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

Conclusions

This report set out to evaluate the extent to which child health reviews as part of the UHVP are being delivered and, in addition, whether the delivery of these reviews differed by either health board area or levels of deprivation. To address this, relevant information was compiled about the child health reviews carried out in Scotland for children born between 1 January 2011 and 31 March 2019. This report describes the births in Scotland over this period, the child health reviews that took place, how the reviews were conducted, and the measures used for identifying concerns for children's expected development.

The report aimed to answer the following research questions:

1. What is the extent to which the universal child health review elements of the pathway are being delivered, the equity of these contacts, and the extent to which this varies by health board?

2. What is the extent to which child and family needs are being identified in a timely manner?

The findings of this report in relation to these two questions are summarized below. This will be followed by a discussion of the implications of these findings for health visiting policy in Scotland, and the limitations of these conclusions.

What is the extent to which the universal child health review elements of the pathway are being delivered, the equity of these contacts, and the extent to which this varies by health board?

Delivery of the Programme

Overall, for the three more established reviews (first visit, 6-8 week review and 27-30 month review), coverage is high at over 90%. Average monthly coverage of 98% is recorded for the first review (aged 11-14 days), 93% for the 6-8 week review, and 91% for the 27-30 month review. Two reviews (13-15 month and 4-5 year) were introduced through the UHVP which published in 2015. Coverage for these two reviews is lower initially, as Boards began to roll out the UHVP, but coverage increases over time. The 13-15 month review increased coverage over the initial years of implementation to 91.4% for birth cohort September 2018 (the latest point in the data extracted where children would be eligible for the review). The coverage of the 4-5 year review increased to 63.5% to birth cohort March 2015 (the latest point in the data extracted where children would be eligible for review). However, the 4-5 year reviews relate to an earlier introduction by some health boards only (see Supplementary Table 1), which explains the relatively low coverage in comparison to the other more established reviews. The Phase 2 report will be able to provide a more detailed overview of the implementation of this visit.

The review data also showed evidence of seasonal variations, with consistently lower coverage in December/January over the winter festive period.

In relation to SIMD quintile, at the first visit there was no significant difference in coverage across SIMD quintiles.

At the 6-8 week visit, coverage in the most deprived areas is 3.8 percentage points different, on average, compared to the least deprived areas, with generally the highest coverage in the least deprived areas, and lowest coverage in the most deprived areas.

Referring to PHS published data on coverage of the 27-30 month review for reviews conducted between 2013/14 and 2018/19, coverage in 2013/14 was slightly higher for children in the least deprived quintile, however, in the following five years coverage among all SIMD quintiles slightly increased and no differences could be seen between quintiles.

In the 4-5 year review coverage, published in the PHS data for the two years covered by this report show no discernible pattern between SIMD groups.

Context of reviews

The context of how reviews were delivered was also examined. Both the location and health care professional conducting the review were explored. This evaluated the extent to which the UHVP guidance has been implemented - that where possible, child health reviews should be carried out in a child's home, and by a qualified health visitor – these conditions were met across the reviews.

Location

The available location data shows that for all reviews, the percentage carried out in the child's home has increased year on year. By 2018/19, 97.7% of first reviews, 87.6% of 6-8 week reviews, 67.6% of 13-15 month reviews, 54.5% of 27-30 month reviews, and 45.2% of the 4-5 year reviews were carried out in the child's home. Therefore, the UHVP guidance for carrying out reviews in the child's home is being met for most children in the earlier reviews, but for many children in 2018/19 this key element of the UHVP policy had still not been achieved for the three later reviews, which were also being delivered in a clinic or GP practice.

Practitioner

Guidance states that UHVP reviews should be carried out by a qualified health visitor. While predominantly child health reviews are carried out by one practitioner, occasionally more than one practitioner was present at the reviews. For example, a health visitor and a GP, staff nurse, nursery nurse, student health visitor or family support worker might be present. Similar to the location findings, the practitioner(s) present could not be recorded from the beginning of the study period for the first visit; the field was introduced on the first visit form in February 2016.

Based on the available data, however, by 2018/19, 95.9% of first reviews, 91.0% of 6-8 week reviews, 76.3% of the 13-15 month reviews, 77.8% of 27-30 month reviews and 90.0% of 4-5 year reviews were conducted by a qualified health visitor. The presence of other practitioners was generally lower in the more recent years of reviews. This indicates that for the majority of children the guidance is being followed and these reviews are being conducted by a qualified health visitor.

Development tools

In 2015 UHVP recommended that the Ages and Stage Questionnaire (ASQ) be used to assess children's development in the 13-15 month, 27-30 month and 4-5 year reviews. Prior to the UHVP being published, a range of tools were recommended in the clinical guidance and used for the 27-30 month review. This legacy resulted in a mixture of tools still being used in 2018/19 to assess children's development, with health visitors being encouraged to use professional judgement and continue to use additional tools to assess specific domains in more depth if required.

By 2018/19, the ASQ was used in 86.0% of 13-15 month reviews, 65.3% of 27-30 month reviews and 68.8% of 4-5 year reviews. In NHS Greater Glasgow & Clyde (GGC), the largest health board, 13-15 month and 4-5 year reviews had not been introduced by March 2019, nor was the ASQ used in the 27-30 month review. The ASQ was used in 87.0% of 27-30 month reviews that were delivered in the other health boards in the financial year 2018/19. The use of the ASQ-SE, alongside the ASQ, had also increased in more recent years, whilst the use of alternative measures was reduced in reviews in later years.

Therefore, although the ASQ has been used in more reviews, there are still many reviews (for example, more than 17,800 for the 27-30 month review) in which this standardised tool, recommended by the UHVP, was not being used routinely in 2018/19.

Health Plan Indicator (HPI)

Following the introduction of the UHVP, there are two HPI scores (together with unknown) that can be assigned to a child following their child health review:

• core, when the child only requires the core contact from professional services; and
• additional, when a child requires sustained additional input from professional services to support the family and child so that the child can reach their full health or development potential; and
• unknown, when the health visitor has not had adequate opportunity to make an assessment.

In reviews that took place between 1 January 2011 and 31 January 2016 prior to the introduction of the UHVP, a third category was also used: intensive. This category was no longer used after the introduction of the UHVP.

The percentage of children with an additional HPI status after the first and 6-8 week visits declined in the more recent years. In the first visit, the percentage of children with unknown HPI increased steadily over the eight-year period, from almost 17% in 2011/12 to over 29% in 2018/19; however, for the 6-8 week visit, there was no discernable pattern. For the other reviews, the percentage of children with an additional HPI status was similar to that allocated in the 6-8 week visit, although it should be recalled that the 13-15 month and 4-5 year reviews had been recently introduced and thus had been delivered to fewer children.

What is the extent to which child and family needs are being identified in a timely manner?

The evaluation was able to explore the extent to which developmental concerns were recorded at each review. Developmental concerns were not included in the first review form, but a developmental concern was recorded for around 2.5% children at the 6-8 week review, over the 8 years of the study period.

At the 13-15 month review, newly introduced in 2017 as part of the UHVP, a new concern was recorded for on average 10% of children, of whom only 0.02% were recorded as having a previous developmental concern. This is important because this 10% of children would potentially not previously have had a development assessment at this point which may have made it more difficult for health visitors to reliably assess and detect developmental concerns at this earlier stage. Previously the 27-30 month review would have been the point at which concerns would have been assessed. This could have led to a delay in the offer of additional support and guidance from health visitors.

At the 27-30 month review, a new developmental concern was recorded for on average 14.4% of children. Overall, 4.5% of children show as having a previous concern recorded. However, at the 27-30 month review 13% of children with a new concern have no previous concern noted and only 1% of these children with a concern at 27-30 month have a previous concern noted in a different domain.

At the 4-5 year review, on average 6.7% of children have a new developmental concern recorded. Overall, 4.2% of children show as having a previous concern recorded. However, at the 4-5 year review 5.8% of children with a new concern have no previous concerns noted and only 0.9% of these occurring for children with a previous concern noted in a different developmental domain. This demonstrates that new developmental concerns are being picked up by health visitors at all the reviews, which identifies children that may need a referral or additional support to achieve their developmental potential.

Overall the introduction of the 13-15 month review would indicate that this offers an opportunity for health visitors to pick up concerns about children at an earlier development stage than prior to the introduction of the UHVP. Additionally, the 4-5 year review also appears to be picking up additional concerns, albeit fewer new concerns.

Policy relevant findings and implications

This report has found that for all reviews which were offered to all children under the UHVP, coverage in more recent years is high. When reviews have been introduced, coverage has taken time to increase, demonstrating the need for the 'bedding in' of the revised programme. Evidence from later years confirms that the child health review elements of the UHVP are being delivered to most children in Scotland in a timely manner.

This report also concluded that the majority of recent reviews have been undertaken in children's homes and by qualified health visitors. Under UHVP guidance it is stipulated that child health reviews should be carried out where possible in the child's home and by a qualified health visitor. This report demonstrates that this aim has increasingly been met in successive years since UHVP began. However, there are still some children for whom this is not the case. To ensure that reviews are delivered as set out in UHVP to all children in Scotland, the reason why some reviews are still not carried out this way should be investigated.

A further aim of UHVP was to identify children and families that may require additional support, but who might be missed in early reviews, as the signs are not apparent until the later stages of development, when children are older. This report has demonstrated that new concerns are being identified in the newly introduced reviews at 13-15 months and 4-5 years. A large proportion of these new concerns are raised for children who previously were not identified as having an area of developmental concern. This implies that the later reviews under the UHVP are picking up children who may have been missed by the previous health visiting provision. It would appear that the extension of UHVP may be achieving its aim of identifying these children who might otherwise have their developmental support needs missed, although the situation may be clearer at the end of Phase 2, when the UHVP has been implemented for longer by all health boards.