Developing a community child health service for the 21st century

A report on a review of the community child health service in Scotland.

Section 3: Background and Development of the Community Child Health Service in the UK

History of CCH

Today's community child health service had its roots in the early part of the 20 th century and was considered a branch of the public health service. Community paediatricians were employed by local authorities as part of the public health workforce. These doctors came from a variety of clinical backgrounds but often without formal paediatric training. They tended to focus on screening examinations, child development and examining children "in need of special educational treatment" as defined in the Education Act (Scotland) 1946. Essentially these medical examinations of children and young people continued without question until the publication of Health for All Children in 1989.

In 1973 the Scottish Home and Health department published "Towards an Integrated Child Health Service" which laid the foundations for the present service with the emphasis on joined-up working between clinicians and other statutory bodies. In England one of the main recommendations of the Donald Court Report - "Fit for the Future" - published in 1976 36 was that consultants should be appointed in the community. The first consultants "with an interest in community child health" were appointed in the 1980s across the UK.

Individual clinicians with particular specialisms or interests tended to develop services serendipitously according to those interests. Service planners were often constrained by the availability of trained doctors rather than meeting the needs of a population, especially in more remote areas. Some doctors specialised in physical disability, others in mental health issues and others in learning disability and sensory problems.

There was a large cadre of less experienced doctors (later called staff grade doctors) who learned on the job and were promoted by virtue of their experience and contribution to the service. Formal training opportunities for these doctors were extremely limited. Often they worked on a part-time basis because of domestic commitments. There was no implementation of integrated hospital and community children's health services until the early 1990s. Subsequently, the need for formal training programmes was acknowledged and competency frameworks have been developed by RCPCH.

Public Health Nursing: CCH Partners

The origins of health visiting in the UK lay in the mid 19 th century. The Women's Sanitary Inspector's Association was founded in 1896. The role became associated with infant welfare clinics from 1900-1948 whereafter HVs were incorporated into the NHS.

Public health nursing for children was based on a cadre of highly skilled health visitors and school nurses. Community paediatricians had a close relationship with their health visitor colleagues through a network of child welfare clinics, and with school nurses through school-based clinics. School nursing did not really fulfil its potential until 2001 when a more dynamic 'public health' role for the school nurse was defined to promote the health of school-aged children 37 to develop health promotion programmes for populations. Research has shown a poor justification for routine screening medical examinations 38 of school children although many areas in Scotland continued to undertake these especially at school entry until the late 1990s.

Attention continues to be focused on redesign of public health nursing with the recent formation of the Modernising Community Nursing Board by the Chief Nursing officer in Scotland 39 . As new models of care for children emerge, the vital role of community children's nurses and public health nurses may become even more important. If nurses and their AHP partners are to play a greater role, then there will be a need for more training in this area.

The Modern CCH Service

Throughout the 1990s there was increasing demand for services for vulnerable children and young people in need of protection. Challenges such as enhanced responsibility for child protection were absorbed by the community child health service, which became consultant-led in most areas of the UK including Scotland. Some of these consultants were senior doctors who took advantage of a regrading scheme in the mid-90s. Quite a number of these doctors are now approaching retirement and it seems timely to review the development of the service across Scotland.

In 1990 the doctors' training body, the Joint Committee on Higher Medical Training, published the requirements for Higher Specialist Training for doctors aiming for accreditation in 'Paediatrics with a special interest in Community Child Health'. These recommendations resulted in the designing of specific senior registrar training programmes in many paediatric teaching centres, and encouraged a new generation of paediatricians to enter what had by now become known as the speciality of Community Paediatrics .

In 2002 RCPCH published "Strengthening the Care of Children in the Community" following a review by Professor Alan Craft. He outlined the following principles

  • The service will be provided by a fully trained workforce
  • There must be a flexible and adaptable workforce working in a multidisciplinary environment
  • No paediatrician should work in isolation
  • Parents and children must have ready access to a knowledgeable paediatrician
  • The service must be provided as close to the child's home as feasible
  • The service must include a comprehensive locally-based community child health service aiming to promote child health as well as treating disease
  • When necessary, there must be a clear pathway from the local paediatrician to a tertiary specialist through managed networks
  • Each local area must ensure that it has a full range of skills available to deal with all aspects of paediatrics and child health, which are appropriate to be delivered locally.

In addition, in 2001 the RCPCH published "The Next Ten Years" which suggested a future paediatrician would need to be flexible and skilled in both the practice of paediatrics in a hospital setting and in the community. It also foresaw that the boundary between acute hospital and community-based work would become more permeable.

However, despite the attempts to build sustainable training and produce adequate numbers of CCH consultants, the number of consultants has always been fewer than required and in 2004 Dr Mary Mather's leader "Community Paediatrics in Crisis" in the Archives of Disease in Childhood 40 stimulated a robust debate, resulting in the publication in 2005 of "Community Child Health: the Future" 41 by BACCH which outlined the scope of services which should be available for children in the community from primary care through to tertiary services (see Annexe 2). This service outline from 2005 remains the specialty guideline for what should be in place across the UK. The CCH21 Project has sought to compare what is in place with this specification.


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