SYMPOSIUM: SOCIAL PAEDIATRICS

The Healthy ChildProgramme: how did we gethere and where should wego?Mitch Blair

Chloe Macaulay

AbstractA Child Health Promotion programme has developed over the last century.

Its remit and content has been revised and updated over the last 50

years. The current programme, the Healthy Child Programme, enshrined

in law, offers a comprehensive schedule of checks, reviews and support

from pregnancy to 19 years of age. This is the first nationally agreed pro-

gramme, and yet we are not clear whether it is achieving what it sets out

to do. We review the aims of the HCP and ask whether it is doing too little

or too much? We explore the outcomes that matter and assert that we

often don’t have the data to make this judgement. We call for more

data and argue for the importance of getting to know your local data,

in advocating for children and young people. We ask paediatricians to

step up and take a role in the promotion of health and wellbeing of fam-

ilies in their care: child public health is everybody’s business.

Keywords Child Health Promotion Programme; child public health;

Children and Young People’s Outcomes Framework; health outcomes;

health promotion; Healthy Child Programme; screening; well-child care

Origins

The origins of child public health in the UK can be traced back to

activities such as Edward Jenner’s discovery of the smallpox

vaccine, legislation including the 1832 Factory Act which

stopped children under the age of ten working in factories and

John Snow’s reducing cholera in the water supply by removing

the pump handle in Broad Street. Most of these changes came

about from recognition of the role that social and environmental

conditions play in the health of children rather than the appli-

cation of direct medical interventions. A Child Health Promotion

Programme (CHP) as such did not really develop until the end of

the nineteenth/beginning of the twentieth century, and began

within the education system.

Mitch Blair MBBS MSc FRCPCH FRCP FFPH (Hon) FHEA is Reader in Paediatrics

and Child Public Health at the River Island Academic Centre for Pae-

diatrics and Child Health, Imperial College, UK and Consultant Paedi-

atrician in the North West London Hospitals NHS Trust, Northwick Park

Hospital, Harrow, UK. Conflicts of interest: none.

Chloe Macaulay MBBS MSc MRCPCH PGCert Ed is Paediatric Registrar in North

West London Hospitals NHS Trust, Northwick Park Hospital, Harrow,

UK. Conflicts of interest: none.

PAEDIATRICS AND CHILD HEALTH 24:3 118

The 1876 Education Act made elementary education

compulsory and children were brought together for the first time

as a population in schools. Recognizing the poor health of many

children once they were within schools, and the similar poor

health of many recruits for the Boer War, in 1907, the school

boards came under a legal obligation to consider (with little

ability to address) the health needs of all children. Subsequent

legislation set out to improve children’s health including the 1918

Maternal and Child Health Welfare Act which established health

visitors and medical officers in infant welfare centres, both

organized by the local authority. Provision of services varied

around the country with little uniformity.

Their focus in the first half of the 20th century was largely

nutrition and prevention of infectious disease through appro-

priate sanitation, good quality food and clean water supplies.

These services were distinct from hospital and General Practice

(GP) services and it was not until 1974, that these doctors and

nurses working in this service were brought within the NHS in an

attempt to more closely align preventive and curative services.

Around this time, the government commissioned the Report on

the Committee of Child Health Services, to look at what was going

on around the country (both within acute, community and public

health settings) and make some recommendations for best prac-

tice. This report, the 1976 Court Report, marked a cultural shift in

out of hospital care, and preventative services. It started with the

premise that the burden of disease had shifted fromnutritional and

infectious causes to developmental and behavioural problems. In

addition to various other suggestions, such as the development of

Community Paediatrics, and the GP Paediatrician, the report rec-

ommended a full programme of health surveillance including

monitoring of health, growth and developmental progress of all

children, an immunization programme, support and advice for

parents and parental health education and training. It advocated

that the GP and health visitor should lead these activities. This

marked the beginning of a more formal CHP.

The changing focus of CHP e evidence based medicine

Over the last 40 years the content of this programme has

changed, to reflect a changing focus from an active “seek and

treat” paradigm to one of “protect and promote” e explore risk

factors and health education and support. This represents both

the development of an evidence base and, arguably, a political

change in terms of the role of the state.

The Court Report set out a “best-buy” programme of sur-

veillance involving seven examinations between birth and school

entry. The Royal College of General Practitioners also produced a

document outlining recommended reviews. Despite this, practice

varied across the country greatly at this time, both in terms of

what reviews and surveillance were being done, and who was

undertaking these activities.

At this time Professor David Hall was invited to lead a

multidisciplinary working group for the then British Paediatric

Association (the forerunner of the Royal College of Paediatrics

and Child Health) to assess the efficacy of the multitude of

routine examinations of infants and children. His review of the

evidence base, the first Health for All Children Report (HFAC)

(1989), was critical that many of the components of the CHP had

little evidence to support their use. As a result a more limited

programme was recommended.

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SYMPOSIUM: SOCIAL PAEDIATRICS

Subsequent HFAC Reports have continued to appraise the

evidence base for our CHP. The Third HFAC Report in 1996

marked a further shift in direction: it placed more of an emphasis

on health promotion and focused on the role of parents through

parental health education. It moved away from routine surveil-

lance and screening and promoted opportunistic and targeted

examinations.

A further HFAC Report in 2006 became the basis for our

current CHP e the Healthy Child Programme (HCP) e and was

further strengthened by the National Service Framework (NSF)

which recommended high quality standards for maternal and

child health promotion as a cornerstone of support for women

and children. This is the first national programme of CHP, set out

in Government legislation.

The Healthy Child Programme e aims and content

Our current incarnation of the HCP was launched in 2009. It

encompasses pregnancy, infancy, childhood and early adult-

hood. In addition to the evidence base set out in HFAC4 it also

draws upon guidance from NICE, and a review of health-led

parenting programmes conducted by the University of War-

wick. It sets out to offer every family:

“.a programme of screening tests, immunizations, develop-

mental reviews, and information and guidance to supporting

parents and healthy choices.that families need to receive if

they are to achieve their optimum health and wellbeing.”

The overall aims of the programme are listed in Box 1.

There are several themes which are new or changed:

� A major emphasis is placed on parenting support, recog-

nizing the integral role that parents play in the develop-

ment of emotional health and behaviour.

� It reflects changed public health priorities such as

increasing breastfeeding rates and a focus on prevention

and early intervention of obesity.

� It places an emphasis on integrated services with HV as the

lead.

� There is an increased focus on vulnerable families with the

adoption of a model of progressive universalism e a

Overall aims of Healthy Child Programme

C strong parent-child attachment and positive parenting

C care that keeps children healthy and safe

C prevention of serious infectious diseases through

immunization

C good breastfeeding rates

C readiness for school and improved learning

C early recognition of growth disorders including obesity

C early detection of and action on developmental delay and ill

health

C identification of factors that could influence health and well-

being in families

C better outcomes for children at risk of social exclusion

Box 1

PAEDIATRICS AND CHILD HEALTH 24:3 119

concept similar to Marmot’s “proportionate universalism”,

referring to specific tailoring of the programme to the

needs of individual families. This acknowledges that an

“all or nothing” approach is too simple and there are many

different levels of need.

One of the key changes has been to introduce a comprehen-

sive two year review. This was identified as a key time to review

development, transition and behaviour. As we write, the inten-

tion is that this review will be integrated with a review of child

development as part of the Department for Education’s Early

Years Foundation Stage requirements.

Figure 1 below shows the programme contents for 2013.

What are other countries doing?

Our current model of CHP has been noted to be “light touch”

compared to other countries and has a different emphasis and

focus. In the UK growth monitoring and child health reviews are

only formally done at the 6e8 week check, and the 2-year re-

view, and then as required. In Australia, Canada, the USA and

Sweden these are carried out at every contact, and there are

many more contacts in the first 2 years: on average 9 in Australia,

9e10 in Canada, 14 in the US and 18 in Sweden. Sweden, in

particular places an emphasis on children’s development at all

points of contact.

Whilst specialist nurses deliver the majority of the reviews in

Australia and Sweden, (equivalent to our HVs in the UK) in

North America the lead provider is mainly GPs (Canada) and

Primary Care Paediatricians (US). In addition to child health re-

views, the screening programmes in all the other countries

studied are also more extensive, but, interestingly, with the

exception of Sweden, vaccination coverage is much lower that

the UK. It is clear that despite a similar worldwide evidence base,

traditional and political considerations have shaped any one

particular country’s preferred programme.

So, are we doing too much or too little?

In an NHS climate with immense pressure to cost-save and an

increased emphasis on outcomes, the scope and reach of the HCP

is continually being debated. Several commentators suggest that

we have gone too far in pulling back the remit of the HCP.

Bellman and Vijeratnam cite several pieces of evidence sup-

porting the assertion that many conditions cannot be detected by

a process of selected screening. They lament the fall in HV

numbers and the diminished formal training that GPs receive

around CHP. The recent call to action to increase health visitor

numbers and HCP e-learning curriculum may go some way to

ameliorate this but they are concerned that the current delivery

model based on progressive universalism is simply not reaching

all those that need it, and indeed there is evidence that this is the

case in Scotland.

Others question whether the CHP is doing too much. Without

good enough evidence for interventions, should we be doing any

of it? A recent article from the US suggests that traditional pae-

diatric preventive services e well-child care (WCC) e may be

largely ineffective in addressing the outcomes that really matter,

such as obesity and heart disease.

There is a real need to look at how the whole programme can

be delivered effectively as opposed to its individual parts. How

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Figure 1 The Universal elements of the Healthy Child Programme 0e19 years. Source : Public Health functions to be exercised by NHS England Service

Specification no.27 Children’s public health services (from pregnancy to age 5 years) April 2013 HMGO.

SYMPOSIUM: SOCIAL PAEDIATRICS

effective are the recommended reviews and interventions and

which parts of the community are being reached? As different

countries debate the merits of the different methods of delivery of

child health services it has become clear that we need to return to

a focus on the outcomes we desire for our children as they

progress through the lifecourse.

What are the outcomes that matter?

In response to a number of high profile national enquiries and

international surveys showing that UK children have relatively

poor outcomes, the Government commissioned the development

of a Children and Young Person Health Outcomes (CYPHO)

framework in 2012. This had the intention of highlighting the

health and wellbeing of 13 million children and to allow appro-

priate benchmarking of service provision and quality within and

across countries.

Table 1 below shows which indicators from the CYPHO

framework are most relevant to the CHP at different parts of the

lifecourse from pregnancy to school leaving. Clearly, this is a

beginning but the question arises, how will they be measured

and who will scrutinize these to make improvements?

Can we measure them?

We already collect a wealth of data from a variety of sources such

as Hospital Episode Statistics data (HES) and disease registers.

These contribute to a “picture” of child health but are not specific

enough. There is already routinely collected data on some of the

key indicators, for example the percentage of babies exclusively

breast fed on discharge from neonatal units. Data collection for

other indicators is in development (for example 2e2.5-year child

development) and requires further testing in the field. Collection

PAEDIATRICS AND CHILD HEALTH 24:3 120

of data for other indicators through specialist surveys is required

but yet to be implemented.

A challenge at local and national level is to collect these

measures as part of routine operational activities. Preferably,

they should be collected electronically and shared appropriately

and confidentially between those responsible for providing in-

terventions. It will be some time before the quality and credibility

of these measures will be sufficient to make an adequate

assessment of the different domains of child health between

separate geographical areas.

Regular feedback of data and discussion about its quality and

meaning is one method by which quality of the CHP can be

continually improved.

For example, in the USA the Child and Adolescent Health

Measurement Initiative (CAHMI) has developed sophisticated

measurement of office based preventive care using feedback and

discussion to continually improve the quality of care. In the UK

The Family Nurse Partnership (FNP) e the enhanced intensive

care prevention programme for teenage parents and infants has a

similar real time data collection system which allows practi-

tioners to receive valuable performance data. We need to learn

from these systems.

Are we measuring up: using the data to make change?

How effective is the CHP currently in delivering immunization,

screening, health promotion and parental support? One metric

often used is coverage, that is the proportion of the population

which has received the test or intervention being recommended.

Ideally a high quality programme will reach all those in the

eligible population. However, in practice, this is often less than

optimal. Scotland has a tradition of excellent data collection at

� 2013 Elsevier Ltd. All rights reserved.

Child Health Programme indicators of quality at different stages/ages. Selected indicators from the Children and YoungPeople’s Outcomes Framework

Life course stage HCP domains and indicators (including screening, immunization, surveillance, health promotion)

Pregnancy/birth Smoking status at time of delivery (% smokers who have quit by delivery)

% women who have healthy weight at time of booking 1st and subsequent pregnancies

% women abusing alcohol or non-prescription drugs at time of booking with maternity services

% initiation rates for breastfeeding

Breast feeding at 6e8 weeks, 4 months (exclusive)

% of babies on exclusive breast milk at discharge from neonatal units

Emergency admissions of home births and re-admissions to hospital of babies within 14 days of

being born/1000 live births

Low birthweight of term babies

Infancy-2 years Proportion of mothers with mental health problems including post-natal depression

Proportion of parents with appropriate levels of self-efficacy

Proportion of parents where parent-child interaction promotes secure attachment

Child development at 2e2.5 years

Early years/School

entry

School readiness

% children of healthy weight at 4e5 years

% of children at school entry with no dental caries

Population immunization coverage of vaccine preventable diseases 0e5

School Nutrition

% children of healthy weight at 10e11 years

Percentage of children and young people who eat at least 5 portions of fruit and vegetables a day

Physical activity

5e9, 10e14 and 15e19 year olds

Injury

Hospital admissions as a result of self harm

Hospital admissions and A and E attendances for accidental and unintended injuries, non-accidental

injuries, neglect and maltreatment in children and young people

Proportion of children who experience bullying

Killed or seriously injured casualties on England’s roads

Sexual health

Under 18s conception

No. of births to under e 18s

Disability

No. of children and young people with disability

Emotional health

Self reported well-being (all children and young people, LAC, and those with LTC and disabilities

Lifestyle

Prevalence of drinking and substance misuse in children and young people

Smoking prevalence 15 year olds

Alcohol related A and E attendances and hospital admissions

Children young people and families who have access to age appropriate health information to support

them to lead healthy lives

Proportion of children and young people who play games on a computer for 2þ hours on weekdays

Population immunization coverage of vaccine preventable diseases 5e19

Table 1

SYMPOSIUM: SOCIAL PAEDIATRICS

national level. Coverage at each CHP review diminishes with age

and disproportionately for those in disadvantaged circumstances

i.e. poorer children are less likely to receive these. A study in

Nottingham indicated that screening for heart, hearing, eye,

testes and hip impairments in 29 general practices was effective

in detecting most cases but also resulted in large numbers of false

positives which in themselves can cause a great deal of parental

PAEDIATRICS AND CHILD HEALTH 24:3 121

anxiety. Ni Bhrolchain showed that the median age for orchid-

opexy surgery fell from 4 years to 2 years old after an agreed

guideline and system of parental and professional reminders was

instituted.

With increased localism of public health and NHS services, it

becomes all the more important that we understand our local

data including CHP.

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SYMPOSIUM: SOCIAL PAEDIATRICS

Such data is helping to inform the development of joint stra-

tegic needs assessments and the political prioritization process at

health and wellbeing board level.

Figure 2 below shows how Child Health and Maternal Intel-

ligence Network (formerly, CHIMAT) profiles can highlight

unmet need, in this case obesity, in a particular area by

comparing local with national data.

Rethinking the model

Our thinking about what causes disease and ill health has

changed over the last century, particularly with the development

of lifecourse epidemiology and a deeper understanding of epi-

genetics and neurosciences. This requires us to have a different

working model for how children’s health and wellbeing can be

best optimized and protected. It is a paradigm based on multi-

disciplinary working and very much a child public health

perspective i.e. through the coordinated efforts of society. As

such, Halfon et al describe a model consisting of community

hubs or centres with better, coordination of care between co-

located agencies, providing a range of services for families

delivered across the lifecourse.

This model is well suited to our current service delivery

especially with the development of childrens’ centres and

extended schools as the central hub of activity in the community-

essentially the place where children spend increasing amounts of

time. It is estimated by 2015 that 60% of 2 year olds will have

places in early years settings as the economic drivers for

maternal employment increase. Health promoting activity is

increasingly being placed in such settings e.g. cookery classes,

parenting support, sleep clinics, reading and language enhance-

ment. Services such as community midwifery, health visiting and

speech and language therapy are increasingly setting their stalls

in these community settings in an attempt to increase access

especially for the most vulnerable. Where does the paediatrician

fit in?

Child Health and wellbeing: the role of the paediatrician

The expectation is that the HCP is led by health visitors and as

capacity in the UK continues to increase, this is likely to become

the norm. However, we would argue that paediatricians have an

important role to play in providing additional leadership and

Figure 2 A typical comparison graph available on the Child Health and Matern

children classified as obese or overweight in reception (aged 4e5 years) and

neighbours. This area has a higher percentage in reception and a higher percen

average.

PAEDIATRICS AND CHILD HEALTH 24:3 122

clinical support to health visitors and General Practitioners. The

child health promotion coordinator role is still very much needed

in bringing together all the parties involved including dieticians,

public health intelligence staff, immunization coordinators,

midwives, GPs, surgeons, other medical specialists, and early

years staff to review training and monitoring of the programme

outcomes as a whole.

The latest RCPCH census has indicated that only 35 in-

dividuals (this is likely to be an underestimate) in the UK have

specific child public health responsibilities as part of their current

job roles, with approximately one day per month dedicated to

this. The Faculty of Public Health and the Royal College of Pae-

diatrics and Child Health are exploring ways in which joint

training and support for paediatricians can be obtained in these

tasks. There is a real need to maintain a network of such in-

dividuals and the newly formed UK Child Public Health Associ-

ation (formerly Child Public Health Interest Group CPHIG) may

well act as such a forum.

Paediatricians should use every opportunity to help influence

decisionmaking at Health andWellbeing Boards at local authority

level by discussing child public health priorities, supported by

local data collection as previously discussed, with their local Di-

rectors of Childrens’ Services and Directors of Public Health; for

example supporting infant mortality reduction, injury prevention,

breastfeeding promotion, obesity prevention and supporting

healthy adolescent lifestyle. In theUSAwhich has a strong primary

care paediatric service provision, programmes such as CATCH

(Community Access to Child Health) have been very successful in

funding and rewarding individuals who dare to stray outside their

practices and help support improving child health in the commu-

nity. Their motto is “one paediatrician canmake a difference.”

The future

The links with the local authority become even more essential as

the CHP moves into the responsibility of Local Authorities and

Public Health from National Health England in 2015. These

changes represent both an opportunity and a risk. Those with

child public health training and expertise will be leading on a

number of different population based interventions as described

above and paediatricians will continue to have a major role to

play in what is essentially a “population paediatrics”. The cur-

rent reorganization offers the possibility of true multidisciplinary

al Intelligence Network website. These charts show the percentage of

year 6 (aged 10e11 years) by local authority compared to their statistical

tage in year 6 classified as obese or overweight compared to the England

� 2013 Elsevier Ltd. All rights reserved.

SYMPOSIUM: SOCIAL PAEDIATRICS

working e health, education and social care e and we must

seize this. However the real test of a comprehensive child health

programme is its ability to track children and young people

across the community/hospital divide in a seamless way by

appropriate record linkage which allows us to follow through

referrals from screening and demonstrate the effectiveness of

health promotion activities on key outcomes such as smoking or

alcohol related morbidities or injury prevention. There is promise

in the integrated care approach which promotes the “paediatri-

cian without boundaries” who can work in a variety of settings

and thus appreciate different perspectives of child health.

The Healthy Child Programme is here to stay. It may well

change its name again over the years and as research progresses,

it will undoubtedly change its content and focus too. We would

argue that there will always be a need for paediatricians to be

part of the child public health team planning and supporting the

prevention of ill health, the protection of children from envi-

ronmental harm, and the promotion of optimum health and

development. We must step up to the challenge.

� The Healthy Child Programme is a National programme of

Child Health Promotion

� It covers from pregnancy to 19 years

� The programme is evidence based but no complete data

exists about its impact

� The ongoing work of the Children’s and Young People’s

Outcomes Forum may give us better indicators to bench-

mark against

� The current NHS reorganizations offer both an opportunity

and a risk for the health of children in the UK

� Paediatricians have a responsibility to engage with stake-

holders in promoting the Child Public Health agenda A

FURTHER READING

HEALTHY CHILD PROGRAMME DOCUMENTS

Department of Health. The Healthy Child Programme 0e5 years. London:

DH, 2009. https://www.gov.uk/government/publications/healthy-child-

programme-pregnancy-and-the-first-5-years-of-life.

Department of Health. The Healthy Child Programme 5e19 years. London:

DH, 2009.

PAEDIATRICS AND CHILD HEALTH 24:3 123

Department of Health. The two year review. London: DH, 2009.

Healthy Child Programme e-learning programme can be found at: www.e-

lfh.org.uk/projects/healthychild

BACKGROUND READING

Blair M, Stewart-Brown S, Waterston T, Crowther R. Child public health.

Oxford: Oxford University Press, 2010.

Court SDM. Fit for the future. The Report of the Committee of Child Health

Services. London: HMSO, 1976.

Fair Society. Healthy lives the Marmot review, www.ucl.ac.uk/

marmotreview; 2010.

Halfon N, Inkelas M, Hochstein M. The Health Development Organization:

an organizational approach to achieving child health development.

Milbank Q 2000; 78: 447e97.

Hall DMB, Elliman D. Health for all children revised fourth edition. Oxford:

Oxford University Press, 2006.

Kennedy I. Getting it right for children and young people: overcoming

cultural barriers in the NHS so as to meet their needs. London: DOH,

2011. https://www.gov.uk/government/publications/getting-it-right-

for-children-and-young-people-overcoming-cultural-barriers-in-the-

nhs-so-as-to-meet-their-needs.

UNICEF. An overview of child well-being in rich countries. Florence Italy:

UNICEF Innocenti Research Centre, 2007.

Wolfe I, Cass H, Thompson MJ, et al. Improving child health services in the

UK: insights from Europe and their implications for the NHS reforms.

BMJ 2011; 342: d1277.

SPECIFIC PAPERS

Bellman M, Vijeratnam R. From child health surveillance to child health

promotion, and onwards: a tale of babies and bathwater. Arch Dis

Child 2012; 97: 73e7.

Coker TR, Thomas T, Chung PJ. Does well-child care have a future in

paediatrics? Paediatrics 2013; 131(suppl 2): S149e59.

van Esso D, del Torso S, Hadjipanayis A, et al. Paediatric primary care in

Europe: variation between countries. Arch Dis Child 2010; 95: 791e5.

Wood R, Blair M. A comparison of child health programmes recommended

in selected high income countries. Child Health Care Develop. in press,

http://dx.doi.org/10.1111/cch.12104, published online 30th

September 2013.

� 2013 Elsevier Ltd. All rights reserved.