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The UK Government introduced a large-scale early childhood intervention programme, Sure Start, in 1999. Sure Start is to be further expanded, to achieve national coverage. US experience is highly relevant for anticipating challenges that this expansion will raise.This is a focused, narrative review. We examine the impact, funding, quality-improvement and programme objectives of Head Start and Early Head Start programmes.(1) Early childhood interventions can make a significant difference to children's life chances; (2) expansion without adequate funding threatens quality; (3) narrower objectives, which are easier to measure, can crowd out broader objectives, which are difficult to measure; (4) programmes must balance fidelity to the model and flexibility to local conditions; (5) multiple objectives may conflict; and (6) programmes may have differential impacts. We consider the implications of these findings for Sure Start, focusing on funding, quality control and parental involvement. We also consider that the potential Sure Start should offer for tackling health inequalities in early childhood and suggest ways in which this aspect of the Programme could be enhanced.Head Start has been dogged by concerns about quality and effectiveness. Many of these problems stemmed from an over-hasty expansion, which locked the Programme into inadequate funding and uneven project- and staff-quality. These issues have been addressed through large funding increases and more rigorous performance measures. Nevertheless, concerns about the aims of the Programme and the extent of parental involvement in management remain. Current funding for Sure Start appears to be adequate, while systematic evaluation procedures have been built in from its inception. Concerns have been raised about the implications of expansion for funding, quality and for parental involvement in management of local programmes. US experience shows that these are centrally important issues and that, if they are not addressed early on, they can take many years to rectify.