From child health surveillance to child health promotion, and onwards: a tale of babies and bathwater
- 1Department of Community Paediatrics, Royal Free Hospital, London, UK
- 2Paediatric Department, Chase Farm and Barnet Hospitals, Enfield, UK
- Correspondence to Dr Martin Bellman, Children's Service, Kentish Town Health Centre, 2 Bartholomew Road, London NW5 2BX, UK;
- Accepted 9 March 2011
- Published Online First 3 April 2011
Child health surveillance (CHS) has evolved greatly over the past 30 years from a proactive screening process by health professionals to a more passive approach of child health promotion (CHP), which places the main responsibility for detection of developmental problems on carers. The impetus for this change came from the Hall Report (1989), which reported a lack of evidence for CHS.
Although research on developmental screening is sparse, some data show that use of structured methods for identifying deviations from normal increases the pick-up rate of abnormalities, compared with informal or parent-initiated methods. The majority of countries recommend a universal ‘CHS’ type of programme, in contrast to the UK and some other European countries. Alternatives to universal CHS include ‘targeting’ which, however, has been criticised for including too many ‘normal’ children and missing those who are most in need.
CHS and CHP are basically primary care activities but require essential support from secondary paediatric services. There are concerns about the competence and numbers of general practitioners and health visitors who deliver child healthcare. Both these professional groups are under great pressure because of continuing reorganisations of the National Health Service in the UK.
Politically driven agendae complicate the fundamental aim of enhancing child health at the primary level and it is vital to keep the focus on providing high-quality services to the most needy children. CHS has evolved beyond CHP to a Healthy Child Programme (HCP). Hopefully this is not an ‘emperor's new clothes’ situation and will improve outcomes. A major problem is the ‘inverse care law’, and reliance on carers runs the risk of excluding those children who need most input. Inequality is currently a headline problem and the change from CHS to HCP may not have helped.
More research is urgently needed to resolve uncertainty about the application of these fundamental procedures for secondary preventive of childhood disability.
Child health surveillance
One of the most comprehensive reviews of child health services in England and Wales was commissioned by the UK Government and published in 1976 under the title of ‘Fit for the Future’.1 It was chaired by Professor Donald Court and was acclaimed by paediatricians but met opposition from other sections of the medical establishment and many recommendations were not implemented. The report emphasised the importance of prevention of illness and handicap and recommended a programme of health surveillance which included five principal professional activities:
▶ oversight of health and physical growth of all children
▶ monitoring the developmental progress of all children
▶ providing advice and support to parents, and treatment and referral of the child
▶ providing a programme of effective infectious disease prophylaxis
▶ participation in health education and training in parenthood.
It was suggested that these activities would be best performed by the primary care team (general practitioner (GP) and health visitor (HV)). The Court Report recommended that child health services should be integrated between the then current arrangement of community health services provided by local authorities, general medical services delivered by GPs and specialist services provided by hospitals. In order to implement this strategy it proposed the establishment of two new professional crafts: the consultant community paediatrician and the GP paediatrician. The former took off and is now one of the most popular subspecialties in UK paediatrics; however, the latter was aborted and did not emerge, although many general practices include GPs who have special expertise in child health.
In 1989 Butler basically reiterated the above list in his Report to the Department of Health on child health surveillance (CHS) in primary care and endorsed Court's recommendation that GPs were the best professionals to deliver it.2 He emphasised the importance of secondary prevention by detection of developmental problems at an early stage.
In 1989 a report entitled Health for All Children (the Hall Report)3 was also commissioned and published by the British Paediatric Association (which became the Royal College of Paediatrics and Child Health (RCPCH) in 1996). This reviewed the CHS programme and identified a lack of evidence for many of the procedures in practice at the time. Many of the historical interventions to detect developmental abnormalities were dismissed as universal procedures because they did not meet epidemiological screening criteria.4 The report was welcomed as a critical analysis of established practice but also strongly criticised as muddled and contradictory.5
A second edition of the Hall Report in 1992 recommended a reduced programme of CHS which did not include procedures that had no firm evidence base. The key person to implement CHS was a health professional trained to identify developmental defects so that intervention could be provided (secondary prevention). The proposals of the third Hall Report in 1996 embraced the concept of health promotion which emphasised health education to empower parents to identify problems in their own children. A ‘best buy’ menu was suggested, consisting of an examination at age 6–8 weeks by a doctor, enquiry and examination by a HV at age 6–9 months, enquiry and observation by a HV at age 18–24 months and enquiry and examination by a doctor or HV at age 36–48 months. The primary aim of the health professional was to promote good child care practice (primary prevention) by working in partnership with parents. Proactive procedures, such as universal developmental screening, were minimised and, instead, opportunistic and targeted examinations were proposed. A unique opportunity for scientific comparative evaluation of this proposal was lost when it was not piloted in selected areas but introduced nationally. Research after the fact has been sparse and inconclusive. A fourth edition of the Hall Report in 2003 re-emphasised the predominant role of health promotion, in which parents had the primary responsibility, and extended the scope of the recommendations to school age children. After the 6–8-week check the only universal screening procedures that were recommended were vision tests by orthoptists at age 4 years and measurement of height and weight plus sweep test of hearing at school entry by a school nurse. A revised fourth edition was published in 2006 to take account of several national policy documents, particularly the National Service Framework for Children, which set out quality standards for child care services.6
Hart, Bax and Jenkins surveyed a geographical population of 400 preschool children in 1981 who attended a child health clinic for routine and non-routine checks.7 Attendance was nearly 100% and a wide range of medical, developmental and behavioural problems were raised at both types of appointment. Mothers valued the service highly, which was only available because of the routine surveillance structure.
There is evidence that experiences such as neglect and negative social influences adversely affect brain development in early years8 and it could be possible to specifically identify and target such psychosocial factors. In practice, however, this can be difficult.
Some developmental problems such as autistic spectrum disorders cannot be efficiently diagnosed early by a process of selective screening. A study of children referred to a child development team under the age of 3 years found that the majority were identified by HV screening at 2 years of age, and not by parents self-reporting their child's developmental difficulties.9
A cohort of 351 school entrants (age 5) in London, who had a detailed assessment by a nurse and doctor, were followed to age 10 with a neurodevelopmental scoring tool and clinical examination by a trained school doctor.10 Seventy-seven per cent of the children who had a high neurodevelopmental score had learning or behavioural difficulties that required intervention. The predictive value was greatly enhanced if the results of direct examination were also included. The implication is that without proactive assessment some of these problems would have been missed or their diagnosis delayed, preventing timely remediation.
A study of 59 schools in Kent found 21 children with confirmed autistic spectrum/pervasive developmental disorder.11 Concerns had been identified in 63% at a 2-year check and 94% at the 3.5-year check. Sixty-eight per cent of the children were referred on for appropriate intervention as a direct result of the routine checks. Without surveillance, diagnosis would have relied on parental recognition of symptoms followed by presentation for assessment.
In Copenhagen children about whom health nurses had developmental concerns in the first 10 months of life and matched controls were given a psychiatric examination with standardised measures at age 18 months.12 Concerns about development were significantly associated with neurodevelopmental disorder at follow-up and concern about the mother–child relationship was associated with mental health problems.
A survey in the north east Thames area in 2008 found that after the 6–8-week check which was mainly done by GPs, HVs were the main providers of CHS.13 After a change from universal to targeted screening as recommended by the Hall Report, referrals to audiology and orthoptics fell by 40%.
Thus, there is substantial evidence that CHS by trained professionals can identify developmental abnormalities in young children, which would have been missed without active surveillance.
In the USA ‘early intervention services for all handicapped children and their families’ are enshrined in law.14 Regular CHS is recommended by the American Academy of Pediatrics15 and is provided under Medicaid.16 No specific methodology is recommended from the wide range currently available but structured developmental screening is strongly advocated.17
The prevalence of developmental disability in developing countries is higher than in the developed world and developmental screening by primary healthcare physicians, using a standardised tool, is highly recommended.18
In Europe, however, general developmental screening is discouraged and surveillance by opportunistic and targeted observation of children by knowledgeable professionals is recommended.19 However, within Europe a recent survey demonstrated substantial variability in preventive child health examinations.20
Advantages of CHS
Universal CHS is expensive in terms of professional time and the cost:benefit ratio. Outcomes are often measured only by reference to abnormalities detected and referred on for remediation. However, a CHS programme has a secondary, but equally important benefit, which is to support parents, who are often young and inexperienced, with simple health education about child rearing and to reassure them if things are going well.1 The benefits of these actions are not easily measured and therefore not usually taken into account. The CHS ‘ticket’ gains a health professional (usually the HV) admittance to a child's home, without which it may be refused. In the absence of a universal programme, children who would benefit from professional advice may not be seen unless the parents present them for advice. Hence, for some children, the opportunity for early identification and treatment, before overt symptoms appear, is lost.
An example is preschool vision screening, which is currently not a uniformly commissioned service and there are significant differences in delivery of this service across the UK. The National Screening Committee Child Health Sub-Group Report on Vision Screening reports that ‘Ideally strabismic ambyopia should be treated before 3 years of age’.21 The Hall Report states that such screening should be carried out by orthoptists. As this service is not universally commissioned, there are districts that do not offer a screening programme for strabismus in the preschool years. Approximately one in 20 children aged 6–7 years have uncorrected refractive errors and require glasses but do not have them.22
The theory behind targeting of services is that some sections of the population are at higher risk of problems and that concentrating services on these people is a more efficient way of deploying resources.
The concept of ‘at-risk’ registers has been recognised since the 1960s and was advocated by the pioneering developmental paediatrician, Dr Mary Sheridan.23 However, it was found that such a register, based on appropriate criteria, included the majority of children, negating the desired cost–benefit of the selection process24 and that only about half of children with disability were identified.25 An adverse effect of this targeting strategy was that children not on the register may be neglected.26 One suggestion was to hold an ‘observational’ register of children with a ‘handicapping condition’ identified at or shortly after birth, and for all other children to be seen at regular intervals.27 A compromise is ‘progressive universalism’ which is a term used to refer to a selective screening programme offered to ‘high-risk’ children while a basic set of screening tools is used universally, especially in the first year of life.28
A recent study in a deprived inner city high-risk area of targeted intervention by HVs found that less than half the families with high needs were identified by the target criteria and that most families who live in deprived areas need regular help to protect the most vulnerable children.29
Thus, it can be concluded that the targeting ‘safety net’ gives a false sense of security and many children, who in fact need help, fall through it.
A potent negative driver in these circumstances is the ‘inverse care law’, which rules that the most needy people are the least likely to receive services, either because they do not access them or the services are less available where they live.30
A reduction in the HV establishment prompted a redesign of the CHS programme in Essex.31 The programme rejected abandonment of the 2-year check and offered group sessions instead of individual checks. Groups of eight children were assessed by observation during play and parents held a facilitated discussion. There was a high level of satisfaction from parents and HVs. However, attendance was only 52.5% of those invited.
Change from child health surveillance to child health promotion
Since the death of ‘Baby P’ more emphasis has been given to child protection and the scope and content of child health work is expanded to cover ‘safeguarding’ of children.
Most preschool children make contact with their GP about six times per year. These contacts are made primarily in relation to self-limiting illnesses and routine immunisations.32 It would be difficult to deliver high-quality child health promotion (CHP) at these brief points of contact. However, GPs have a high uptake of the 6–8-week developmental check, which is primarily a physical examination, and this is possibly an opportunity for expanded intervention. Nevertheless, it has been authoritatively proposed that the focus of preventive children's services should change from health surveillance to promotion.33
Delivering CHP: professionals and training
The CHS programme was mainly delivered via the primary care health services, predominantly through HVs and GPs, with support from secondary care community paediatric services in some urban areas.13
In parallel with the shift from CHS to CHP, the number of HVs being trained is decreasing and there is a significant reduction in the HV establishment employed by primary care trusts.34
Although GPs are the main providers of CHP, they have diminished training in this field.32 Practical experience in CHP is now not considered to be part of essential training for the Membership of the Royal College of General Practitioners (MRCGP) examination, in contrast with the situation a few years ago. A review of primary care paediatrics in the UK shows that only 40% of practising GPs had formal experience in paediatrics as trainees.35 Furthermore, it is likely that a significant proportion of GPs who have had general paediatric training would not have had adequate training in CHP.
In the document ‘Achieving equity and excellence for children’, the Department of Health sets out the role of GPs as providers and commissioners of CHP.36 This has significant implications for clinical and management practice and training.
Similarly, HVs have less experience and training and rely on support and supervision by HV team leaders, who, in turn, are becoming more stretched.37 The Healthy Child Programme (HCP) e-learning curriculum developed by the RCPCH in collaboration with other Royal Colleges and professional organisations (launched in January 2011) may be an effective way of developing standardised training modules for all professionals involved in CHP and CHS.
A tangle of red tape (or are we lost for words?)
A recent Department of Health document, writing on aspects of commissioning CHP, now renamed the HCP, clearly states that the community services element of this programme must include quality assurance of performance of service providers with some weight given to local priorities.38 This document states that some child community service elements need to be delivered universally. A 2-year ‘full developmental review’ is recommended in this document, but there is a lack of clear guidance as to how this is to be delivered. The HCP advises on the use of validated tools that are evidence based.39 As mentioned in the introduction, such information is lacking. Tools used, such as the 2-year HV questionnaire (http://www.healthvisitors.com), which was previously administered by HVs at a face-to-face interview, is now available as an ‘e’ questionnaire on the HV web site. Hence it is an optional extra for parents who are able and willing to use it. This inevitably excludes many families from deprived backgrounds, although it is precisely those children who most need professional support. Although this is not a validated tool for the 2-year check, there is evidence that it helps in early identification of children with significant communication difficulties.9
Strategies like these invariably fall foul of the ‘inverse care law’ referred to above. Although initially propounded 40 years ago, it remains a major obstacle to comprehensive provision of health and social services.40 This is essentially bound up with the intractable issue of health inequality, which is currently the subject of intense national debate following publication of another government-sponsored document.41 Implementation of this vital provocative review requires redirection of statutory (health, social and education) services. The National Health Service (NHS) in the UK is undergoing enormous politically driven changes42 and we hope that the needs of this initiative on inequality in general, and those of children in particular, do not get lost.
A way forward
This review attempts to examine the current problems in providing a comprehensive CHP/HCP that includes essential aspects of CHS. We have identified many questions and few answers.
In the process of moving from an essentially universal to a targeted programme, vital aspects of professional experience, training and workforce have deteriorated, leading to marked variation of the delivery of CHP. Recent information published by BBC News London reports that the uptake of the recommended health review for children at age 1 year varied from 0% to 98% in the pan-London area.43 Some HVs have been recruited back to practice by NHS London by an incentive scheme to retrain and numbers of HVs in training have increased in London primary care trusts from 18 in 2007/2008 to 109 in 2010/2011.44
During the process of information gathering with emphasis on local commissioning, the importance of information sharing both locally and nationally must be emphasised. It is important that child health data are collected on a national basis for analysing the effectiveness of aspects of CHP and CHS, and the fact that there is a paucity of national data on issues relating to CHP may account for the difficulty in validating the tools currently used for CHS as part of a HCP.
At a time of rapidly changing goalposts it is impossible to identify a stable comprehensive programme that will achieve the aims of CHS as defined by Court and Butler. It is recognised by politicians downwards that there is no better investment for a nation than promoting optimal child care, in its broadest sense. Identification of disability at the earliest opportunity to give remediation is part of that investment. Outside Europe, many countries endorse a universal programme for developmental screening. As stated by Hall and Elliman, ‘absence of evidence of effect is not the same as evidence of absence of effect’.6 We suggest that the zeal for evidence-based practice has led to the loss of an essential safety net and the baby has been thrown out with the bath water. In current circumstances we doubt whether ‘progressive universalism’ is a compromise that will succeed. It seems to us to be the worst of both worlds: it has the disadvantages of a targeted programme but requires a large investment of resources. The importance of secondary prevention of childhood disability cannot be overemphasised. The research base for the change from CHS to CHP is sadly lacking and it is not too late to perform some carefully designed epidemiological studies. This is an area of health services research that should be prioritised for central funding so that future generations of children can reach their full developmental potential.
Competing interests MB is a joint author of a developmental screening schedule.
Provenance and peer review Commissioned; externally peer reviewed.