Quality standard


This quality standard covers services to support the health, social and emotional wellbeing of children under 5. This includes: home visiting, childcare, early intervention services in children's social care, and early education. The standard includes vulnerable children who may need additional support. It does not cover clinical treatment or the role of child protection services. For more information see the early years: promoting health and wellbeing in under 5s topic overview.

NICE quality standards focus on aspects of health and social care that are commissioned locally. Areas of national policy, such as free nursery places for children under 5, are therefore not covered by this quality standard.

Why this quality standard is needed

Social and emotional wellbeing is important in its own right. It also provides the building block for healthy behaviours and educational attainment. Poor social and emotional wellbeing increases the likelihood in later life of antisocial behaviour and mental health problems, drug or alcohol misuse, teenage pregnancy, poor educational attainment and involvement in criminal activity.

Relationships and environment

A child's relationship with their main carers has a major impact on the child's social and emotional development. In turn, their carers' ability to provide a nurturing relationship depends on their own emotional and social wellbeing. This can be affected by a range of factors, for example, the family environment, their social networks and employment status. Young parents may themselves be children in need.

Most parents living in poor social circumstances provide a loving and nurturing environment. However, children living in a disadvantaged family are more likely than other children to be exposed to parental drug or alcohol misuse, mental health problems, neglect, abuse and domestic violence. This can result in emotional and behavioural problems. For example, measures of 'school readiness' show that the poorest 20% of children are more likely to display conduct problems at age 5 than children from more affluent backgrounds.

Most opportunities to close the gap in behavioural, social and educational outcomes occur when the child is preschool age.

Early care and education

The level and quality of early childcare and education services varies. Only 69% of children aged between 2 and 2½ years in England are assessed as part of the Healthy Child Programme[1] (Health visitors service delivery metrics 2014/15 NHS England). In addition, not all families are offered antenatal and parenting support.

The quality standard is expected to contribute to improvements in the following outcomes:

  • school readiness

  • child development

  • antisocial behaviour

  • mental health

  • educational attainment.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – safety, experience and effectiveness of care – for a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 Public Health Outcomes Framework for England 2016–19


Objectives and indicators

1 Improving the wider determinants of health


Improvements against wider factors that affect health and wellbeing and health inequalities


1.01 Children in low income families

1.02 School readiness

2 Health improvement


People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities


2.02 Breastfeeding

2.05 Child development at 2–2½ years

2.06 Child excess weight in 4–5 and 10–11 year olds

2.07 Hospital admissions caused by unintentional and deliberate injuries for children and young people under 25

4 Healthcare public health and preventing premature mortality


Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities


4.01 Infant mortality*

4.02 Proportion of five year old children free from dental decay**

4.03 Mortality rate from causes considered preventable**

Alignment with Adult Social Care Outcomes Framework and/or NHS Outcomes Framework

* Indicator is shared

** Indicator is complementary

Table 2 NHS Outcomes Framework 2016–17


Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicators

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

ii Children and young people

1c Neonatal mortality and stillbirths

Improvement areas

Reducing mortality in children

1.6 i Infant mortality*

ii Neonatal mortality and stillbirths

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Enhancing quality of life for carers

2.4 Health-related quality of life for carers**

3 Helping people to recover from episodes of ill health or following injury

Overarching indicators

3a Emergency admissions for acute conditions that should not usually require hospital admission

3b Emergency readmissions within 30 days of discharge from hospital*

Improvement areas

Improving dental health

3.7 i Decaying teeth**

ii Tooth extractions in secondary care for children under 10

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Safety and people's experience of care

Ensuring that care is safe and that people have a positive experience of care is vital in a high-quality service. It is important to consider these factors when planning and delivering services relevant to health and wellbeing in under 5s.

Coordinated services

The quality standard for early years: promoting health and wellbeing in under 5s specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole early years care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to children under 5 and their families.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality early years service are listed in related NICE quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health, public health and social care practitioners involved in assessing and caring for children under 5 and their families should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard.

Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development source on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role extended families and carers have in supporting children under 5 and their families. Health, public health and social care practitioners should ensure that family members and carers are involved in the decision-making process about investigations, treatment and care unless there is a specific reason why they should not be involved.

[1] This is the key universal public health service for improving the health and wellbeing of children. It is led by health visitors and delivered through integrated services.