· Train any professional who has contact with pregnant women about their role in Healthy Start.

Both evaluation teams experienced issues accessing certain datasets (Lucas et al. 2013; McFadden et al.). McFadden et al. (2013) considered the utility of the data collected by the companies commissioned by Department of Health to manage the Healthy Start phone line and the reimbursement unit – Homescan and Kantor. Neither company could provide data in a workable format that could support the evaluation. In addition, the evaluators identify data that exists, but was not accessed. For example, McFadden et al. (2013) tried to access commercially accessible data and found that although commercial information on how Healthy Start is used in Tesco (one of the most used supermarkets by Healthy Start beneficiaries) exists and is held by Dunhumby – a large market research company, it could not be accessed, presumably due to the financial cost.

It was valuable for McFadden et al. (2013) to include data from the first purposeful sample included in the 2010 Infant Feeding Survey. McFadden et al. (2013) state that the 2010 Infant Feeding Survey (McAndrew 2012) is ‘the single most promising dataset for analysing the demand of Healthy Start –supported products and for judging the impact of vouchers on this demand’ (p.126). For the first time, in 2010 the IFS included a purposive sample of women who would be eligible for Healthy Start and included questions regarding their infant feeding practices. The value of the inclusion is that prior, there had been no data on the infant feeding practices of families in receipt of Healthy Start. Key findings were that the sample population had considerably lower rates of breastfeeding then the general population and Healthy Start vouchers were primarily spent on infant formula.

The evaluation reports provide really valuable insights into the how Healthy Start operates on the ground and provides scope for lots of further research on specific aspects of Healthy Start in practice. The reports can be accessed on the resources page of this website.

By Georgia Machell, Feb 16 2015 02:18PM

Before the publication of the recent evaluations of Healthy Start, the last Infant Feeding Survey and the last Diet and Nutrition Survey for Infants and Young Children (DNSIYC) there was very little information on how beneficiaries actually used Healthy Start and whether or not Healthy Start was indeed supporting women and children to get better nutrition at key stages of development. The picture is still a bit hazy, but we now know more then we did before these reports came out.

The recent evaluations indicate that beneficiaries used Healthy Start food vouchers to purchase fruits that they wouldn’t previously be able to afford, like strawberries and grapes. Conversely, the last Infant Feeding Survey and the DNSIYC indicated that Healthy Start beneficiaries primarily spend vouchers on infant formula, but the age of this sample is children aged 6 -18 months, many of whom will still be receiving formula. The Infant Feeding Survey also reported that initial breastfeeding rates were considerably lower among Healthy Start beneficiaries (56%) compared to the average (81%). It is internationally established that breastfeeding is beneficial for all mothers and infants, and should therefore be promoted by the state and health professionals.

In theory breastfeeding is supported by enabling mothers to buy fruits, vegetables and milk for themselves to consume while breastfeeding and by ensuring contact time with a health professional when the application form is signed, therefore presenting an opportunity for the health professional to talk to the mother about the benefits of breastfeeding. Specific breastfeeding education is not part of the Healthy Start scheme. However, all pregnant women in the UK can receive advice on breastfeeding if they attend free ante-natal classes provided by the NHS in their area. It has been reported that about 75% of low-income women do not attend ante-natal classes (Redshaw and Heikkila 2010). There are examples of local areas that have successfully integrated nutritional services into the Healthy Start by referring beneficiaries to services at government funded community centres for families with young children. Some examples of activities that Children’s Centres provide include: breastfeeding support groups, healthy eating sessions and cooking classes.

We want to know what you do to promote breastfeeding through Healthy Start? Are there examples of innovative approaches to promoting breastfeeding to Healthy Start beneficiaries? Are there resources that are useful for using Healthy Start to promote breastfeeding? Please get in-touch with examples, ideas and questions. We'd love to hear from you!

By Georgia Machell, Feb 9 2015 01:38PM

‘Nutritional Safety Net’ is a term that gets batted around quite frequently, but it’s not always clear what it means. Healthy Start is often described as a nutritional safety net. It’s a nice to imagine that a net (possibly made of healthy food) exists which can catch people who may be falling quickly towards nutrition insecurity. However when you want to pinpoint how a nutritional safety net actually works it becomes a bit more complicated.

Given the intricacy of food and nutrition poverty, a really strong nutritional safety net needs to combine a number of different interventions. Healthy Start aims to influence dietary diversification and supplementation in a very specific population group. The fact that Healthy Start provides vitamins and vouchers to purchase healthy foods is a good basis for a nutritional safety as it combines interventions. Although, it’s unclear if the two interventions are successfully being combined to create a really robust nutritional safety net. Recent evaluations (which can be found on our resources page) indicate that there is a lot more focus given to the vitamins component of Healthy Start and still not a lot of support for getting the most out of Healthy Start food vouchers.

There is a lack of data that can tell us how effective Healthy Start is as a nutritional safety net. We think the nutritional safety net could be a lot more sturdy and effective if the value of Healthy Start food vouchers was increased, enabling low-income families to purchase more fruits, vegetables and milk with their Healthy Start food vouchers. It could also be expanded to a greater proportion of vulnerable families. The value of Healthy Start food vouchers has not increased since 2009, despite the cost of food increasing. It’s therefore timely to reconsider the value of Healthy Start food vouchers and ways to support families to get the most out of both the food and vitamin aspects of the scheme. We need to ensure the nutritional safety net has not worn thin overtime and can support the needs of Healthy Start eligible families.

By Georgia Machell, Jan 28 2015 04:25PM

Remember Milk Tokens? Milk Tokens were the main feature of the Welfare Food Scheme for 66 years. Women would collect their milk tokens along with other benefits and exchange them for infant formula or cows’ milk. The problem was, you could get a lot more infant formula with a milk token then cows’ milk. Why was this a problem? The public health recommendation from the government is, and was, that breastfeeding is the safest and healthiest way for infants to be fed in the first year of life, and beyond. The Welfare Food Scheme was therefore at odds with this public health recommendation.

Alongside this concern, later 20th century research evidence increasingly supported nutrition in pregnancy and the early years as being of vital importance, and the damage to health and well-being caused by health inequalities was fully accepted in public health. Alongside this growing awareness of the importance of fruits and vegetables through campaigns such as 5-A-Day made it an opportune time to revisit the Welfare Food Scheme and move it into a more public health focussed arena (and give it a better name that had a more positive connotations!). Healthy Start was formed in 2006 after proposals and consultations took place (we’ll go into more detail on how these were performed and the policy process in a separate blog post).

Healthy Start is a different to the Welfare Food Scheme in a number of ways: beneficiaries get a food voucher that they choose how to spend on either fresh or frozen plain fruits and vegetables, milk or infant formula; they also receive vouchers for free Healthy Start vitamins and to access the scheme women have to go through a health professional. It is interesting when talking about Healthy Start with health professionals and beneficiaries, however, how many people still refer to Healthy Start as Milk Tokens. A recent evaluation (Lucas et al. 2013 - the full report can be found here) provided insight into how the shift from Welfare Food Scheme to Healthy Start has not been as smooth as originally hoped. The confusion is summed-up in the following quote from a Healthy Start beneficiary in Leeds: I only knew about the milk not the other things because they are milk token vouchers. (p.80)

Let’s try to emphasise the food in Healthy Start and leave the Welfare Food Scheme in the past. How do you promote Healthy Start food vouchers? Are there any examples from your local area of how Healthy Start has been differentiated from the Welfare Food Scheme?

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