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A healthy start?

16 June, 2008

A healthy start?

The RCM has responded to the Department of Health’s reform proposals for the Welfare Food Scheme.


The RCM has responded to the Department of Health’s reform proposals for the Welfare Food Scheme. 


Midwives magazine: March 2003


In December the RCM Midwives Journal reported that the Department of Health (DH) was consulting on proposals to reform the 60-year-old Welfare Food Scheme (WFS), to widen the foods available on the scheme with an overall aim of reducing child poverty.


The Healthy Start proposals have caused some controversy and debate amid accusations that the DH is trying to police women. The RCM submitted a consultation response to the DH and the main points of concern are outlined below.


Breastfeeding promotion as a first priority


While the proposed new scheme goes some way to redress the disincentive to breastfeed that the WFS provides, it does not go far enough in actively promoting breastfeeding. A scheme designed to address poverty and nutrition among infants, but does not pay due attention to breastfeeding, fails in its aims at the outset.


Health professionals need more training and support, and greater availability of appropriate resources for effective breastfeeding promotion both in pregnancy and the pospartum period. Furthermore, if there is a substantial uptake in breastfeeding, mothers will then be able to use the WFS vouchers on other types of foods, which is not allowed under the current scheme.


Healthy Start fails to acknowledge two crucial recommendations made by the Committee On Medical Aspects of Food (COMA) with regards to breastfeeding: to find more information on the reasons for the social inequality in breastfeeding; and to examine the effectiveness of interventions in communities where breastfeeding rates are lowest. These points are integral to any scheme that aims to redress nutrition poverty.


The DH needs to acknowledge and provide appropriate financial support to those women who either cannot or choose not to breastfeed, so that their babies are not disadvantaged or their health compromised under the new scheme.


Face value of the voucher


The current WFS voucher of approximately £2 a week does not go far in buying foods such as cereals or fresh fruit and vegetables. There needs to be careful research into geographical variations in the price of foods and what poorer families can realistically afford. It may be difficult to find a cheap nutritional substitute to milk, unless the mother understands the nutritional content of foods. Again, this provides an even greater incentive to accompany the proposed scheme with a comprehensive breastfeeding and nutrition awareness programme.


In addition, the RCM recommends that fortified cereals are included on the list of products that women are able to purchase with vouchers, although consideration must be given to the (at times) high prices of these products. Also consideration must be given to the labelling and marketing of foods, which can sometimes provide misleading information about the nutritional content.


The need to register


By stipulating that women must register to receive benefits, Healthy Start automatically introduces exclusion into the equation. The poorest women in society do not necessarily register their pregnancy early on, and most women do not routinely go to their midwife or GP in order to confirm their pregnancy.Where parents do not seek help, it is often because they perceive the service provision to be inaccessible or inappropriate to their needs. The NHS – including the maternity and child health services – has a serious task ahead in making its services relevant and accessible to those who are socially excluded, or otherwise disadvantaged.


The RCM is hesitant to support a scheme requiring women to register in order to gain benefits, on the grounds that it undermines a woman’s authority and autonomy. In particular, the RCM is concerned by three points of principle:

_ The desirability of making a benefit aimed at child welfare conditional on the behaviour of the mother

_ Using people’s poverty to control the choices that would otherwise be freely available to them – in this case, to erode their right to choose or refuse the assistance of healthcare professionals

_ Using health professionals to police – however indirectly – behaviour in order to guard the gateway to state benefits, and the implications this has for professional-client relationships.


The DH needs to consider the risk of eroding these principles and be certain that the end justifies the means. It should also consider the possibility of women opting out of claiming this benefit because – for whatever reason – they wish to avoid contact with the NHS or with a particular healthcare professional group, and the likely impact of this on their family’s wellbeing.


Ways of registering


The DH should think imaginatively about how to access and promote the scheme to the unseen poor in the UK. This includes those who are homeless, are often moved from hostel to hostel several times, seeing different health professionals at many different clinics – if they attend at all. It also includes teenagers, who may conceal their pregnancy. Thereis a need to clarify the situation regarding the availability of benefits, which are enumerated according to financial status (i.e. income support eligibility), to teenagers who are not working and are too young to claim income support. Special consideration should also be given to asylum seekers, who do not receive benefits such as income support.


Finally, there are many children who do not attend school for various social reasons – they are usually the poorest and most in need of access to nutritious food.While the idea of linking benefits to health services, health advice and support may be desirable and appear logical, it is idealistic in nature and fails to address or acknowledge the complex realities of life today for the poorest groups in our communities.


Monitoring of vouchers


It is surprising that the scheme retains the use of vouchers, given their associated stigma and relative unpopularity with some groups. The proposals do not include detailed plans of how the use of vouchers will be monitored, or how to ensure that the vouchers are exchanged for the correct items? Safeguards are required to prevent instances where unscrupulous shopkeepers have manipulated the voucher scheme to their benefit.


If vouchers are to be retained, they should be accepted in a wider variety of shops, including local grocery stores and the larger supermarkets. If they become a recognised form of currency among the public it may ease any stigma associated with the benefit and ensure their use is understood.


Role of health professionals


There is a real need to provide information, as well as advice, to women and parents so they can make decisions for themselves and be supported in their choices.However, women living in poverty need more than information – they need ongoing support that meets their individual needs. Providers should not be complacent by implying that ‘providing advice’ is equivalent to providing appropriate care and services. Some health professionals may need to be given training in all aspects of the relevance of nutrition and health.


Healthy Start will require a comprehensive training and information package for all relevant health professionals. As the providers of many different sources of information for women, midwives would benefit from readily available information on benefits, rather than expending finite time seeking out the appropriate benefits. There is sometimes confusion among health professionals about the availability of relevant benefits and how they can be accessed, in which case the situation is likely to be even more unclear for women.


There is therefore a need for an awareness/ education programme to accompany the implementation of the scheme directed at midwives and other health professionals who come into contact with women and children.


The role of midwives


The RCM response believes the DH should clarify the role of midwives in assessing the eligibility or otherwise for vouchers.Will midwives be required to validate claims? The College also highlighted the ongoing staffing shortages in midwifery units, pointing out that any such work required of midwives must not be an additional burden. Furthermore, an essentially clerical job of registering women should not fall upon midwives, who are already overstretched in trying to fulfil key aspects of their role.


An interprofessional,multi-agency approach needs to be adopted in order to reach the poorest sectors of society. This would include collaboration with those who work with homeless families, teenage parents and asylum seekers (and who may not necessarily be healthcare professionals) to ensure all mothers are made aware of the benefits available to them.


A flexible scheme to meet diverse needs


The RCM would question a rigid structure for implementation of the new scheme in the absence of convincing evidence. In order to fulfil its broad aims of reducing poverty, the scheme must adapt to the diverse needs and fabric of modern society in the UK.


Range of foods covered by the scheme


Little attention is given to the rich ethnic mix and the diverse cultural dietary requirements in the UK. This was all the more surprising given that a significant proportion of the scheme’s main beneficiaries may be derived from black and ethnic minority communities. The scheme as it stands presupposes a western diet and must adapt to take account of foods essential to different ethnic groups.Wide consultation with representatives from different sectors of society and nutritionists would be necessary to redress this imbalance.


Joined up approach


This scheme needs to be part of a coherent government strategy that addresses the causes of health inequality – poverty, nutrition and access to appropriate services throughout the life cycle.


Primary Care Trusts should work more closely with local community food initiatives, link up with local food suppliers/producers, and with those Sure Start projects that have initiated innovative schemes to address the povertynutrition link. One example could be holding cookery classes (what will women do with this additional food if they do not know how to cook?). Another example is a scheme in Newham, which delivers a fresh box of vegetables to mothers registered under Sure Start.


Local enterprise in Tower Hamlets, one of the poorest boroughs in the country, has ensured the availability of a variety of fresh produce, including fruit and vegetables at affordable prices. Considered planning and development has enabled this community to access culturerelevant nutritious foods, in order to raise their health status.


The DH must be innovative in finding solutions to health and food poverty. This includes looking at ways of empowering women and their families, building social and health capital, and in the process creating sustained change. Health promotion can take place outside healthcare systems. It then becomes part of everyday life, and not negatively associated with the doctor’s surgery.




While there are some good aspects to the proposals, there are also some critical flaws that may need addressing. Breastfeeding needs to be given greater emphasis, while at the same time support maintained for infants who are bottle-fed.


The practicalities of implementing such a scheme need to be thought out carefully, and the RCM believes the DH should look more closely at the impact of the proposed scheme on those who are most in need of such benefits. More details on the scheme are available at: www.doh.gov.uk/healthystart/healthystart.pdf


Louise Palmer is the RCM policy and research officer.


Janet Fyle is the RCM midwifery adviser.







Achesdon D, chair. (1998) Independent Inquiry into Inequalities in Health. The Stationery Office: London.


Department of Health. (2002) Healthy Start. A proposal for the reform of the Welfare Food Scheme. DH: London.










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