Government policies and programmes have not significantly improved the health of the under-fives in the past decade, according to a new study by the Audit Commission. Giving Children a Healthy Start1 reports that although more than £10 billion has been spent, directly or indirectly, on improving the health of under-fives in England since 1998, the results are disappointing considering the level of investment. Some aspects of young children's health have improved. There are fewer deaths in infancy and obesity rates are slowing overall. However, gaps between the health of children in disadvantaged areas and those in better off places have grown. An Audit Commission spokesman comments: "Although it's encouraging to see some improvement in the health of babies and young children, the under-fives rarely seem a priority locally." The report recommends how to achieve better value for the money being spent on young children's health. It says that acting now could cut diabetes, heart disease and hypertension and ease a future strain on NHS resources.

One recommendation is for health services for the under-fives - provided by GPs, health visitors, hospitals, children's centres and the voluntary sector - to be integrated to be efficient and effective. It cites 23 case studies showing practical examples of such initiatives (these can be viewed online in a separate document).

The report notes that health visitor numbers have declined by 13% since 2004. Fieldwork conducted for the report found that safeguarding is a high priority for health visitors but limited capacity made it difficult for them to discharge their wider responsibilities. Fieldwork evidence also showed problems with the recruitment and retention of health visitors, e.g. one PCT had 14 out of 75 positions vacant. The report also notes that "Some young parents admitted that without support from health visitors they would have remained either unaware of, or wary of, using health services". Other recommendations are that councils and the NHS need to be clear about how much they are spending on the under-fives. The money should be targeted to have the most impact on the most vulnerable groups, and the impact must be monitored and reviewed. The report also recommends that government and local organisations with responsibility for children's services should monitor the impact of the economic downturn on children's services.

The Audit Commission (www.auditcommission. is an independent watchdog set up by the Government to drive economy, efficiency and effectiveness in local public services such as local government, health and housing.