Her chances, your choices - Introducing Kirsty, the Holyrood baby

In 2014, in a campaign video for the referendum on Scottish independence, Nicola Sturgeon asked us to imagine a Kirsty and asked what kind of Scotland we wanted her to grow up in. Now, born on 12 May 2016, this is our Kirsty. She will grow up in the real Scotland. What kind of life does Scotland want Kirsty to have, and what will you do to support or hinder that?

As the newly elected First Minister of Scotland, Sturgeon recently used a newspaper column to pledge: “Let’s all resolve that, when this parliament dissolves five years from now, we’ll be able to say we’ve done everything we can to give all of Scotland’s young people the best possible future.” 

And as the Scottish Parliament’s fifth session begins, Holyrood heralds another beginning. Kirsty is our Holyrood baby, a child born into one of Scotland’s most deprived communities.

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Every choice, priority and piece of legislation made by MSPs will have a direct impact on Kirsty and her life chances, as she undertakes her journey from birth to school over the lifetime of this parliament.

Will the Scottish Parliament do everything it can, as challenged by the First Minister? Holyrood will hold our parliament to that promise through the eyes of Kirsty and her mother.

However, Kirsty faces an uphill struggle and poor prospects, having been born into one of Scotland’s most deprived communities.  

Evidence shows poverty has a negative impact on a child’s health, cognitive development, social, emotional and behavioural development and educational outcomes.

In fact, we are already quite far down Kirsty’s life-chances journey. While our new politicians were campaigning for election, Kirsty’s circumstances were already having an impact on her life chances while she was forming in the womb.

Kirsty is lucky. In the most deprived areas in Scotland birthweights average 200g less than in the most affluent. Smoking among mothers is much more likely, but at 7.6 pounds, Kirsty has been born a healthy weight. 

Stillbirths and mortality in the first week of life are twice as likely among low economic status groups as high ones. 

Folic acid, a B vitamin, helps develop a baby’s brain and spinal cord, but Kirsty’s mother, Caley, did not take it as a supplement until week five, by which time any birth defects would have already occurred.

Kirsty is lucky.

Looking ahead, however, Kirsty is far less likely to perform well at school or be offered opportunities to fulfil her potential. She is more likely to be obese, have serious illness or suffer from mental ill-health by age three.

And, starkly, Kirsty is expected to live almost a decade less than a girl born at the same time into one of Scotland’s wealthiest communities.

However, Caley is determined to give her the best chance in life. She doesn’t want her to experience the same life she’s had. 

Dr Anne Mullin is a GP in Govan at one of the ‘deep-end’ practices which serve the most deprived communities in Glasgow and Dundee.

“I have been a GP for 23 years, I think, in Govan, and I honestly don’t think I have ever met a parent who has not wanted the best for their child, and had ambition and aspiration for their children to do something better. It’s a common human condition, I think. It’s universal. With that in mind, there’s a lot people can do to make that a reality,” she tells Holyrood.

Parents of children living in poverty are more likely to suffer poor mental health, relationship and financial problems and substance misuse, which can affect their parenting behaviours, and which often have negative impacts on children’s outcomes too.

The Child Poverty Strategy, updated in 2014, and the 2009 Early Years Framework, show Scotland is aware of the problem. 

The country’s overall framework, ‘Getting It Right For Every Child’ (GIRFEC), is specifically designed to improve outcomes for children by focusing on interventions and support at the right time to maximise prevention. The Early Years Collaborative brings voices from many different services and organisations round the table to share learning and innovative practice. 

However, for all the good intentions, one in five Scottish children lives in poverty, a higher rate than many European countries. What’s more, child poverty is expected to rise dramatically in the years to come, according to independent modelling by the Institute of Fiscal Studies (IFS).

Moreover the Child Poverty Action Group (CPAG) in Scotland points out some policy decisions on benefits taken since may make things even worse.

CPAG has set up an ‘early warning system’ to gather information and case studies about the impact of welfare reform on children and their families as the changes take effect.

As part of its recently published ‘Programme for Scottish Government’, CPAG suggests a child poverty act for Scotland should be introduced, setting out a clear legislative framework for prevention, reduction and eradication. 

Speaking to the Scottish Parliament’s Health and Sport Committee, global health inequality expert Sir Michael Marmot said levels of child poverty were a political choice.

Instead of focusing on the poorest in society, he argued, policy should recognise the gradient.

“The fact is people near the top have worse health than those at the top, and people in the middle have worse health than those near the top, and that applies to every marker of good early child development. 

“If you look at children’s physical development, growth, if you look at children’s cognitive development, linguistic development, social and emotional development, it’s a gradient. Look at performance in school by socio-economic characteristics of their parents or the area in which they live, it’s a gradient,” he told MSPs.

The UK nations, Marmot pointed out, perform badly against other OECD countries in tackling this gradient using tax and welfare.

He recounted an encounter with an economist at the UK Treasury, showing a graph of the gradient of inequalities in the UK.

“He said, ‘Oh, don’t come to me with that Scandinavian nonsense – we’re Anglo-Saxons here,’ adding, ‘We focus on the worst off. That’s the default position of British social policy, and this Scandinavian nonsense is not for us.’”

Marmot said he was careful not to make political points, but to point out the political choice being made. “If the Chancellor says he is happy with that choice, that is absolutely fine. However, I feel a responsibility to say, ‘That will damage our children.’”

As a doctor himself, Marmot said he adopts the thinking of 19th century German public health pioneer Rudolf Virchow, who said doctors were “the natural attorneys of the poor,” but his ‘proportionate universalism’ advocates universal services with spending proportionate to need.

The NHS in Scotland operates such a model. Kirsty is born into a community which is likely to have several robust local initiatives, but her progress will depend on how Caley relates to them. 

If she is lucky enough to live in Inverclyde, Govan, Edinburgh, Tayside or Grampian, she may have access to one of the Scottish Government’s new primary care test sites, which integrate local services and allow GPs to signpost to necessary support from the third sector, housing associations or elsewhere. The latest such hub, in Lanarkshire, launched in March.

Family nurse partnership, which gives quality one-to-one support by family nurses to vulnerable families, operates in ten of Scotland’s health boards. 

However, at 24, Caley does not qualify for this support. The Scottish Government says it aims to expand the programme to support 20-24 year old mothers, but it will be too late for Caley.
Dr Mullin says women at the Govan SHIP (Social & Health Integrated Partnership) project tend to attend their antenatal appointments. 

“Good antenatal care is really important, and we have the infrastructure for that here. We would only get agitated by that part of the pregnancy if they weren't attending their antenatal appointments, not turning up, which is actually highly unusual,” she says.

After birth, health visitors provide much of the early screening and advice, and a proposed increase in their numbers in Scotland is welcomed by Mullin. Both they and the GP signpost to other services and third sector organisations at the Govan SHIP project, helped by link workers. 

However, outwith the family nurse partnership, health visitors have a much higher caseload. Unless she is flagged up as specifically vulnerable, they, like the GP, will have less time available for Caley.

“What the Govan project has taught us is if you give us more time we’re much better at dealing with vulnerability, in terms of bringing it to wider services,” she says. “Because you need time to do that work. You need longer appointments with complex families. There are lots of issues you have to deal with.”

Mullin says that despite the pressures of demography and budget, ‘deep-end’ GPs make time to know the family situation and ascertain other factors such as diet, quality of housing, levels of family support and mental health.

“You need to spend time writing down the narrative that will determine which services and input you need for that family, so you definitely need more GPs, but that’s across the board. In areas of deprivation you need to acknowledge that,” she adds.

For Mullin, the relationship is key. “At the centre of this is patients knowing where to go for help and having trusted professional support. The importance of relationships can't be overestimated.”

The University of Edinburgh’s Centre for Research on Families and Relationships (CRFR) is a partner in the Growing Up in Scotland study, which is tracking 10,000 real children across the country in two cohorts.

The work is carried out by ScotCen Social Research in collaboration with the CRFR and the MRC Social and Public Health Sciences Unit at Glasgow University.

Comparing the two cohorts born in 2004 and 2010, the study has produced some interesting results. Improvements include the number of mothers abstaining from alcohol in pregnancy, the number engaging with books with children at 10 months and mothers with three-year-olds not smoking. 

There are some declines, though. The number of longstanding illnesses at age three had increased, as has the number of mothers in “excellent health” at the same point.

CRFR co-director Professor Lynn Jamieson says trust that those providing services won’t be judgemental is an issue, but all relationships are key to Kirsty’s development, not just those with services. 

It is likely the maternal grandmother will play an important role, according to the findings of the Growing Up in Scotland study. 

“Most infants in Scotland benefit from grandparents contributing to their family life and, for some struggling parents, a grandparent may be keeping chaos at bay, plugging gaps in care or holes in budgets,” says Jamieson.

The relationships with peer groups are also vital, she says. Caley’s social network may help or hinder her chances of breast feeding, for example.

“The first child is often a shocking experience in lots of ways, as well as rewarding – the sleep deprivation, the all-consuming demands and responsibility of infant care. 

“It's reassuring, then, to know people who are actually having or have had the same experience. But that then knocks out all of their social network who are childless. That's maybe why, having made some new friends through antenatal services can be quite important, and if that's not happened and you don't have any other friends who have had children, then you're already in trouble, lacking social support. 

“Most of us know our own mother has had children because we are our mother's child. Becoming a parent sometimes result in a big shift in how we see our relationship with our own parents and particularly our mother. It becomes renewed.”

With Caley’s normal timetable and routine disrupted by a very young baby, Jamieson suggests her relationship with the surrounding community will also play a factor. With evidence suggesting trust in neighbours can be low in areas of deprivation, this might make life more difficult for Caley.

“If you don’t trust your neighbours and know about local trouble you have reason to be more vigilant, fearful and protective on behalf of your child.”

Everyday hazards like air pollution will also be more prevalent, she says. 

Caley will be up at different times of night, like every parent, but Jamieson points out she is unlikely to have a car or feel safe enough to go out for a walk with her baby at night. 

And as Kirsty grows, access to green space and playparks will be important, she says, as well as public libraries.

Dr Mullin says Govan’s green spaces have been well maintained and improved child development in the area.

“It sounds like a bit of a silly thing, but urban planning is really important to the debate. You need usable, safe community spaces. Community education projects. Social investment, but you have to have the vision to actually do that,” she says.

Community health hubs like the one in Govan have taken an asset-based approach to health improvement, empowering the community to be part of it. Elsewhere in Scotland, however, there may not be such a sense of agency. 

Scotland’s Children and Young People Commissioner (SCCYP), Tam Baillie, works to ensure children understand their right to be heard, but as a newborn, how can Kirsty’s voice be heard?
Dr Beth Cross of the University of the West of Scotland wrote a report on engagement with babies for the SCCYP and found the approaches in the community health hubs have made a difference through a culture of listening. They have even branched out to other community empowerment activities, she points out, citing the success of community radio in Rutherglen, and ‘books for babies’ in Craigmillar.

“They have a baby book of the year award and they don’t use experts to shortlist. They are the experts. In fact, that award is now named after a local grandmother, rather than Sainsbury’s or something,” she says.

Empowering communities, she says, will have a direct effect on a baby’s development. “If parents aren’t listened to, and children observe parents not being listened to, from very early on they learn disadvantage. They learn their place in society by how their parents are treated.”

In fact, over the next few months Kirsty’s mind is going to grow faster than at any other point in her life. Approximately 1000 synaptic connections are formed every second during this period, according to research for UNICEF.

In each of those connections, the choices of Caley, her family, the services around her and the policies that affect them and their community, will be reflected. 

Research psychologist Dr Suzanne Zeedyk says Kirsty’s brain has been developing an attachment with Caley already, especially since February. 

“Many people don't realise how much babies’ brains are developing before birth, especially during the last three months of pregnancy. Or more specifically, they don't realise how much the brain is developing in a way that will let it fit into the particular world that will greet the baby when he or she is born,” she says. 

“When a baby is born, they already recognise the voices of the people they've been hearing on a daily basis. So they will know Mum's voice or Dad's voice or Granny's voice. 

"They will also know if Mum and Dad speak happily to one another or argue a lot. If they argue, the baby's brain will already be producing higher levels of the stress hormone cortisol at birth, because the baby's brain has been anticipating a world that is filled with scary shouting. When there's a lot of cortisol in a baby's brain, it changes brain development in ways that most mums and dads don't want for their baby. 

“All of this information helps us to think about the connection that babies bring with them at birth.  Their brains are already preparing for the world they will live in.  

“That's the point of being born with a brain that's as immature as infant human brains are. It lets you grow a brain that matches your particular world - whether that world feels connected and reassuring or uncertain and scary.  

“What we need to be doing, as parents, families and a society, is using the neuroscientific insights that we now have so that we can think more deeply about creating the world we want our babies to live in. We are failing to achieve that in ways we don't realise and wouldn't choose if we did.”