HSIU=Healthy Start Issuing Unit
The letter did not say where to obtain the vitamins and mothers did not recall being told, particularly in the targeted area: “I now know it was my midwife who should have told me from day one!” EM13−T. Some entitled mothers were aware of receiving the vitamin vouchers but did not use them (EM30−T, EM25−T, Table 1).
Dissatisfaction with taste (“too chalky” EM38−U) or palatability (“I just throw up” EM06-U) also stopped vitamin use. Complicated administrative processes and perceived unfairness also caused dissatisfaction:
“I have a friend who has just turned 18 [in January] and she’s pregnant. She can’t get her vouchers until she claims child tax credits. She can’t claim child tax credits because they’ve just changed the rules and her mum has to claim child benefit for her until September... So, the government is expecting her to live, and her baby, to live off £20… [sighs]...” EM38−U
For some entitled mothers in the targeted area, poor vitamin supply discouraged continued use: “[children’s centres] just never have them.” EM26−T. Futile searching for children’s vitamin drops was typical: “everywhere I ask they go ‘we haven’t got them in’, like in the children’s centre…” EM27−T
Health professionals from both areas also explained low vitamin take-up in terms of suboptimal awareness (of mothers and health professionals), accessibility, attention, agency, and adequacy of supply (but not acceptability).
The vitamin voucher ‘hidden in plain sight’ was a substantial barrier (HP04−U, Table 1). One health professional attributed poor maternal awareness of vitamin benefits to lower socio-economic status and education (HP14−T, Table 1).
From universal and particularly targeted areas, health professionals lacked knowledge (e.g. which vitamins; from where; or whether suitable for special diets). Some health professionals knew of colleagues withholding the vitamins through misunderstanding the constituents (mistakenly “thought vitamin A was in the pregnant woman’s [vitamin tablets]” HP02−T), blaming this on suboptimal training. Vitamin vouchers were not a priority in consultations (“we midwives can be quite precious about our time” HP05−U) or training:
“They probably said ‘oh here you are, you can give these healthy vitamins’.” HP36−T
Some health professionals (mainly from targeted area) did not know where mothers could redeem vitamin vouchers: “…there should be a list of addresses…” HP24−T. Some were unclear about the administrative processes:
“I had absolutely no idea until last Thursday, that, when you’ve had your baby, in order to get the vitamin drops, you have to let [HSIU] know...” HP02−T
Health professionals sometimes forgot or attended poorly to discussing the vitamins, particularly blaming inadequate training and perinatal staffing and a crammed consultation:
“We definitely need to cover reducing the risk of cot death… We then talk about immunisations, ask them to sign an intent form for the Child Health department for when the immunisations are due. We talk to them about development checks, their own health, any family history of anything, and we also talk about smoking, alcohol, diet, and smoke alarms, child benefits, and somewhere in there we have to fit in the vitamins! And that’s for a straightforward mum; some of the cases I come across in the community have safeguarding issues and the like.” HP05−U
Nevertheless, no-one suggested improving communication between, for example, midwives, health visitors, and social workers to improve their individual and collective agency in the system. Staying connected with close colleagues was hard enough:
“Even within your own team, […] even when you’re all working towards the same goal, you are working in silos to a degree...” HP08−T
Complicated administration introduced delay, blocked access, and frustrated staff with the form-filling (chasing applications “for a 97p bottle of vitamins” HP15−T), ‘hidden’ vitamin vouchers, and poor supply:
“…quite frequently I get people ringing me asking me for the Healthy Start number, because they haven’t heard [about their application]…” HP04−U
To avoid ‘red tape’, health professionals thought that they should personally hand mothers the vitamins, particularly if vulnerable (“instead of the mothers having to go somewhere else” HP04−U, i.e. to another centre):
“…then they have to ‘re-register’ † once the baby is born so it’s… a lot of red tape and forms...” HP15−T [†This can be by telephone though.]
“I am working with [a family in a complex situation] and she has had difficulties of obtaining the vitamins, due to [moving] a few times, and she’ll have been backwards and forwards with… in care, and the child is nearly 3 and could have really done with them, and all of the red tape has completely put her off… I have even rang the Department of Health and they can’t speak to me about it, because it’s her...” HP14−T
Illustrating lack of agency, some health professionals in the targeted area felt frustrated and powerless at being unable to give vitamins to non-entitled families requesting them:
“…we had a family recently... She was from an ethnic minority and there were definitely some signs [of vitamin D deficiency], and I did recommend that she go to a doctor… she didn’t do that but… …She goes, ‘please just let me buy them’… ‘I can’t because there is a lot of red tape, again, surrounding the purchase of them’. She understood the need [but] all I could do was recommend… her to… find something similar, which was a big, big deal for her.” HP15−T
Commissioners from both areas highlighted aspects of awareness, accessibility, agency, and adequacy of supply, but also accountability. Besides mothers’ lack of vitamin awareness (C03−U, Table 1), commissioners appeared surprised and disappointed at poorly-informed health professionals, particularly in the targeted area. Some health professionals offered no vitamins as they believed mistakenly that:− they had to judge maternal socio-economic status; the vitamins for pregnant women inappropriately contained vitamin A (present in children’s vitamin drops only); or the vitamins were unsuitable for special diets. One commissioner highlighted health professionals’ lack of awareness of decision-making about eligibility (C01−T, Table 1).
Commissioners also cited poorly visible vitamin vouchers. One commissioner who had worked in the universal area since Healthy Start began highlighted improvements though:
“Healthy Start put a lot of things in those letter packages to people. And originally […] it was one line [about vitamins] on the letter and the writing was very small, but Healthy Start improved the look of the voucher; […] but it still wasn’t as big as the food voucher.” C03−U
It was costly for mothers to telephone the HSIU to ask questions or to declare the birth to obtain children’s vitamin drops (albeit simpler than originally having to re-apply):
“women can [now] just make a phone call and say, ‘I’ve had my baby’ […], …but it’s complicated… […] often, women who are in low income households do not have a landline within their house, and they were using mobiles, […] on premium-rate numbers...” C01−T
Underfunding of local Healthy Start vitamin programmes affected both accessibility and supply, with complicated administrative processes. The commissioners described how the HSIU would fulfil their vitamin orders via the NHS ‘supply chain’ (distribution service), which delivered only to NHS estates. Without extra funding, the commissioners were responsible for local distributors (e.g. children’s centres) receiving vitamins. Delays meant out-of-date vitamins. Commissioners relied on the goodwill of other local distributors to overcome national governance requirements:
“Through seeking the help of Estates [in the commissioning organization], we identified a local mailing van, like the NHS mail-van that goes from clinic to clinic. We identified one that goes from children’s centre to children’s centre. This really made distribution of the vitamins simple.” C03−U
“Estates were involved in distribution of the vitamins ‘cause there was a lot of governance issues because we had NHS providing to the local authority […]. …but the way that we worked, it worked absolutely fabulously […] …Department of Health kept on saying to us – no you can’t do this because [of] governance issues, whilst it worked for us.” C22−U
Within commissioning, their ‘collective agency’ was over-reliant on goodwill to ensure vitamin distribution via hospitals and rather resistant general practices: “how much are you going to give me for doing this?” C01−T). Logistics were tricky:
“…[NHS] people… say, ‘hang on a minute, you are asking me to do something that’s out of my job description!’ And […] the Department of Health had never thought this through properly… […] This was all supposed to be done out of goodwill!” C01−T
Children’s vitamin drops were a medicine (not a supplement), requiring local pharmaceutical approval. One commissioner worked around this with local Medicines Management:
“…we had one of their managers… arranged… approval for us to order through her, so everything was purchased up front, everything was distributed from Medicines Management, and then the accountant […] put [that] in as a return.” C01−T
Commissioners from both areas were frustrated at the ad hoc vitamin supply affecting take-up:
“…health visitors were reluctant to tell somebody to go and get something that they thought was highly likely not to be there for them. So, even when you had them stocked, they’d end up in the bin, because no one claimed them; we were paying to throw vitamins in the bin…” C03−U
Commissioners believed that improved vitamin take-up required more accountability. One commissioner was astonished that the HSIU did not “want to know if the vitamins actually got to mothers; all they want is purchase data” C01−T. Regular steering-group meetings in both areas encouraged accountability for vitamin distribution and take-up. In the targeted area, local authority staff in children’s centres appeared more engaged than NHS staff, possibly because local authority targets and inspections included Healthy Start vitamin performance:
“Children’s centres […] have ‘OFSTED’ inspections... Distributing Healthy Start vitamins is another way that they can show that they’re being beneficial to the community...” C01−T
The HSIU was unconvinced about challenging ‘nought returns’: “I think it would be unheard of for a government department to legally challenge another bit of the same public sector” DH44−HSIU. One commissioner from the universal area believed that ‘nought returns’ reflected that “it is too costly for them to [file the return]” C03−U.