JSNA topic report: children and young people
13. Current services, local plans and strategies
The Healthy Child Programme
The Healthy Child Programme (HCP) is a national programme that leads the delivery of public health services for children aged 0 to 19 years.
The 0 to 5 years element of this programme is led by health visitors, who are mandated to offer at least five appointments with parents before their children reach the age of 2.5 years: in the antenatal period; in the neonatal period; at 6 to 8 weeks after birth; at one year after birth and at two years after birth. These appointments enable health promotion advice to be delivered and the monitoring of child development to take place. Where additional needs are identified, Health Visiting teams may offer additional targeted support to families (for instance offering support around breastfeeding or later feeding strategies) or through referral to more specialised services. The 0 to 5 years element of the HCP specifically aims to improve population health in the following high impact areas:
- supporting the transition to parenthood
- supporting maternal and family mental health
- supporting breastfeeding
- supporting healthy weight, healthy nutrition
- improving health literacy; reducing accidents and minor illnesses
- supporting health, wellbeing and development: Ready to learn, narrowing the ‘word gap (i.e. ensuring that children have the appropriate language development and other skills to start school)
The 5 to 19 years element of the programme is led by school nurses. Although there are no mandated visits it is recommended that School Nursing teams conduct at least one in person meeting (at 7 to 8 years) as well as regular reviews of a child’s health and development.
This process aims to improve children’s health in the following high impact areas:
- supporting resilience and wellbeing
- improving health behaviours and reducing risk taking
- supporting healthy lifestyles
- supporting vulnerable young people and improving health inequalities
- supporting complex and additional health and wellbeing needs
- supporting self-care and improving health literacy
The HCP is commissioned at a local authority level enabling services to be targeted to the needs of a local population.
As well as the universal Health Visiting and School Nursing Services, additional interventions aimed at improving the public health of targeted at-risk populations can also be provided through the HCP. An example of this is the FNP, a service that offers an intensive parenting support intervention to young mothers.
To facilitate progression of strategic and operational activity within the national policy framework, key national and local policies were identified and summarised. Recommendations relating to the health of CYP that are relevant to the procurement of the HCP were then made.
The full list of the relevant recommendations applicable to local authorities is provided in an appendix of the main HNA report (available on request).
Healthy Child Programme activity
Health visiting
The period of April 2019 to March 2020 represents a time where services were not yet being affected by the COVID-19 pandemic and its associated restrictions. April 2020 to March 2021 covers the first year of the pandemic and April 2021 to March 2022 the second year of the pandemic, for comparison purposes.
The COVID-19 pandemic brought significant challenges to the provision of the Health Visiting Service, including reduced capacity through staff sickness and redeployment, and increased demand due to the need to support families at times of national lockdowns.
From the beginning of the COVID-19 pandemic the mandate for health visitors to complete 2 year checks was removed, enabling the service to prioritise support for the most vulnerable families during this time.
| Outcomes (% of eligible population) | HCP performance targets | 2019/2020 | 2020/2021 | 2021/2022 |
|---|---|---|---|---|
| Antenatal contacts | N/A | 38.7% | 28.1% | 9.2% |
| New baby review by 14 days | 90%* | 95.9% | 94.3% | 75.6% |
| New baby review (including reviews after 14 days) | 100% | 99.0% | 98.6% | 98.2% |
| 6 to 8 week review | 95% | 97.3% | 96.6% | 95.7% |
| 12 month review by 12 months of age | 85% | 82.1% | 80.6% | 76.3% |
| 12 month review by 15 months of age | N/A | 87.4% | 82.0% | 80.3% |
| Children receiving 2 to 2.5 year review | 85% | 79.7% | 55.2% | 75.0% |
* - Whilst new baby reviews are mandated to occur within 21 days of birth, it is considered good practice for visits to occur within 14 days of birth. 90% is a locally determined target. This statistic presents the number of infants having received a new baby review within the same annual quarter that they turned 30 days of age.
38.7% of eligible mothers had contact with a health visitor during the antenatal period in 2019/2020 and this decreased after the start of the COVID-19 pandemic to only 9.2% in 2021/22.
Reductions in activity following the start of the COVID-19 pandemic was also noted in the proportion of new baby reviews carried out within 14 days, from 95.9% in 2019/2020 to 75.6% in 2021/22.
The 6 to 8 week health visitor appointment also offers the opportunity to assess maternal mood, and to signpost/refer mothers to receive support for postnatal depression if required. Maternal mood continued to be assessed in >95% of mothers across 2019 to 2022.
Annual outcomes of this mood review are shown in Table 5. Where mothers were identified as having a potential mental health concern through initial screening questions, health visitors in Buckinghamshire are guided to complete the Edinburgh Postnatal depression questionnaire (a validated tool for assessing postnatal depression).
Further, where a need is identified, they are guided to consider signposting or direct referral of mothers to a Postnatal Wellbeing Group provided by Healthy Minds or alternative talking therapies.
| Outcomes | 2019/2020 | 2020/2021 | 2021/2022 |
|---|---|---|---|
| Maternal Mood review at 6 weeks - % assessed | 95.1% | 95.7% | 95.4% |
| Maternal Edinburgh Postnatal depression score (EPDS) undertaken- % and (number) | 9.5% (516/5450) | 5.1% (260/5126) | 7.4% (410/5556) |
| EPDS score above 13 – as % of those assessed and (number) | 17.1%(88) | 23.5%(61) | 23.4%(96) |
| Number of mothers identified as having an EDPS score >13 who attended a postnatal wellbeing group | 43 | 40 | 46 |
The number of infants receiving a 12-month review has reduced since the beginning of the COVID- 19 Pandemic. In 2019/2020 82.1% of infants received this review by 12 months of age, compared to 80.6% in 2020/2021 and 76.3% in 2021/2022
As shown in Table 6.2, 79.7% of children received a 2 to 2.5-year review in 2019/2020. This percentage fell to 55.2% of children in 2020/2021, with a recovery to pre-pandemic coverage in 2021/2022 with 75.0% of children being reviewed.
No significant changes in the annual percentage of children identified as having problems related to communication, gross motor, fine motor, problem solving, personal social skills or socio-emotional development were observed across 2019 to 2022 (see below).
| Type of 12 month review | 2019/20 | 2020/21 | 2021/22 |
|---|---|---|---|
| Socio-emotional development at 1 year -percentage within the expected scores | 98.6% | 99.0% | 98.8% |
| Type of review | 2019/20 (% above or at expected level) | 2020/21 (% above or at expected level) | 2021/22 (% above or at expected level) |
|---|---|---|---|
| Communication skills | 90.9% | 91.5% | 90.1% |
| Gross motor | 95.8% | 96.6% | 97.2% |
| Fine motor | 96.1% | 97.3% | 97.9% |
| Problem solving | 95.8% | 97.4% | 96.9% |
| Personal social skills | 95.9% | 96.8% | 96.8% |
| All 5 areas listed above | 88.3% | 89.2% | 87.7% |
| Socio-emotional development at 2 years | 97.7% | 96.8% | 96.9% |
Communication, gross motor, fine motor, problem solving and personal social skills were assessed through the Ages and Stages questionnaire 3 (ASQ-3), and socio-emotional development was assessed through the ASQ Socioemotional (ASQ SE) questionnaire.
No major changes were observed in health visitor caseload over the pandemic period.
School nursing
The number of school drop-in sessions fell from 89 in 2019/2020 to 20 in 2020/21, and the number of referrals for assessment, and of one-to-one interventions conducted, also fell significantly during this period, matching a large reduction in the school nurse workforce.
The School Nursing Service was also impacted by COVID-19 and the closure of schools during this period, but in some cases had come to people’s attention for this reason
The Family Nurse Partnership programme
Supported 94 families in 2019/2020 and 82 in 2021/2022; with the relatively small numbers involved, there was no obvious change in outcomes over this period except for a possible increase in the proportion partially or exclusively breastfeeding at 6 to 8 weeks.
Summary of key findings of qualitative assessment
We have found that:
- experience of the Health Visiting Service was particularly mixed and clearly impacted by COVID-19
- the quality of the Health Visiting Service, and communication in particular, was often described positively
- physical access to a health visitor was a concern at times, either because of the convenience of the location or the nature of venue. Some people received visits from the health visitor, but home visits were not available to all and it was unclear why this varied
- there was some concern that Health Visiting Services were not returning to ‘normal’ pre- COVID-19 format quickly enough, for example for ‘drop-in’ services such as weighing clinics and ‘stay and play’ sessions, which help parents form local networks
- other comments about the Health Visiting Service included a suggestion that privacy could sometimes be improved, as well as consistency between the information provided by different health visitors and between midwives and health visitors- clearer understanding of the differences in roles of health visitors and GPs was also suggested e.g. association with the COVID-19 vaccination programme and potentially supporting children with anxiety
- a number of respondents did not feel they knew enough about the School Nursing Service, did not know if they could access it directly or if so, how they could make contact
- the Family Nurse Partnership is a small service targeted at a particular population. Survey respondents were, without exception, positive about the service they received, including the easy access, listening and reassuring support provided, and help from a trusted individual with finding solutions to problems
- other services that were mentioned and about which survey respondents raised concerns related to availability and access included CAMHS and support for young people with eating disorders. There was also a suggestion that the weighing programme focussed heavily on obesity, and that this could result in stigma and could potentially miss children with eating disorders or even possibly exacerbate them
- there is a clear understanding from service users that all these services, considered essential, are under significant pressure. There were strong feelings about this, especially where there were perceived to be inefficiencies or inequalities in delivery