More information about text formats
We thank Dr Cliona M Ni Bhrolchain for her interest in our paper and her comments. With the exceptions of newborn hearing and blood spot screening, there is unacceptably wide variation at local level and a lack of commitment at national level in implementation and monitoring of preventive child health programmes. We suggest that this is just one manifestation of a wider problem - the serious inadequacy of NHS investment in leadership, education and training, both in general practice and in the specialties. Morale is low and there are chronic shortages of staff with the relevant skills, when medicine is changing and public expectations rising faster than ever before.
David Hall and David Sowden (affiliations as on our original paper)
Hall and Sowdon regret that the Newborn Infant Physical Examination (NIPE)/child health surveillance (CHS) programme fails to deliver improved outcomes for developmental dysplasia of the hip (DDH), contrasting with the success of other screening programmes. I would like to make some proposals for improvement.
Current NIPE standards are focused on timeliness of the screening pathway and explicitly exclude treatment outcomes as ‘outside the screening pathway’1. Yet potential outcome measures are routinely available for three of the four NIPE screening programmes and shown to be measurable for two of these. McAllister et have demonstrated that records of surgical intervention for DDH can be used to show variation in outcomes2. Similarly, the NHS Atlas of Variation has demonstrated that age at orchidopexy can be used for undescended testis (UDT)3. Surgery for congenital cataract could be used in the same way. While I accept that definitions and actual measures might need some discussion to reach a national consensus, measuring these outcomes is possible from routine data.
McAllister et al conclude that dedicated leadership of the DDH screening programme is associated with improved outcomes. This has also been shown for UDT4. Unfortunately, clinical leadership of the Healthy Child Programme (HCP) has been dismantled in recent years and the RCPCH recorded a community paediatric HCP lead in only 16% of services in 2015.
Lastly poor outcomes may indicate...
Lastly poor outcomes may indicate a lack of training. The DDH and UDT examples describe multifaceted interventions including training and support of practitioners. Health visitor training now concentrates on health promotion and safeguarding with a reduced emphasis on child development and clinical skills. There are no longer any specific training requirements for general practitioners (GPs) who perform CHS. This is concerning as we know that only a proportion of GPs have any dedicated training in paediatrics before entering general practice.
There are, therefore, a series of proven measures that, if implemented, could improve the programmes’ performance.
1. Public Health England. Our approach to newborn and infant physical examination screening standards. 2018 https://www.gov.uk/government/publications/newborn-and-infant-physical-e... (accessed 11.01.19)
2. McAllister D A, Morling JR, Fischbacher C M et al. Enhanced detection services for developmental dysplasia of the hip in Scottish children 1997 – 2013. Arch Dis Child 2018; 103: 1021 – 1026.
3. Child and Maternal Health Observatory. NHS Atlas of Variation in Healthcare of Children and Young People. 2012. Ch Map 25 Proportion (%) of all elective orchidopexy procedures performed before the age of 2 years by PCT 2007/08–2009/10 p.68-69. Available at https://fingertips.phe.org.uk/profile/atlas-of-variation
4. Brown JJ, Wacogne I, Fleckney S, et al. Achieving early surgery for undescended testes: quality improvement through a multi-faceted approach to guideline implementation. Child: care, health and development 2004; 30: 97–102.
5. Royal College of Paediatrics and Child Health. RCPCH Medical Workforce Census 2015. London 2017. Available at https://www.rcpch.ac.uk/resources/workforce-census-2015 .