The Sure Start programme was introduced in England in 1999 with the aim of improving the life chances of children living in poverty. Five years later, it became a service for all children. At its peak in 2009–10, it accounted for £1.8 billion of public spending (in 2018–19 prices), but since then there have been funding cuts, consolidation and centre closures as funding fell to £600m in 2017–18.
Sure Start centres – now known as children’s centres – bring together services such as health, education, childcare and employment support for families with children under the age of five. Improving health was one of the main objectives of the programme, and health services were an important component of its offer. Yet the evidence on the impact Sure Start has had on the health of children and their families is scarce.
We wanted to know the effect the Sure Start programme had on children’s health between its inception in 1999 and its peak in the late 2000s.
Our study focused on the impact of increasing access to Sure Start, which we define as the average number of centres per thousand children under five. At its peak in 2010, Sure Start coverage was at about one centre per thousand children across England.
Huge fall in hospital admissions
We found that Sure Start significantly reduced hospital admissions among children by the time they finish primary school. These effects build over time: while we find no significant effect at age five, by age 11, one more centre per thousand children prevents around 5,500 hospitalisations per year (18% of the pre-Sure Start baseline).
When we look at specific causes of hospitalisation, we find that Sure Start drives a significant fall in hospital admissions for injuries at every age we considered in our analysis. At younger ages, the probability of an injury-related hospitalisation falls by around 17%. By ages ten and 11, the fall is 30%.
At age five, there is also a fall in the number of children needing hospital treatment for infections. This could suggest that Sure Start is helping young children to develop their immune systems, perhaps through supporting immunisations or exposing children to other children’s illnesses, for example, in childcare.
Sure Start benefits children living in disadvantaged areas most. While the poorest 30% of areas saw the probability of any hospitalisation fall by 11% at age ten and 19% at age 11, there was practically no impact for those in the richest 30% of neighbourhoods.
The bigger benefits in the poorest neighbourhoods could come about because disadvantaged children are more able to benefit from Sure Start, because the services Sure Start offers in poorer areas are more helpful or because children in disadvantaged areas were more likely to attend a centre. Regardless, greater Sure Start coverage closes around half of the gap between rich and poor neighbourhoods in hospitalisation rates.
A simple cost–benefit analysis shows that the benefits from hospitalisations can offset about 6% of the programme costs. Measured on a purely financial basis, the reduction in hospitalisations at ages five to 11 saves the NHS about £5m, about 0.4% of average annual spending on Sure Start. But the types of hospitalisations avoided – especially those for injuries – have big lifetime costs both for the individual and the public purse, for example, through healthcare costs and the tax and benefit system. Including these savings, the financial benefits of Sure Start’s effects on hospitalisations amount to 6% of its budget, based only on its impacts on hospitalisations.
At least when it comes to health outcomes, our research provides strong evidence that the Sure Start model has worked better in poorer neighbourhoods, reducing health inequalities. Unpicking to what extent this is driven by choices these centres make or the characteristics of the families they serve should be a top priority for future research into Sure Start. For now, though, this suggests focusing limited resources on poorer neighbourhoods rather than spreading them more thinly.