Universal Health Visiting Pathway evaluation: phase 1 report - routine data analysis - implementation and delivery

Methods

Child health reviews

The Universal Health Visiting Pathway home visit schedule offers eleven home visits to all families in Scotland, eight of which occur in the first year of life. This report focuses on the implementation and delivery of the five visits that include universally offered formal child health reviews (CHRs), where nationally collected data are available from the Child Health Surveillance Programme (CHSP). Health boards introduced reviews at different times; see Supplementary Table 1 in the Appendix for more information regarding which year each review was introduced in each health board.

First visit

This review should be delivered when the baby is 11-14 days old. However, it may be delayed (for example, for if a child is in neonatal care) and therefore some late reviews will be expected. The review is longstanding; data for this report have been provided from 1 January 2011 onwards.

6-8 week visit

This review should be provided by the time the baby has reached 12 weeks. However, note that this review is subject to gestational correction (i.e. children born prematurely – at less than 37 weeks gestation – are scheduled for review by their due date rather than their actual date of birth). Again, this review is longstanding and data for this report have been provided from 1 January 2011 onwards.

13-15 month review

This review should be delivered by the time the child is aged 18 months, although it is also subject to gestational correction (see above). The review should have been provided by health boards from 1 April 2017 (i.e. for children born from 1 April 2016 onwards); in practice, some health boards have implemented this review later than anticipated (i.e. after 1 April 2017). (See Supplementary Table 1 for information on when reviews were introduced in health boards.)

27-30 month review

This review should be provided by the time the child is aged 32 months (gestational correction is not required for this review). The review has been provided from 1 April 2013 (i.e. for children born from 1 January 2011 onwards).

4-5 year review

This review should be delivered after the child's 4^th birthday and before the child starts school (thus maximum age of child at review is 5.5 years). The review is not subject to gestational correction. Health board implementation of this review varied: whilst all children aged 4-5 years from April 2020 onwards (i.e. for children born from April 2016 onwards) should have received this review; in practice, some health boards implemented this review as early as April 2017 and other boards implemented it in 2020 (see Supplementary Table 1).

Data

Years of available data

In this report, nationally available data relating to the provision of child health reviews for the period from 1 January 2011 to 31 March 2019 have been used. January 2011 was selected as the start date of the evaluation, because children born in that month were the first group eligible to receive the 27-30 month contacts in April 2013.

Data sources

The source for all child health data included in this report is the Child Health Surveillance Programme – Pre-School (CHSP-PS); data were extracted in May 2020, from Public Health Scotland. The source for live births is the National Records of Scotland (NRS)^[5] data for live birth statutory registrations were also extracted in May 2020 from NRS.^[5]

Aggregate data have been used throughout this Phase 1 Process evaluation report. The birth data from NRS and the child health review data have not been linked, but have been compared for context and comparison

There are a number of limitations associated with this approach. For example, in the review coverage analyses, children who moved to Scotland after birth can subsequently appear in the numerator (i.e. 'number of children born in month X with a subsequent record of a review'), but are excluded from the denominator (i.e. 'number of live births in month X'); children who died or moved out of Scotland are not removed from the denominator; and children are assumed to remain in their birth board of residence until the date of their review. For example, a child living in Grampian at the time of their 27-30 month review is assumed to have been born in Grampian, and hence contributes to the birth cohort review coverage for Grampian. However, it is probable that these numerator/denominator mismatches balance out, and the estimates generated using an unlinked approach are likely to be reasonable.

The number of live births in specified quarters was taken from the National Records of Scotland (NRS) live birth registrations and was based on the date of birth, not the date of registration.

For analyses relating to the numbers of each review recorded and the coverage of each review, data are available for the whole of Scotland and for individual health boards; data are also stratified according to Scottish Index of Multiple Deprivation (SIMD) quintiles, based on the child's home postcode. For the 27-30 month review and the 4-5 year review, coverage will refer to the tables published by Public Health Scotland (PHS), which are based in the year in which the review was conducted and the residence of the child at that time. This is because by 27-30 months and 4-5 years, a substantial proportion of children had moved home, and this was not evenly distributed across the SIMD quintiles i.e. more children from the least deprived group moved than children in the most deprived group, which made the analysis based on birth cohorts of children inaccurate when findings were explored by SIMD group at these stages. Earlier reviews did not appear to be affected in the same way as families were largely residentially stable.

In order to try to align the live birth data (from NRS) with the child health data (without the data sets being linked) for the birth cohort analyses (i.e. the figures where the x-axis is 'month in which babies or children born') in a specific month, for the 13-15 month, 27-30 month, and 4-5 year reviews, the postcode at birth was used to derive the NHS health board of residence wherever possible. However, if this postcode was missing, then the postcode on the CHI in the quarter following birth was used instead, if available. This was not done for the first visit and the 6-8 week visit, as these take place so close to birth. For these first two visits, the postcode at the review was used first, and if this was missing, then the postcode at birth or postcode on CHI in the quarter following birth has been used.

For all the cross-sectional analyses (i.e. figures where the x-axis is 'number of reviews in a month or year'), the postcode at review has been used to derive the NHS health board of residence; if this is not available, the postcode on CHI is used for the later three reviews or the postcode at birth for the first two visits.

Child health surveillance review records

Child Health Surveillance Programme – Pre-School (CHSP-PS) national data have been used to explore delivery of each of the five universal child health reviews (see above) where national child surveillance data are collected. The CHSP-PS national information system supports delivery of child health reviews and some screening contacts for pre-school children. The system works by facilitating the invitation of children for reviews/contacts as they reach the appropriate age, and recording and reporting the outcomes of reviews/contacts.

Generally speaking, when a child is due for a child health review, the CHSP-PS system sends an invitation to the family and sends the appropriate review form to the relevant health professional (e.g. health visitor). In some instances, the health visiting team will arrange the appointment locally with the family. During the child's review, the health professional completes the form, which then provides a summary record of their discussion with the family as well as findings and actions required. A copy of the completed review form is returned to the relevant NHS health board's child health department, where administrative staff then key the information provided into the child's electronic CHSP-PS record. Any issues listed on the form are also "Read coded" at this stage. This allows any problems to be followed up and further reviews scheduled, if necessary.

Quarterly extracts are taken from the CHSP-PS system (in February, May, August, and November) and data transferred to the Information Services Division (ISD)^[6] for statistical analysis purposes until March 2020; data are now transferred to Public Health Scotland.

These data provide information on the extent to which the child health review elements of the programme have been implemented within each health board by:

• month and year
• reach of these contacts (including in terms of inequalities)
• information about delivery (e.g. which professionals are delivering contacts, where these take place, whether agreed developmental assessment tools are used as part of reviews).

In addition, data are recorded on the Health Plan Indicator (HPI) for each child (indicating level of ongoing need, see below), any concerns identified for the child or family (in particular, concerns about the child's development at 6-8 weeks, 13-15 months, 27-30 months, and 4-5 years), as well as plans for future support.

Descriptive statistical analyses

The analyses included in this report are all descriptive, with data presented graphically in the form of line graphs and bar charts, as most appropriate.

Coverage of child health reviews

In this section, coverage of each of the five formal child health reviews is examined from two perspectives:

1. the number of reviews provided by practitioners each month for Scotland; and

2. the percentage of children born in Scotland in each month who have been recorded as having received a review.

A strong emphasis exists throughout the UHVP policy documentation about the provision of services consistently to all families, together with an aim to reduce inequalities through early and appropriate intervention.^[3] These data are therefore explored separately by SIMD quintile. This enables assessment of the extent to which children from different deprivation groups are receiving the UHVP. The absolute difference in coverage that is, the coverage for children living in least deprived areas (SIMD 5) compared with the coverage for children living in most deprived areas (SIMD 1)) are calculated. The relative differences (coverage in SIMD 5 / coverage in SIMD 1) are also calculated, where appropriate.

Context of reviews

Key elements of the UHVP guidance states that the reviews should primarily take place in the family home, and be delivered by qualified health visitors.^3. This section of the process evaluation report explores the percentage of reviews that were undertaken in the child's home and delivered by a qualified health visitor.

Developmental assessment of children

A key aspect of the UHVP is the promotion of strong early child development (particularly social/emotional and language/cognitive development) within the family context.^[3] The universal approach to child development within the health visiting pathway includes routine development assessments using validated tools, at fixed time points for all children.

The UHVP specifies that the ASQ should be completed for all children as part of their 13-15 month, 27-30 month, and 4-5 year reviews (or at least that their parents should be offered the opportunity to complete it). Other validated measures of specific aspects of children's development may also be used as clinically indicated, and the guidance provides a list of approved measures and tools. Prior to the implementation of the UHVP, a variety of assessment tools were used across the Health Boards from an as part of the 27-30 month review. Therefore prior to 2016, data collected in relation to developmental concerns at the 27-30 months review was collated using a variety of assessment tools.

The extent to which ASQs (and other measures) have been used in the 13-15 month, 27-30 month, and 4-5 year developmental assessments is examined in this section.

To ensure that needs are being detected early, and children and families who require it receive additional timely and proportionate support, the HPI (health plan indicator, see below) allocated to a child, together with developmental concerns detected, are explored in Phase 1 of this evaluation. In addition, the levels of new developmental concerns raised are investigated at the relevant review points.

Health Plan Indicator (HPI)

The Health Plan Indicator was created in 2005, prior to the UHVP implementation, and at the 6-8 week review the health visitor would allocate the child a status to indicate whether the family required more frequent health visitor input, or no health visitor input, unless requested by the family. The HPI status was recorded on the CHSP-PS system. However, by 2010 concerns were raised that HPI allocation at 6-8 weeks was not being used effectively in identifying children with future difficulties, for example, that HPI was not being reassigned based on need on a continuous basis. This led to some children who later experienced developmental delay (for example, speech and language delay) not coming to the attention of health services in a timely manner to receive appropriate support.^[7]

In 2015, in the outline of the Universal Health Visiting Pathway,^[3] the HPI definition was redefined to include an emphasis on wider family health:

An additional HPI indicates that the child (and/or their carer) requires sustained (>3 months) additional input from professional services to help the child attain their health or development potential. Any services may be required such as additional HV support, parenting support, enhanced early learning and childcare, specialist medical input, etc.

At the end of each child health review, an updated HPI is requested. Until February 2016, there were three available HPI categories, plus 'unknown':

• 'core',
• 'additional' (see definiton in the paragraph immediately above),
• 'intensive' indicating the need for interagency input, and
• 'unknown', before the health visitor has had an adequate opportunity to assign an HPI.

From March 2016 it was recognised that both intensive and additional were actually definitions of situations in which a family had an additional need, so the categorisation was simplified to ensure that all additional needs were considered in a more holistic way when identifying any support needs of a family.