Adventures In Evidence

Here’s my final response to the consultation on student funding, run by the SG’s Student Support Review.

The  questions are still quite open ended, although the review is now in its final few weeks: it is due to report in the autumn. Where questions are asked about a specific proposal, a “minimum income guarantee”, what is meant by that is not defined. The SG uses this to mean “the maximum amount of support, available only to those at the lowest incomes”, but the questions make it sound like what’s envisaged is something more like the Welsh plan for a uniform support entitlement, provided in a different mix of grant and loan, depending on income.

It’s not clear whether the review is prepared to argue for increased cash investment in support for low -income students, or is asking its questions in the context of taking a zero-sum approach to non-repayable funding. That matters a great deal.  The difference between FE and HE support, in value and legal entitlement, is a critical issue for the review. But it’s had to see how that gets fixed with no new cash.

The concern about this review must be that, having been told that fees are outside its remit, if it is not looking at increased cash investment, it will be tempted to suggest that the SG makes much more use of student loans to plug holes in its living cost support, particularly for those from low incomes and those studying on FE-level courses (there’s  some overlap there).  In stacking up debt even more disproportionately among those from the lowest incomes, that would be a regressive move.

In theory, however, the review offers the chance to make some improvements, including to reverse some of the worse features of the 2013 changes: not just lower grants but also a lower income threshold for maximum support (only partially corrected last year), the introduction of very sharp stepped reductions in support at particular incomes, and the removal of any extra support for study in London.  It is also a chance to sort some longer-standing issues, such as the lower grant offered to independent (mature) students and the relatively poor levels of support available at incomes between £34,000 and around £45,000. There are new things to look at, such as whether students on 1+4, 2+3 or 2+4 models should have a year (or two) of their debt written off, so that the SG is putting its money where its mouth is, in regard to its increased emphasis on college entry to HE as a route to university.

It’s also a chance to remind everyone of the current government’s commitment in its manifesto to increasing the loan repayment threshold to £22,000 (it is currently around £17,500; it is £21,000 in England and in Wales) and reducing the write-off period from 35 years to the 30 years used in the rest of the UK.  Although this unqualified manifesto commitment was remitted to the review (not a common move for a single party government so soon after an election), surprisingly perhaps the consultation does not include questions asking specifically about it.  It would be the most effective way to help lower-earning graduates, and if the review does not hold the SG to making these changes, it will be very disappointing.

The consultation ran from the end of June to the end of August. That’s less than the SG’s standard 12 weeks, and coincided with the summer break.  If the review nevertheless gets a decent number of responses, it will be evidence that a consultation like this has been long overdue. If it doesn’t, then I suspect the timing will turn out to have been a large issue.

Sections in italics below are my responses.  I’ve only answered the ones where I felt I had something to say.

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1 – Greater alignment of financial support for students across colleges and universities with increased fairness in what all students can access;

Rationale: to create parity for all students whatever the level of study

1.1 Should there be parity in funding levels available to all students, based more on need rather than the level of study?

This is a hard principle not to support. But if it would simply mean spreading the existing cash resources available for those in the greatest need even more thinly, it would be very problematic.  Taking already limited support from one low-income group to help another cannot be the right answer.

There is already some evidence (previously shared with the review team) that take-up of grant, particularly the £500 level of YSB, has fallen as grant has reduced in value: it is plausible that some students do not regard it as large enough to justify asking their families to go through means-testing. Cutting existing HE grants further therefore risks not only higher debt or reduced grant support at low incomes, but low income students falling out of means-tested support entirely.

What is meant by “need” also matters here. Underlying expectations of family support (cash and kind) at different ages and stages are especially important. Does a 17 year old studying at school have the same need for state help as a 19 year old from the same household who is entering post-school education?   There is a strong argument that post-school level young people need to be supported in having more choice over where they study and live, and that our expectations of direct family support should reduce at that stage.  The review could usefully take a view on this.

1.2 How could parity be achieved and how can we maximise the income available to students?

It is very important that grant and loan are not treated as inter-changeable forms of living cost support. Otherwise, it is very likely that those most dependent on state help with living costs will end up either with the most debt (particularly if they do not move directly from school to  university) or not taking out their full notional entitlement.

My MSc research (already discussed with the review team) showed that a significant minority of those entitled to YSB do not take out the loan required to top it up to obtain their maximum entitlement to support.  Those in college-level HE are particularly likely to be non-borrowers, especially in first year.  Any proposals here should take into account the evidence we already have of the lower propensity to borrow of those on sub-degree courses in college.  Grant-only HE students receive less support than those who receive an FE bursary.

It is not clear whether the review is prepared to argue for higher investment in non-repayable forms of targeted student support for those from lower incomes. This is however the only way to improve living cost support for those at low incomes which can be relied on to be largely taken up by that group, and which will clearly avoid them facing a later penalty for their lower-income starting point, in terms of having to repay a larger debt.

1.3 How can parity in funding be achieved without having a negative impact on benefits?

I cannot comment on the interaction with benefits, although I would hope the devolution of some benefit powers to the Scottish Parliament would give Ministers more flexibility to deal with the interaction with student support, for example by filling gaps where benefits are withdrawn. I am aware that the interaction with Carers’ Allowance can be particularly difficult for some students.

1.4 What is the most effective way to determine which students are most in need of bursary support?

The Rees Reviews in Wales noted that there was scope to refine the means-test and that some systems include wealth/assets in the assessment. 

The system could do more than it currently does to take into account the number of dependents there are in a household and the impact of that on family liquidity. Students from middle and higher income households which are supporting multiple children in post-school education could be given access to an additional loan entitlement, as a de facto way of enabling parents in this situation to spread their contributions to their children over a longer period.

The move in 2013 from tapers to large losses in entitlements at three particular incomes (especially £34,000) should be reviewed: it results in disproportionate loss of support for minor changes in income.

The age discrimination in HE grants should be removed, so that students no longer receive a lower grant (and higher loan) because they are classed as “independent”. The original justification for the different treatment of young and independent students was that independent students had access to a separate Mature Student Bursary Fund and were not liable for the graduate endowment. Neither of these is still true. Mature students are disproportionately from disadvantaged backgrounds, and have historically received additional support in recognition of their great financial liabilities: yet in Scotland at present are expected to borrow more.

2 – A simplification and clarification of the systems used to provide financial support to students in Scotland today;

Rationale: to remove some of the unnecessary complexities and enhance the student experience

2.1 What are the key features of the current system that may deter or make it more difficult for students to access, or stay in college or university?

The heavy reliance on loans for living cost support at lower-incomes risks deterring some students from taking out their full support, increasing the risk of excessive term-time employment and/or dropping out.

The sharp drop in total support available as soon as income reaches £34,000 and relatively low total support to those from households with incomes between this and around £45,000-£50,000 carries the same risk.  The total support for those in this income range is unusually low, and therefore the expectation of family contributions unusually high, within the UK. Scotland is also exceptional in the UK in withdrawing all grant support at £34,000. There is a strong case for using grant rather than loan to improve the support for this group.

2.2 Do any of the current rules and/or practices in place make it harder to access or maintain study?

2.3 How could the way in which financial support is delivered to students at college or university be improved?

3 – Better communication of the funding available, including a clear explanation of the repayment terms of student loans;

Rationale: to assist students and prospective students to understand what financial support is available and when and how they access it

3.1 What type of information on funding would be helpful to students – both prospective and continuing?

More information should be available in an easily absorbed form similar to that developed by Sarah Minty of the University of Edinburgh (here).

The SAAS website should be substantially improved, to be more intuitive and more easily navigable between sections.   An online calculator, as available for other parts of the UK, should be developed.

3.2 How and where should that information be made available? Would a particular format be more helpful?

Online, paper-based and face to face information all have a role.

3.3 When should potential students first be given information on financial packages of student support?

Young peoples’ concerns about funding as a barrier to future study should be explored early, possibly at the point when N5 subjects choices are being made, to make sure that serious misconceptions aren’t limiting choices. But detail on funding may be better left till later, not least as it can change. Decisions here should be guided by research, or further research should be commissioned, if it does not exist.

3.4 What role should colleges / universities/ schools play in providing information on student support?

They should all have staff able to provide reliable advice on this.

3.5 What more could be done to support parents/guardians to better understand the student support funding available?

This group should be specifically targeted with information, as there is emerging evidence that they are the single largest influence on young people’s understanding of their financial choices.

It is not clear why parental contribution expectations ceased to be published several years ago. Even if there are (legal?) reasons for this decision, some way has to be found to tell parents about their expected contribution, for as long as support decreases as income rises, and to make it clear that this is a very long-standing part of student support in Scotland at middle and high incomes.

3.6 What could be done to help students understand more about student loans, including how and when they are repaid?

Scottish Ministers’ negative rhetoric about student debt, used to make comparisons with other parts of the UK, risks feeding Scottish students’ reluctance to make use of student loans. The Scottish Government needs to consider whether it is sustainable to rely so heavily on student loans for living costs while being so generally critical of student debt elsewhere. The common implication that £27,000 of debt is unreasonable sits uneasily with that being around the amount a low-income student is expected to accumulate in Scotland over 4 years.

The leaflet produced by Sarah Minty, cited above, provides a very good summary of the loan system for students, which could be the basis of information provided in other media.

4 – Further consideration of the levels of funding required for all students and the funding mix.

Rationale: to provide more funding, particularly for students from the most deprived backgrounds, and funding choices for students

4.1 Should a ‘minimum income’ guarantee be introduced across all students?

Does this mean following the Diamond Review model of giving all students access to the same value of support, using a mixture of grant and loan? If so, two considerations are:

first, the more this is provided by loan at low incomes, the more likely it is that a substantial of minority of students will either not benefit in practice or will be relatively disadvantaged long-term by having larger debts (see above);

second, if loans to those at high incomes are made available at the current  highly-subsidised interest rate, it is more likely that this cash will be used not for immediate support needs, but to give these students additional long-term advantages, for example by  being used as low-cost funding towards buying property, funding unpaid or low-paid internships, or postgraduate study. The Rees Review found evidence of such practices in Wales when interest rates there were pegged to inflation, as here.  There is a strong argument that any loan support made available to those at higher incomes for living costs should be provided at a less subsidised interest rate, as a disincentive students from higher incomes using student loans to increase their relative  advantage.

4.2 What should the ‘minimum income’ guarantee be, and why? Should it be linked to the Living Wage?

4.3 Under what circumstances should a ‘minimum income’ apply?

A “minimum income” would imply that it is a minimum for everyone.  However, that label is currently used in Scotland to mean the value of the maximum support available to those at the lowest incomes, which may be confusing for students. 

If this question is intended to explore the income level up to which the maximum value of support should apply, in line with the meaning of the current Scottish MIG, then the current cut off is relatively low, particularly given that support then falls by £750 in a single step. It is lower in cash terms than applied in Scotland in 2012, and therefore now even lower in real terms. It is substantially lower than in England. It is closer to the Welsh and NI level but these systems do not then withdraw support so sharply.  There is a strong case for increasing the income threshold for maximum support, especially if a stepped system continues.

4.4 What is the appropriate balance of bursary / loans within a ‘minimum income’?

Bursary should provide the bulk of support for those at lower incomes.  It should at least be high enough to mean that they are not expected to rely more heavily on loans than those at higher income, as is currently the case.

4.5 Rather than only Higher Education students, should all students have the option to access student loans, regardless of their level of study at college or university (in addition to existing bursary entitlement)?

The rationale for the introduction of student loans in 1990 was that graduates are likely to have higher earnings from their participation in HE. There is already evidence that this is far less likely to be true for those on HN-level courses. It is very questionable whether this argument can be applied to FE students.  Unless the repayment threshold is set much higher, these students would face a significant risk of seeing a net financial loss from taking part in FE, if they take out student loans which they then have to repay.

At a more practical level, as already argued, it is very likely that many FE students would not take out a loan, so that the government might have addressed their living cost support needs on paper, but not in practice.

Loan support for FE is also likely to lead to a much greater accumulation of debt by low income students who later progress into HE, unless such students can have earlier years written off if they progress.

4.6 Are there ways that the terms and conditions attached to student loans ( e.g. interest rate or repayment threshold) could be reviewed to support consideration of extension to all students?

The present government undertook in its manifesto to substantially increase  the loan repayment threshold and bring the write-off period into line with the rest of the UK. As Barr et al have shown, these two changes would do the most to protect low earners and thus make the loan scheme more progressive. The review should strongly recommend that these commitments are honoured for all students.

5 – Any other comments, ideas and innovations

5.1 Please use this space to provide any other comments which you believe are relevant to the review. In addition, your ideas and innovative suggestions are welcomed to help inform our final report on how the student support system can be fit for the future.

The decision to remove the additional living cost allowance for those studying in London should be reversed. Scotland is the only UK jurisdiction not to provide such an allowance.  Only small numbers are affected: the cost would be small and would come from the loan not the cash budget, if models elsewhere are followed. 

Ways to limit the accumulation of additional debt by those at lower incomes in 2+3, 1+4 and 2+4 models of study should be explored, including debt write-offs for repeat years.  Although this might reduce the incentive for students to avoid repeat years, (a) these  students would still face a penalty of later labour market entry and (b) it would encourage these students to make post-college choices based on their best educational outcome, not on limiting debt. It would also increase the incentive for government to reduce the scale of repeat years.

The University of Edinburgh recently announced that it would, for the first time,  be offering some places through clearing which would be reserved for students from Scotland from the most disadvantaged areas.  It’s an inventive response to the difficulty the university faces (I’m assuming) in getting more applicants from these parts of Scotland.

It made me think about what puts people off applying to certain universities, and something I’ve heard just often enough to think it’s worth some attention.  We need to talk about open days.

I think of the relative who visited St Andrews in the 1970s and felt so at odds with who they encountered that they didn’t go (to university at all, in the end). The friend who also went to a St Andrews open day (in the 1980s this time) and had the same reaction, spending four very happy years instead at Strathclyde.  Other much more recent anecdotes, from friends and Twitter contacts, about Edinburgh and (less often but also) Glasgow.  It seems possible that the experience of visiting certain universities as a potential applicant on a general open day can be specifically off-putting.

I have been around and about George Square in Edinburgh over a couple of recent open days, seeing young people with their parents. Poor things, is my immediate reaction: the choice seems so enormous, so life-determining. I’m happy never to face that again.   But I also notice the signs of social class. This is not a very mixed crowd.

There’s some relevant personal history here, too. In 1984, I went to an open day at Oxford. No-one else from my school, an average sort of local comprehensive,  was interested, so I did the 5-hour-each-way train trip solo, arriving blurry from an early start in a strange city much bigger than the place I lived, its station on the edge of the centre, pre-Google maps and smart phones. Two colleges were being open that day. At the first, very old and distinguished, I arrived late and stressed: the benches in the lovely medieval dining hall were already full. It felt as though most people there had come in gangs, buses even, from the big public schools of southern England. With their teachers. I did the tour that followed the welcome speech, half of which I’d missed, but it was agony. I felt like a gatecrasher the whole time, awkward and scruffy and excluded. Then I bolted for the other college on my list, a 1970’s concrete thing on the fringes. I remember it was raining hard.  They were surprised to be reminded it was still their open day, but dug me out a friendly undergraduate who wandered me round, and dropped in on a couple of friends, who made me a coffee, cracked jokes and were brilliantly normal. My day improved.  Maybe Oxford might be alright.

Reader, here’s my confession. Both my parents went to Oxford. It’s where they met and they remembered it with huge affection.  Yes, they were first generation university students and entirely dependent on scholarships.  But  my father was a university professor. He’d been to one of those big public schools (more scholarships). The very old college was his old college.  But that open day nearly torpedoed my application to the entire university, because I felt so out of place among the other potential applicants I met there. It certainly took college number one off my list.  And yet I was someone whose family background should have put me at the top end of the feeling-entitled-to-be-there scale. So if I felt like that, I wonder where that leaves so many others.

So here’s my modest proposal.  People from fee-paying schools should be contained in a separate open day. That’s it.  Everyone else should be able to come on the other days without being confronted with that extraordinary, overwhelming  wall of outward confidence and upper-middle-classness which can be so daunting and alienating, particularly when you meet it for the first time.  Now anxious parents are involved, it must surely, if anything, be worse.

I don’t mean here that there should be special open days for “access students”, but for once applying the thinking of quotas etc to the other end of the spectrum: putting the “difference” badge on someone else for a change.  Not because I have anything against any of these young people individually, but because en masse they are so bloody daunting. They can’t help it. They may not even like it. I know now that cultivating that outward air of self-possession is a fundamental part of what private schools do, and that it can conceal plenty of insecurity and confusion.  But at 17 that wasn’t at all obvious.

Indeed this could be taken a step further.  Some state schools are also conveyor belts to the ancients; maybe they should be separated out too.  The criterion could be schools which have sent more than x% of their leavers to ancient or Russell Group universities.

Most access initiatives target the people identified as disadvantaged. We remain less comfortable curtailing the effects of privilege.  This proposal indeed barely does that: these young people still get their open day.  I suspect it would be regarded as an unacceptable, even so: however radical we say we are willing to be, acknowledging the negative effects of advantage as well as disadvantage remains alien to most policy-making and practice.

Footnote

My mother only made it to university in 1947 because of the new system of scholarships introduced at the end of the second world war. I am literally a product of the post war student funding settlement.

Baby boxes are due to be given out to all new mothers in Scotland who have a due date from 15 August onwards.

There’s not been much coverage of how this is being achieved in practice, but there’s some interesting points to make about that, ahead of the media coverage which can be expected round the launch.

Who is providing the boxes?

The Times reported back in April that the contract for all aspects of baby boxes – getting the box made, obtaining the contents, filling it, delivering it, dealing with questions about its delivery – had been given to APS Group (Scotland) Ltd. This is a firm which began as a print services company but has developed a more general publishing and marketing brief.  This is the main APS website, and here’s details on its Scottish arm.  The most recent accounts for the APS parent company mentions its business roots in printing.  APS (Scotland) is 75% owned by APS and its last filed accounts recorded a turnover of just over £9m: the baby box contract roughly doubles that.

A print and marketing firm is not perhaps the obvious body to be sourcing and distributing baby care goods to new parents nationwide out of the health budget (see the Level 4 health budget here). But there’s one strong reason for their having this contract.

Since 2014, APS has a “call off” contract with the Scottish Government for “publishing, printing, design and associated services”: here’s a piece from when they first won the contract. The call off contract is a product of the out-sourcing by government (a long time ago) of various publication services.  This particular call off contract means that officials don’t have to go looking for a designer/printer every time they produce something – they can just go straight to APS.  It’s a very useful arrangement once you no longer have in-house services, and has been around for ages.  The call-off contract was won via a competitive tendering process and in fact covers a range of Scottish public sector bodies, not just the SG (more on that here). This is part of a general efficiency drive: the Director of APS Scotland was a guest speaker at a McKay Hannah event in 2014 on managing public sector budgets.

The nature of the contract

A PQ answer to Elaine Smith MSP confirmed that

The [baby box] contract awarded to APS (Scotland) Group Ltd, takes the form of a call-off to the existing Publishing, Print, Design and Associated Services Scottish Government Procurement Framework. This is a single-supplier framework agreement to which APS Group (Scotland) Ltd were appointed in 2014 following an advertised procurement process.

This means no further specific competitive bidding process has been required for the baby box work. There is nonetheless a specific contract for the boxes on the SG site (link).  Here’s what it says:

All this means that

The provision and delivery of approximately 56,000 boxes (with contents including baby clothing and maternal and infant health products) per year. The provision of associated operational services including printing, claims processing, customer contact centre, warehousing and distribution.

has been interpreted as falling within “Publishing, Print, Design and Associated Services”.

That’s a surprisingly wide interpretation of those terms. The more detailed coverage, see here includes “promotional goods” and “warehousing and logistics”, which I suppose might have been felt to provide enough cover.   Still, procuring and delivering 56,000 large multi-item boxes to new parents is clearly a bit different from  producing a few campaign-specific lanyards or pens, and posting out documents.  So the decision not to submit this to competitive tendering must surely have to had to be put through the legal wringer, given how it stretches the interpretation of the terms of the existing call-off contract and that it is so large in value, at £35.3m. The legal implications of its size relative to APS Scotland’s existing scale must also presumably have had to be examined (“due diligence” is the fancy term here), as this contract would prima facie raise capacity issues well beyond any explored when the original call off contract was let.  This is pretty exceptional stuff, in other words, and worth noticing for that reason.

Costs

The contract formally runs from February 2017 to July 2019, suggesting around 6 months of preparation and then around two years’ worth of supplies boxes, with a “max extension option” of 24 months.  The Times established however that the £35.3m cost assigned to the contract covered the whole four years (this has also now been confirmed in a PQ response), up to summer 2021, so it’s not clear how “optional” the extra two years are, or why this wasn’t simply let as a four year contract.

The total implies a cost of £8.8m a year, compared to £6m a year originally quoted and the £7m in the most recent budget (which it becomes clear was only a part-year cost).   As the Times piece notes, the SG confirmed it was expecting each box to cost £160, rather than the £100 originally expected.  This does mean however that  it has managed not to get pulled to something close to the £500 or so which was the cost of the boxes in the pilot.

Answering a further PQ from Elaine Smith MSP on why costs had increased, the Minister said:

We considered the views of parents in determining the contents for the initial national roll-out of boxes.

Consequently, we have included more expensive items, including the digital thermometer and the baby wrap, which parents involved in the pilot have indicated that they found more useful than they originally anticipated. These are the sort of items that some families on low incomes might consider to be unaffordable, yet they are recommended by professionals as being helpful for babies’ wellbeing.

…We will keep the contents and costs of the box under constant review to ensure we continue to achieve effective value for money.

Asked by Monica Lennon MSP how much of the cost was specifically attributable to the box and the mattress (an important point, because doubts are being increasingly raised – not just in Scotland – about claims made about the boxes specifically: it might be a lot cheaper just to give everyone the contents in a jolly bag), the minister declined to provide a split of the costs due to commercial sensitivity.

The case for taking more time

One argument for by-passing a competitive process may have been lack of time.  The decision to go straight to a full national scheme this year is because of promises made by Scottish Ministers early on.  There are good reasons to argue that a more cautious approach would have been better.  Other places are running pilots which cover the whole of the expected period of use, and then allowing time for reflection on the experience before committing further: see here. Scotland is exceptional in making a political commitment to a national scheme, ahead of any piloting.  Here, the evaluation was conducted less than 5 months in, and while it was published in June, the contract for national implementation had already been let (without any announcement, as far as I can see) since February.

There was no external reason to rush. Finland has had these boxes since the 1930’s, we are often reminded.  Scotland could have taken a little longer to lay the ground for a scheme here. If the politically-set timetable was a significant factor in the decision not to hold a competitive tendering exercise, that would have been another good reason for taking longer.  A central purpose of competitive tenders is to help control spending, to protect the public purse (this money is, after all, coming out of the hard-pressed health budget). Instead, we have ended up in the odd position where lots of effort has gone into running a competition for the design on the box, but none at all into one to choose the particular commercial supplier handling £35m of public cash.

A competition will be run next year, according to this PQ answer.

Due to the imminent procurement exercise for year 2 of Scotland’s Baby Box, the itemised value/cost of any item is currently commercially sensitive. Once that exercise is concluded, we will review the efficacy and sensitivity of providing itemised costs and if appropriate, provide further information in due course.

As the SG has already done its bit by letting the main contract, this appears to be for the contents only, and it’s not clear whether this competition will be run directly by the SG, or on its behalf by APS Scotland, as the main contract holders (though I’m not sure how public procurement works if done at arm’s length by a commercial body).

Practicalities for parents

The SG has a website for new parents which has more about the arrangements for distributing baby boxes,  with detailed Q&A about the practicalities which anyone following this might find useful. The involvement of health professionals is limited – midwives are asked to fill in a registration card with mothers at around 20-24 weeks and send that off.  APS makes delivery arrangements direct with parents thereafter, on an Amazon-like model.  Anecdotally,  just in the last 2 days I’ve come across a couple of examples where women well past 24 weeks haven’t yet heard anything from their midwife about this, so it’s possible coverage may be a bit patchy to start with.  APS must be providing the forms, but it’s not clear who is responsible more generally for making sure all midwives are briefed and engaging with pregnant women.

Conclusion

Shortly there’s going to be a whole lot more PR about these boxes. So it makes sense at this point to stop to ask which organisation is actually running the project in practice, and is therefore immediately accountable for the practical side, and how they were chosen.

For me, this all feels like further evidence that it would have been better to  approach this idea with much more caution. That would have permitted more time to reflect on the pilot and do a proper cost-benefit analysis of this against other ways achieving particular aims with the same money (indeed, clarifying what those aims are, and the balance between them: SIDS reduction, symbolic gesture of welcome, practical support?).  It’s now also clear that standing up to the political impulse to go national, fast, would have enabled the costs to be pinned down better before the long-term commitment was made, and also allowed time for the government to run a proper competitive tendering process for any national scheme, thus avoiding the need for any special interpretation of the contracting rules.

Footnote 1

Ironic note. The managing director of APS (Scotland) is also the registered director of a firm of funeral directors, and so now literally provides cradle to grave services.

Footnote 2

I have a lot of sympathy with this piece from April in the BMJ by a Scottish GP: “The best health interventions may come without gift wrapping”.

Footnote 3

There’s been a lot of coverage today of an intervention by a cot death charity, the Lullaby Trust, on baby boxes. It’s not specifically aimed at Scotland but adds to general concerns about claims made by box suppliers about a link with reduced cot death. It echoes concerns expressed by others, which I picked up in this (warning: very long) piece a while back.  On a technical point raised by the Trust about baby boxes in general, it’s worth saying that the SG Minister has said that the Scottish box does have specific formal safety accreditation.  But the Trust’s global unease about the claims over cot death still stand.

Acknowledgements

Thanks to Suzanne Zeedyk, who asked me earlier in the week if I knew anything about the tendering process and set me off looking for all this, and to various others (none in government or the parliament, I feel I should add, to prevent anyone from having an unnecessarily bad day) who I subsequently contacted and helped me find various things linked here.

A less complete version of this first appeared on my site late yesterday, before I had seen all the various things quoted here,

In the discussion of the launch of the baby box pilot in Scotland last week, some references were made to schemes also being launched in England.  This post gathers up information about what’s happening there, and in some other places, to help put the Scottish scheme in context.

It reveals that the explosion of interest in baby boxes would make a great case study for someone, into how ideas gain attention, how different people and organisations play a role, and the use of evidential claims. And that a mixture of enthusiastic support and scepticism about some of the claims made isn’t unique to Scotland.

Warning: this is very long. It’ll be of interest mainly to people fascinated by the inner workings of the policy process and/or interested in infant health; it may be a heavy read for others. You can skip to the end for some reflections on what we learn that might be useful for the Scottish project.

Background

Baby boxes have been used in Finland since the 1930’s, but it’s only in the last few years that there’s been a surge of international interest. Many articles and interviews trace this back to a BBC piece from June 2013, which received huge attention worldwide, becoming one of the most shared and read stories the BBC had ever published, as discussed in another BBC piece here.  Reflecting still later again on their coverage of baby boxes, a BBC editor said:

“What the original baby box story showed beyond doubt was that a story about parenting and public health policy can, in certain circumstances, go viral. I had not seen that coming.”

Flipboard 11 April 2016

A follow-up BBC report in July 2013 noted that the article had prompted lots of immediate interest and approaches to the Finnish Government, and  this in turn appears to have led the Finnish Government to send a box to Prince George, prompting further coverage.   The original BBC article seems to have  been a simple product of journalistic curiosity and research.  The BBC ran a piece following up its original report in April 2016.

England

I’ll mention first, as an outlier, very specific research being undertaken at Durham University on using (clear plastic) boxes as sleep spaces.

The most publicised baby box scheme in England is one being piloted at Queen Charlotte’s and Chelsea Hospital, London, part of Imperial College Healthcare NHS Trust. There, 800 boxes are being given out to new parents first come, first served.  Parents’ use is being monitored for 8 months and they are required to sign up to “the Baby Box University”, an on-line information resource (more on this below).  The boxes and on-line resources are being supplied for free to the Trust by the Baby Box Co., a US-based company (again, more about them below).  The educational element provided via the Baby Box University is persistently highlighted by the company as an important component of what it offers.

The publicity for this scheme also mentions schemes taking place at a number of other sites in England, all also using the Baby Box Co/Baby Box University model.  This article gives the best overview of how the English initiatives are linked and Imperial College’s co-ordinating role. Further detail on some of the other sites here: Colchester, Sandwell and West Birmingham, North Middlesex (not all the places listed as possible pilots seem to have started yet).  The Baby Box Co. has said:

The Baby Boxes which are now being delivered en masse to UK parents free of charge through community partnerships account for a much greater percentage of our operations [note: by comparison with commercial sales in the UK]. The products included in these Baby Boxes are unique to each hospital. For example, the contents included in the North Middlesex University Hospital Baby Boxes are slightly different than the items included in the Hillingdon Hospital Baby Boxes or the Sandwell and West Birmingham Hospital Baby Boxes. We believe that enabling hospitals to have input over content selection is significant, as is empowering them to create an exterior design which reflects their special community of patients.

The Dad Network 5 Septmeber 2016

In local English media coverage, a strong emphasis is placed on improving  infant mortality – higher than average infant mortality in the areas taking part is a common theme.

It’s not clear whether the other sites are also getting their supplies for free at this stage, but it seems plausible that the company is investing in all these trials as a step towards increasing its presence in the UK. The annual report for Sandwell Child Death Overview Panel describes Sandwell as having been chosen by the company as one of its “starter sites in the UK” and other articles suggest an intention to expand the business here considerably (as does the very long list of English NHS accounts it follows on Twitter).

Jay Hemingway, manager for UK Baby Box company said: “The idea is that every child has the same start in life and we want the boxes to be in every NHS hospital by this time next year.”

Edmonton Gazette and Advertiser 8 September 2016

With plans to extend the initiative throughout the UK, Ms Clary said the diversity of the country’s population would be taken into account. ‘It won’t be a standardised Baby Box that’s the same across the UK”.

Independent Nurse 1 July 2016

There are around 770,000 births every year in the UK.  The wholesale cost of boxes isn’t easily found, but the Scottish Government’s basis for budgeting for its boxes seems to be around £100 per box, so complete adoption implies a total new annual commitment of around £75m for the NHS across the different parts of the UK. However, there might be off-setting savings, as argued here by Scott Johnston, Imperial College Healthcare NHS Trust head of midwifery:

When asked whether the cost of the scheme may be prohibitive for some Trusts, Mr Johnston said this was not a concern; the programme may actually bring benefits by engaging more parents with services early, thus saving costs later on. He added: ‘I think it’s more about the logistics. Within our service we have about 750 births per month, so actually storing [the boxes] and distributing them can be a bit of a challenge. But I can say, as head of service, it’s definitely worth it. It’s something we’ll get over.’

Independent Nurse 1 July 2016

Abstract millions don’t mean much: one way of looking at this is that £75m is the equivalent of 2,500 FTE midwives or health visitors (or put another way, every 300 boxes equals one FTE person). If this were an intervention justified on its impact on SIDS (cot death) and governed by the NICE guidelines on cost-effectiveness (for England) it looks as though it would normally be required to be likely to reduce such deaths by a little under 15%.  It’ll presumably be calculations about the opportunity costs (ie what the money would be spent on instead), what the trials reveal about overall benefits to children and parents,  and potential savings, which determine how far trials in England lead to a publicly-funded roll-out there. The decision seems likely to lie with individual local NHS Trusts.

Note: The Baby Box Co

It is impossible to look properly at the rapid growth of interest in baby boxes without recognising the part played by the Baby Box Co. There are other suppliers around the world, but this company has been by far the most active in promoting boxes to public bodies and charities as part of more complex interventions. Most of the rest appear to concentrate on mail order to individuals.

The Baby Box Co. was started in California in 2013-14,  is headquartered in Los Angeles, and since last year is also a UK-registered private limited company (it also has offices in Canada, Singapore, Ukraine and Australia).  In this interview, one of the founders explains how she was inspired by seeing the 2013 BBC story about Finland. There’s a summary of their activity here:

While we sell Baby Boxes direct to consumers as a baby shower gift or new parent present, we focus most on partnerships with hospitals and other institutions such as nonprofits, government agencies and insurance companies. Through a single program with a large institution, we can get our Baby Boxes to thousands of new parents, so it really is the most effective method of distribution for us. We are currently working with 20 states through government agencies, hospitals, insurance companies, tribes, corporations and nonprofits to distribute our boxes. Organizations implementing Baby Box Co. programs include Cook Children’s Hospital System in Texas, Alberta Ministry of Health and Human Services in Canada, Mountain Park Health Centers in Arizona and Queen Charlotte’s & Chelsea Hospital in the UK among many others! We are also working globally with 12 nations on significant intervention programs and ship directly to consumers in 52 countries.

Working Mother 18 April 2016

It has a clear strategy for growth:

…  in the crowded space of parenting-related ventures, Jennifer has also been adept at growing The Baby Box Co., not only by selling the box to top hospitals and medical institutions, but also sealing partnerships with top players in the space, including organizations like Every Mother Counts, Children International, Room to Grow, Baby2Baby, and others…… For 2016, she estimates Baby Box Co.’s earnings to be 4.5 times higher than those of 2015 and she’s looking forward to growing the business more.

Axial Made in the Middle “2016 Growth 100” [undated]

“We are on track to have a million Baby Box units in circulation by the end of 2016,” Clary said. She estimates that the company will have five million units in circulation by the end of 2017.

Business Insider 1 July 2016

I can’t quickly find any information on the company’s most recent turnover or staff numbers, or where they manufacture, but they have evidently had a huge impact.

The Baby Box University is integral to the company’s model. Where there are specific projects, on-line educational material has been developed with each partner area. In the pilots underway using the Baby Box University model, some initial interaction with the online material is needed before the box can be taken up, but the larger aim appears to be to encourage continued engagement with the site, which the company describes as providing access to expert advice and research. The article  here also states that the platform can be used to support interaction between health care workers and parents, and that  free product offers and bonus draws are also included, which may indicate some sort of revenue stream for the company via sponsorship/advertising arrangements with product suppliers (the site can be accessed for free by anyone willing to register). Other articles mention the platform being a way for mothers in an area to communicate with one another.

The Baby Box Company is not directly involved in the Scottish pilots, but is following developments in Scotland.  Between 12-14 January, its Twitter acount followed 5 MSPs and a Scottish local councillor, retweeted this STV story about a closure threat to a Scottish charity providing supplies for families in need, and also retweeted the tweet below saying that the boxes were “shown to reduce cot death” and describing some parties as having a politically-motivated bias against the SG scheme. (Note: a Labour MSP responded to say that Labour supports the baby box initiative, which is correct, but largely missed in coverage and debate; a commitment to a pilot also appeared in the 2016 Scottish Lib Dem manifesto.)

The Scottish Government is already committed to national implementation  from summer 2017. The contract for that is not yet out to tender. It’ll be a decent-sized contract (for around 60,000 boxes a year: the budget allows for £7m annual cost to be covered by health funding). It’s not clear how many organisations will be capable of bidding – this company is clearly one.

Ireland

A baby box scheme started in partnership with the Baby Box Co in Limerick in September 2016. As in the English pilots,  local health professionals stress the educational element, noting that they have been given the chance by the company to produce their own educational materials, including videos. Further positive comment from local health professionals here. Around 5,000 boxes are expected to be handed out over a year.

There has been a lot of press coverage, much of it in identical terms and so probably reproducing the news release,  all of which brings out the issue of infant mortality (on which it often reads quite similarly to the English coverge).  I wasn’t able to find anything saying whether this was a short-term pilot or a permanent commitment, whether it was being evaluated, or how it was being funded.

Canada

Canada has several baby box programmes, including what seems to be the largest. All are recently started, so research and evaluation isn’t yet available.

Welcome to Parenthood is a scheme covering 1,500 families, closely tied in with a new programme of extra support and mentoring (see here and here) and funded by a $500,000 research grant from  Alberta Human Services, agreed in 2014. The scheme went live this year, and  is led by an assigned  researcher (Karen Benzies, quoted below). The Baby Box Co appears to be the supplier for the boxes.

Mentors must record their interactions in a journal briefly describing time with the parent and baby, to help researchers in their evaluation of the pilot program.

Benzies said the goal of the project is to evaluate the impact of the various support mechanisms on the developmental outcomes of children and the health of mothers and families, in general.

CBC 4 January2016

Benzies isn’t jumping to any conclusions before the investigation is complete and the data is analyzed.

“As a researcher, I’m always skeptical,” she said.  “We need evidence to say that this is the right thing to do to improve outcomes for children and families. The success for us and for society is around healthy parents and healthy children.”

CBC 9 January 2016

The largest scheme anywhere seems to be in Ontario. It covers  those having a baby between 1 August 2016 and 1 August 2017 (here), estimated to be 145,000 women.  News reports here and  here. At the end of this interview,  the scheme is described as “being funded by the province”, but another piece suggests a more complicated fundingstructure:

[It] includes more than 60 agencies across the province, from midwife practices to family resource centres. Non-profits, charities and the organizations themselves will contribute resources, says Jennifer Weber, chief education officer at Baby Box Co., some through in-kind contributions such as transportation services, product storage and more.

TVO 2 August 2016

The article below gives some further useful detail, including that some contents are provided by sponsoring companies:

In addition to The Baby Box Co.’s education department, which assists communities all over the world with Baby Box program development, the Ontario Baby Box program is organized by The Children’s Aid Foundation, The New Moms Project, and The Mary Berglund Community Health Centre Hub. A network of primary health care facilities spread throughout the province are supporting these groups with distribution to ensure the Baby Box program is accessible to all Ontario residents…..

Contents for the Ontario Baby Boxes are still being finalized, but CEO Jennifer Clary has confirmed that Pampers, which provided the diapers and wipes for Alberta’s Welcome to Parenthood Baby Box program, is supporting Ontario families as well. “We are thrilled Pampers is continuing their partnership with The Baby Box Co. and are so grateful for their contribution of diapers and wipes. ….

The Baby Box Co.’s Chief Education Offer Jennifer Weber also expressed excitement over the company’s partnership with Vroom, a Bezos Family Foundation project.

PR Newswire 10 May2016

From the pieces I have found, it’s not clear what evaluation is planned in Ontario and what is expected to happen after the 12 months covered.

The situation in Ontario is complicated by the parallel presence of a separate local company, Baby Box Canada, offering free boxes of items (but the box cannot be slept in), the cost of which is covered by sponsors: see here.

A much smaller initiative (21 boxes) in a remote Ontario community preceded the current larger one: this was reportedly established by local health professionals who contacted the Baby Box Co for assistance, having earlier seen the 2013 BBC report. The goal was “to guide families toward local services and provide parents with basics that are difficult to attain in Ignace” (from TVO article above).

Separately Nunavut, which has a high rate of infant mortality, is also piloting boxes: here. 800 will be handed out, around one year’s worth of births in this very northerly territory. This is a government initiative, but being funded by donations from companies in Ontario.

There’s been some questioning in Canada about how far these schemes have departed from the Finnish original, and are too commodififed and not enough about support: see here.

The long article from which the extract below comes provides a particularly careful summary of the debates around baby boxes. The article quotes a number of those involved in Canadian projects cautioning about the relationship between lower infant mortality and boxes in a contemporary developed countries, while stressing that Canada still contains substantial numbers of disadvantagaged households.

….  The Ontario baby box initiative’s strength, then, is its commitment to community engagement and providing reliable information regarding infant health, particularly concerning safe sleep practices. …..

Benzies [in Alberta] questions the focus on infant mortality in Canada and the efficacy of some attempts at replicating the Finnish program: “We’ve done an amazing job in [providing] neonatal intensive care, reducing mortality,” she says. “Where we need to focus our efforts is morbidity.” That is, the likelihood of disease, illness and injury to infants. Like Clary, Benzies urges parents to carefully research baby box programs that have sprung up in Finland’s wake — albeit, many decades later — and if they choose to participate, go into such programs with the understanding that stashes of baby supplies can’t address the more systemic issues that affect infant health, such as health care access, poverty and infant care education. “They need to understand why people want you to sign up for something and what the expectations are for that.”

….In her practice [in Ignace], Graff says she sees social barriers to infant and maternal health more often than high-risk pregnancies requiring a neonatal intensive unit. Such barriers include housing concerns, low breastfeeding rates and a lack of resources that might be available in larger cities to deal with postpartum depression and other mental illnesses.

The Ontario baby box initiative aims to bridge the gap in some small way, taking the lead from communities – remote towns, new immigrants, young parents – to ensure the most success. “We’re not saying it will cure everything, but the families, they know who they can actually turn to sooner rather than later,” Baby Box Co.’s Jennifer Weber says.

TVO 2 August 2016

United States

In the US, pre-existing government-funded safe sleeping programmes with a strong outreach and education element who were already providing  portable cots (versions of  folding travel cots) have reacted variously to the advent of boxes.

This one in Chicago has added boxes to what it offers, but not wholly replaced their existing ones, saying boxes are “perfect for families that have limited space” and that “both types of beds will be distributed to families, based on the type of bed needed. Transient families likely will receive the lighter weight baby box.”

However a long-established non-profit  organisation which operates across the US, Cribs for Kids National Infant Safe Sleep Initiative is strongly of the view that boxes are a less good option than the folding device it uses. Its unfavourable comparison of boxes to its established bit of kit  is here (with some further comparison made here).

On the claims about the effect of boxes in Finland on infant mortality, it says:

It also questions claims that the boxes can be used as a bed for up to 8 months (this is included in coverage of the English schemes, for example, including on the Imperial College website), suggesting that 2 to 4 months will be more common,  before babies can no longer use it safely. That looks like an important point to clarify for policymakers motivated by SIDS concerns, because it has implications for how much of the most risky period for cot death is covered,  and for equality campaigners, because the shorter the period for which it is useful, the less practical help it offers parents.

The Baby Box Co. has produced its own comparative summary: here. It’s not a point-by-point rebuttal, so the issues above about research and potential length of use aren’t addressed. It focusses instead on whether the devices used by bodies such as Cribs for Kids are in fact suitable for overnight sleeping, their greater cumbersomeness and higher cost.

Many organizations are transitioning from Pack n’ Play distribution to Baby Boxes. Baby Boxes wholesale for less than 50% of the cost of Pack n’ Plays, thereby allowing non-profits, hospitals, governments, and other institutions to reach double the number of new parents without increasing their program budgets. An extended reach = more lives saved and that is a huge factor in the increasing rise of Baby Boxes’ popularity.

TheBaby Box Co

Another US non-profit organisation, Babies Need Boxes was founded in 2015 and sources its boxes from The Baby Box Co and uses the Baby Box University model.  The Baby Box Co lists partnerships in a number of other locations in the US.

The views of Cribs for Kids deserve the same careful scrutiny as the case put forward by those promoting the use of boxes  – existing schemes could after all be argued to face competition from new arrivals (equally, they may be reacting to perceived pressure to switch suppliers). Even though organisations such as Cribs for Kids are non-profit, it is possible that in some cases the viability of their model of outreach might be reduced if box schemes became very popular, or they might lose funding from public sources.  Also, some of their practical concerns have to be put alongside the successful use of boxes in Finland for decades.

But the strength of Cribs for Kids’ scepticism about boxes, and the detailed way they make their case,  bears including here, not least because it’s the only reference I’ve seen anywhere to anyone doing a literature review about the Finnish case: none of the references I’ve seen to studies/proof/evidence of the boxes’ effects have provided any links or references, and attempts of my own to locate research on the Finnish box scheme also drew a blank. When reports say that the Finnish box scheme” is credited with” reducing deaths, which is a very common phrasing,  they never say who is doing the crediting.

Australia

A number of commercial Australian baby box companies turn up on a search, who are simply selling boxes and their contents on-line. But there are also pilots reported as starting in Victoria (again involving the Baby Box Co.) and Western Australia (involving an Australian charity). Both seem to be targeted on those deemed especially in need, whereas most of the pilot box schemes described above appear not to be targeted in that way. Some further Australian press coverage here.

There has been press interest  there in the claims made about infant mortality. In Queensland, Professor Jeanine Young, a neonatal nurse and midwife who devised the Queensland Health Safe Infant Sleeping guidelines, reportedly “said the company [the Baby Box Co.] was making money by playing on parents’ fears over sudden infant death syndrome (SIDS)” and Fair Trading officers were reported to be investi­gating claims. Prof Young is separately involved with a “Pepi Pod”programme in Queensland targeting particularly high-risk cases for SIDS, which includes use of a plastic box bed from New Zealand (more on the Pepi Pod programme in the New Zealand section below).

“I have a real problem with this,” Prof Young said. “It is not appropriate for this company to be telling people that the boxes help prevent SIDS ­because there is no evidence that this is the case.”

News.co.au 23 September2016

The same piece carries the company’s response:

But when contacted by The ­Courier-Mail, a spokesperson for the company said online education was more important, and blamed the media for reporting the link because it “makes for a simple and palatable feel-good story”.

The spokesperson said: “Baby Boxes distributed thoughtlessly are not a cure for infant mortality.”  The company is calling for Australian hospitals to go into partnership with The Baby Box Company in order to issue the boxes to new mums.

Many of the company’s press quotes emphasise the importance of education, and that the box is not a solution in itself. Its website says carefully and only that the box has “helped” Finland reduce infant mortality:

The Baby Box program has helped Finland achieve one of the world’s lowest infant mortality rates. The initiative, which enables every expecting woman in the country to claim a free Baby Box once she receives prenatal care and parenting information from a healthcare professional, is credited with helping to decrease Finland’s infant mortality rate from 65 deaths for each 1,000 children born in 1938 to 3 deaths per 1,000 births in 2013.

These comments by Jennifer Clary are also typical:

 Q: HOW DO BABY BOXES HELP TO DECREASE INFANT MORTALITY? 

A: I love the Baby Box concept but think the media has a tendency to romanticize and simplify the tradition. Kela, the Finnish social service, should be commended because they established an incredible foundation upon which to build their Baby Box program: every expecting mum in the country has to visit a healthcare facility for prenatal care and basic educational information in order to be eligible for a free Baby Box. This is a fact that frequently gets left out in media coverage, and it’s a shame as this is arguably central to Finland’s statistical success.

It’s not the Baby Box product that decreases infant mortality, it’s the Baby Box program.

What we know is that there are numerous research studies linking increased parenting education to a reduction in infant mortality outcomes, as well as to an increase in breastfeeding, positive nutrition choices, and improvements in maternal mental health. Therefore, my personal philosophy—and our corporate mantra—is to tie Baby Box distribution to parenting education and ongoing community supports to actually have an impact.

The Dad Network 5 September 2016

However, stronger claims about the link with reduced infant mortality have appeared in material from the company. These 2016 slides are credited as copyright to the company and have a reference “BBC Presentation” in the document name. They are titled “A 75 year-old life-saving tradition” and on page 6, after a more general reference to boxes “helping” bring down infant deaths, do also include the sentence, “In Finland, Baby Boxes decreased the infant mortality rate from 65 deaths for each 1,000 children born in 1938 to 3 deaths per 1,000 births in 2013.”

The process by which the nuance Jennifer Clary argues for so strongly gets lost in reporting would be an interesting study, because the experience of reading so many stories from different places in a short space of time brings out that it’s a widespread phenomenon.

New Zealand

New Zealand is a very different case.  Health professionals had been providing safe sleeping spaces (in the form of woven baskets called Wahakura) for new babies in Maori communities since 2006, because of concerns about particularly high infant mortality rates in New Zealand, with deaths concentrated in Maori communities. More recently, the emphasis has been on the use of clear plastic boxes developed in New Zealand, called Pepi Pods.

This document gives a lot of background. Pepi Pods were first used as an emergency response to the 2011 Christchurch earthquakes and then targeted on those at increased risk of accidental suffocation. They are cheaper and easier to supply in large numbers than the Wahakura. Pepi Pod programmes appear to operate under the umbrella  of an organisation called Change for Our Children, which describes itself as a “social innovation company”, which it explains here is a private profit-making company, but where the profits are used for community benefit.  It says:

PSSs are not for all babies. They are a public health response to the higher

risk of sudden infant death for babies who are more vulnerable due to

exposure to smoking, especially in pregnancy, being born before

37 weeks or weighing less than 2500 grams, or in family environments

where use of alcohol and drugs are prevalent. These babies have a

predisposing vulnerability to hypoxic challenges.

… PSS are not free baby beds for poor families. They are a central component of a comprehensive service that needs to be embedded into a SUDI prevention strategy and regional infant health plan. A Pēpi-Pod® service needs a project action group, coordinator, PSSs and bedding packs, referral processes and criteria, agencies and distributors authorised to distribute, a thorough recipient briefing, follow-up of and feedback from users, and systems for recording, monitoring, communicating etc.

Change for Children NewZealand FAQs

There is some actual research available from New Zealand.

On use after earthquakes:

• Cowan S, Bennett S, Clarke J, Pease A. An evaluation of portable sleeping spaces for babies following the Christchurch earthquake of February 2011. J Paediatr Child Health. 2013 May;49(5):364-8. doi: 10.1111/jpc.12196.Epub 2013 Apr11.

On use in high risk communities:

• Young, Jeanine, Craigie, Leanne, Hine, Helen, Kosiak, Machelle. Trial of an innovative Safe Infant Sleep Enabler—The Pepi-Pod. Citation: Women & Birth, 02 October 2013, vol./is. 26/(0-0), 18715192

On the relationship with overall falls in infant mortality:

• Mitchell, Edwin A. ; Cowan, Stephanie ; Tipene‐Leach, David. The recent fall in postperinatal mortality in New Zealand and the Safe Sleep programme:  Acta Paediatrica, November 2016, Vol.105(11), pp.1312-1320

This last concludes that

The recent fall in postperinatal mortality has not happened by chance. It is likely that the components of end-stage prevention strategy, a focus on preventing accidental suffocation, the education ‘blitz’, the targeted supply of ISSDs [infant safe sleep devices] and strengthened health policy, have all contributed to varying degrees.

Change for Our Children has elsewhere said cautiously, “no claims can be made of cause and effect but the statistics are encouraging.”

Up to now, funding of Pepi Pod schemes appears to have been cobbled together locally from a number of public and private sources. However, in August last year the decision was made to make national funding available for a safe sleeping programme including Pepi Pods. The reporting isn’t clear, but this petition suggests the national programme is intended to continue a targeted approach, and is not an all-population approach. The move to national funding has involved the Minister over-ruling advice from officials, who are reported to have cited concerns about insufficient evidence and possible safety concerns. Both these points have been strongly challenged by Prof Mitchell (author of one of the articles above), a meeting with whom is reported to have been important in persuading the Minister to make  funding available. Some articles  here, here,  here and here.

In August, the likely annual cost was estimated at around NZ$1.5m (about £900,000): the emphasis in New Zealand is on the pod as a sleeping space, so the extra cost of other items may not  be relevant.

South Africa and elsewhere

The 2016 BBC story above refers to other projects, including one in South Africa using clear plastic boxes. However, these are used as baths rather than beds.

Back to the source: Finland

For those interested, there’s an English language Finnish government website which has details about their box, the wider support schemes in which it sits,  the obligations to engage with services which are required of parents in order to receive the box, and even quite a lot of detail about its tendering process: all here.  It’s referred to as the”maternity package” in what comes over as a deliberate move to reduce emphasis on the object in its own right. There’s a (non-official)  video about the Finnish baby box at the foot of this piece as well.

There was a bit of discussion last week on Twitter between Suzanne Zeedyk and Elizabeth Jarman, who are interested in child development and children’s environments,  on the design of the box, both arguing that busy patterns inside the sleeping space should be avoided. Interestingly, one commercial supplier based in the UK points out that the Finnish box has no pictures on the inside (see under “Is it safe?”), although it presents that more as a safety point.

In line with guidance from the Finnish manufacturers of the baby box (the same supplier as to the Finnish Government’s Baby Box Maternity Kit) we have not printed the inside of our box. The manufacturers of the box are chosen through a rigourous safety process, and do not print on the inside of the box.

Little Un Baby Box

The Scottish boxes used in the current pilots follow instead the Baby Box Co. model of  internal decoration.

Reflections and conclusions

This is an astonishing story. It is only three and a half years since the BBC’s original article. In that time, baby box schemes have begun around the world, some of them on a huge scale. Many more commercial companies have emerged than are mentioned here. Huge numbers of boxes have been sold, direct to individuals or to public or third sector organisations. Public health officials in many places have embraced box-based programmes. An enormous number of articles have been published. Someone should do some Google stats on the on-line incidence of references.

The impact of the BBC piece and the extraordinary energy , impact and growth of The Baby Box Co are both remarkable features of this story.  The latter’s belief in what it does is evident, and its ability to pitch what it offers, to form positive relationships with public health officials and to understand what to offer them, is impressive. And absolutely fine. In turn, citizens just need public health officials making decisions about resources to keep their analytic heads, confronted with a whirlwind of enthusiasm, claims and proffered help. Journalists too, maybe. That’s all.

What do we learn that might be useful, as Scotland also goes down this route?

I think we’ve done the right thing funding our own pilot. Although it will carry a cost, it has the advantage of not tying anything learnt into a very specific model run by one provider.  In England, the pilots are at no cost to the NHS, but if they are found to be beneficial, the integration of the Baby Box University into the scheme means that it may be difficult to find another supplier: I’m always wary of the public sector ending up in sole supplier situations. It’s not clear whether the NHS retains the intellectual property for the education materials produced by its staff (I hope so): if not, then it’s easy to see that professionals may be very unhappy to lose access to things they have made with huge local care and enthusiasm, and got used to using, after just a year.

Where we compare less well, firstly, is in having a pilot period that can’t be more than a very few months, given the full national programme is due to start this summer. Lots of the clothes will still have been too big even to try, when the SG is already drawing up the contract for the national box. The peak danger period for SIDS will not be past when the pilots finish. Many parents only emerge in a coherent state to reflect on anything some time after 3 months (if then). Everywhere else doing a pilot is running it for 8 months upwards, which seems to me a better length of time to understand how far the box’s contents are useful, how much and how long it’s been slept in, the SIDS incidence in the cohort (though with only 200, statistically – and happily – there were anyway very unlikely to be any cases) and how it may have helped parents, and aided engagement and education more generally.

We’ve also made a mistake (I think) commiting to a national scheme, regardless of what happens. I understand the arguments that there’s something of symbolic value (I really do) that transcends its measurable public health impact. But the reality is that the health budget (from which this is funded) is under huge pressure: and so are all the others it might be moved to. Right now,  it’s right to demand some more substantial benefits from a long-term commitment to anything which will cost £7m every year. Or more? The £7m budget is for a project starting part-way through the financial year, after all.  It would be preferable to let a one-year national contract and treat it as a much more extensive trial, and build in decent evaluation: if any opposition politicians, or oppositional types, or journalists, or indeed people who like and have defended this scheme, are reading this, if the SG go down that route, please welcome it. It would be a wiser approach to using scarce public funds. They could even contract for two years, so that people go on getting boxes while the evaluation is pulled together and considered. Just build in an easy exit route.

We are also less strong than others on the box as a means  to engaging people with education and human support. The publicity has been very much about “the box”.  Most recently there’s been some reference to there being wider support alongside, but what this means remains vague, compared to other places (Ontario is perhaps the next nearest for vagueness of those mentioned here: but it’s at least using The Baby Box University).

There’s nothing here like the detailed safe sleep programme developed to go with the Pepi Pods or the Alberta mentoring scheme developed to go with the box pilot there.  The wider support part still comes across as an afterthought here: it’s not clear  that the £7m budget assigned includes anything for developing new safe sleeping programmes or other new materials to support new parents.  We’re also unusual in not tying receipt of the box (as far as I can tell) to parents engaging with services in any particular way.

The model which I think emerges best from this is Alberta, with a research based, self-funded pilot, with clear aims, which keeps complete control of the design and delivery of the education and support programme and doesn’t over-stress infant mortality goals, as opposed to broader ones of physical and mental health. And New Zealand has an interesting story to tell about targeted intervention in cases where the risk factors for SIDS are known to be especially high. I think it’s a shame we’ve committed entirely to cardboard boxes, and not piloted Pepi Pods as well.  There’s still time to keep the inside unprinted like the Finns, though.

My final comment is about debating this at all. When people (like me) suggested  when the pilot was launched on 1 January that there were some fair questions to ask, not least  about the claims made about infant mortality, and the decision to commit so completely to this, without more evaluation, when budgets are so tight, one of the reactions was to see this as a depressing further symbol of the schismatic state of Scottish public debate.  People seemed depressed at the inability of everyone simply to come together to celebrate something nice.

This exercise has revealed that anywhere in the world where there’s already been a sharp drop in infant mortality since the Second World War (that includes us) and where these schemes aren’t funded by the supplier, especially where a link  to reduced infant mortality is made,  there’s been a debate. That there’s no controversy in England may be due to the fact that it appears not to be costing the NHS  anything, and the pilots are all relatively small scale (Ireland ditto?).  People in Scotland are raising points made in Canada, the US, Australia and New Zealand. If the NHS in England were, as the Baby Box Co hopes, to commit to a nationwide publicly funded programme while its NHS budget buckles, you know, I think there’d be questions there, too. It’s if we stopped hearing people asking questions about high profile (and not free) public policy choices that seem to come almost out of nowhere, that we’d  have real cause to worry about the unusual state of debate here, I think.

This is a post about the information provided by the Scottish Government to the Parliament about its spending plans. It’s prompted by having looked in detail so far at just four lines of the draft Scottish Budget, and finding something wrong with the way the numbers are presented in each case. That seems a high hit rate, given this should be one of the exercises over which the Government takes the most trouble.

Sources

There are two relevant sources.

The draft budget document presented to Parliament by the government, which gives figures to “Level 3” (quite detailed, but not the most detailed) alongside a general text, where the government mentions the points  to which it wishes to draw attention. The document is here.

More detailed “Level 4” figures are also provided – they are produced by the Parliament’s research unit, but using information provided by the government, and are available on the Parliament’s website, here.  There’s no general text, but – very usefully – here there is a comment against every line, explaining any change.

Here are the cases I’ve looked at.

Baby boxes

The text of the Budget document says that baby boxes are a priority within the Education portfolio, and within that come from the Children and Families budget. They are not itemised, but are mentioned in the text, under “What the budget does”.

Extract from draft budget 2017-18 (under Table6.04)

But search the Level 4 data for Children and Families in the Education spreadsheet for more detail – and there’s nothing more on baby boxes.

To find that requires going instead to the Health section (line 137), where baby boxes are listed as having a new budget of £7m within Miscellaneous Other Board Services and Resource Income.

The total for Miscellaneous Other Board Services and Resource Income and for Children and Families in the Level 4 spread sheet matches that given in the draft budget document. That means the text in the draft budget document is out of synch with the numbers it contains.

This means that though the document says that this falls within the Education portfolio (and therefore the  remit of the Education Committee), this is in fact a cost against the Health budget (and sowould normally fall to that Committee). Describing spending as falling within the wrong part of the budget should be a very difficult mistake to make, and then not to spot.

Student Support and Tuition Fee payments

I looked also at the cash funding for student grants and SAAS fee payments, which is given as a single combined figure, in the first line below of Table 6.07 (from the draft budget document). I wanted to know the official explanation for the £26.4m rise and then fall shown. The document text is silent on this.

The Level 4 document doesn’t break this line down further (and never has done, as far as I know) but would, helpfully, be expected at least to provide a specific comment against the relevant line. However, turning to the Level 4 spreadsheet, the relevant line (141) doesn’t have the same figures. It shows the same (lower) one for both 2016-17 and 2017-18 (only these two years are covered), and so no change needs to be explained. It’s possible that SPICe lifted the 2016-17 figures from what they held last year: but the commentary column at minimum ought to have come from the SG. For consistency with the draft budget document, it ought to pick up the change that shows between the two years.

Which version of the numbers gives a true picture of planned spend in this area over the two years? Parliament can’t tell, because the budget document and the Level 4 data are inconsistent.

(The answer is in fact likely to be a third set of numbers – see below – but being able to reconstruct that, more or less, from yet another source, if you happen to know about it, is a poor substitute for having the correct ones in the official budget documentation.)

Cost of student loans

I also wanted to know what the explanation was for the dip and then rise in the cost student loans shown in the Budget document: £175.6/125.6/175.6m – also Table 6.07 above. It’s not reflected in the pattern of the value of loans being issued (£491.3/491.3/560m – also Table 6.07). Again, no explanation is included in the accompanying text.

But again the Level 4 table (above) is no help, as it shows instead a steady £175.6m in each year. Again the budget document and the Level 4 data are inconsistent.  So what’s going on with the lower 2016-17 loan cost figure presented in the budget document to Parliament? It’s impossible to say.

University funding

I also looked at the Level 4 explanation for more on the fall in university current (ie non-capital) funding (“Higher Education Resource”).

Here the figures are consistent between the two documents, and the drop is explained as being offset by the move of all postgraduate funding to loans rather than some grant (previously provided via the SFC), and surplus income from the fees charged to rUK students.

This however raises a different internal consistency issue. The extra £26m for student support in 2016-17 discussed above is in fact almost certainly partially accounted for by an in-year  £20m transfer made by the SFC to SAAS (see para 36 here. from the February 2016 SFC funding circular).  In 2016-17, for some reason the Scottish Government decided to under-budget for student support and fee costs: it knew as early as February 2016 (before the budget was passed by the Scottish Parliament) that SAAS would need a large cash injection during 2016-17 to cover its costs in relation to rising student numbers, and planned for this to be taken from the SFC allocation.

The SAAS figures for 2016-17 in the draft budget document appear to be shown after that transfer. However, the SFC university funding figure appears to be shown before it (£1027.2m is  also the figure which was presented to Parliament in the official 2016-17 budget last year: Table 6.06 here). But if that’s the case, the same £20-odd million would be showing in two places for the current year. That would be a substantial error.

This really isn’t good – if money has transferred between one body to another, it needs to be treated consistently. Also, if this is what explains what’s happening in 2016-17, what’s the plan for 2017-18 regarding transfers from the SFC to SAAS – because if a larger one than this year is planned, it means the real terms fall in university funding is larger than shown here.  Also, there was quite a big transfer from the SFC to SAAS in 2015-16 too (para 22 here) – where does that fit in?  Parliament is entitled to greater clarity about all this.

Conclusion

Commentators (myself included) can be pretty critical of the opposition parties at Holyrood for not being more effective. But if the budget document  – one of the single most important things the government puts before the Parliament – contains these sort of inconsistencies, they really are up against it. Even more so, if I haven’t just been especially unlucky, and there’s more of this to be found  in other lines.

I hope the current review being undertaken by the Presiding Officer will look at this as a case study. It suggests at minimum that the government is under-resourcing the production of this material for the Parliament, because nothing here should have survived the sort of systematic, careful cross-checking these documents (and the Parliament) deserve.