clinical management where medicine meets management

Published: 05/02/2004, Volume II4, No. 5891 Page 28 29

With mounting concern over the relevance of certain tests for babies, a royal college report is calling for a streamlined programme - which could be at odds with the government line, writes Carol Lewis

There is an oft-quoted maxim in healthcare which goes something like, 'Those who need help the most are the ones least likely to seek it.' This is never truer than in child health surveillance. One in 10 mothers from the most deprived areas fail to take their baby for its six to eight-week check, one in four does not attend the 22 to 24-month check and more than one in three do not bother with the 39 to 42-month check.

But while these absent mothers may be missing out on vital health promotion and immunisations for their children, many of the routine developmental tests carried out at the baby clinics frequented by affluent mothers do not stand up to scientific scrutiny.

In a bid to change this, the Royal College of Paediatrics and Child Health's fourth working group on child health surveillance has recommended that a new core screening and health promotion programme should be adopted. This, it is hoped, will leave professionals more time to help those mothers and children most in need. The proposals are in the report Health For All Children, referred to as 'Hall4' after the group's chair Sir David Hall, professor of community paediatrics in Sheffield University.

The core programme advocates an end to one-off tests for specific disorders and which are not backed by scientific evidence in favour of ongoing assessment and health promotion. This is a philosophy with which few could disagree.Yet many children's services are inundated by proposals and are waiting for the national service framework to see how initiatives - including the Laming and Kennedy reports, the green paper Every Child Matters, the chief medical officer's public health agenda, the new general medical services contract for GPs and Hall4 - will fit together.

Under the Hall4 proposals, family health plans are drawn up for each child. Depending on the circumstances these plans may recommend a number of options: the core programme with no additional input; the core programme plus extra support from the community team; or, for those families most in need of help, the core programme together with intensive help from several agencies.

The core programme is complemented by recommendations for more joint working between health professionals and parents, greater team working between agencies and more community outreach to promote early identification and referral for those children suspected of having problems.

One of the report's editors, Dr David Elliman, consultant in community health at Great Ormond Street Hospital in London, says the core programme means dropping ineffective routine screening tests and reducing duplication in favour of more targeted time for families who need it.

For example, the core programme does not include a routine developmental check for babies at nine months.

In the past, the distraction hearing test was carried out at nine months, but gradually this is being replaced - budgets allowing - by neonatal screening.However, in some areas the check has been kept, without the hearing test, because it is popular with some mothers. This is a waste of scarce NHS resources, argues Dr Elliman.

In addition, some face-to-face checks could be substituted with phone calls or letters, he says, with follow-up consultations for those parents with concerns.

However, Community Practitioners and Health Visitors'Association lead professional officer Obi Amadi fears some primary care trusts may be using the core programme idea as an excuse to cut services. She stresses that although some tests like the distraction hearing test may have gone, health visitors are still expected to assess children's hearing throughout the early years. 'It is about providing a universal service rather than a uniform one.

It is about replacing set tests with continual assessment.

This is getting lost in some areas, ' she says.

In Scotland a draft national implementation plan is currently out for consultation.Meanwhile, in England and Wales some PCTs have begun implementation, while others are waiting for the national service framework - it is widely expected that the proposals will be included in the framework and as such may attract funding. This is vital for PCTs hit by staff shortages and tight budgets.

Child Growth Foundation honorary secretary Tam Fry foresees a clash between the chief medical officer's call for greater monitoring and data collection by public health doctors on children's body mass index (BMI) to tackle obesity, and Hall4's streamlined core programme with just one BMI check during a child's lifetime. According to Mr Fry, by insisting on published randomised controlled trials to support tests, Hall4 has gone too far. 'Because there hasn't been a randomised controlled trial to show you need to measure children's height to monitor growth, regular height measurements have been eliminated. There hasn't been a trial because It is obvious.'

Yet some PCTs are hoping to work around these problems and adapt Hall4. This includes Brent PCT, where project coordinator for children's services Ann Laungani says that she plans to adapt Hall4 in consultation with parents and health professionals to fit the needs of parents and national recommendations. This will be accompanied by an assessment of staff training needs and recruitment of professionals needed to carry out the programme. It is hoped that an implementation plan will be approved by the professional executive committee in March.

Ms Laungani says: 'We have more children at risk, with social exclusion and mental health problems, than perhaps elsewhere. So, for instance, an additional check at about two or two and a half years might be beneficial.

We will need to look at the evidence base and consult with local parents before we decide exactly what form the core programme will take.'

A similar approach of local consultation is being taken in Oxfordshire, where the clinical directors at the five PCTs have just agreed to a countywide Hall4 implementation programme to start on 1 April. Oxford City PCT senior manager for children's services Caro Fickling explains that by drawing up a framework for the whole of Oxfordshire they aim to ensure continuity and communication across the PCTs.

'We have been developing strategies around targeting services more effectively via self-referral, opportunistic assessment and community-based work.We have been trying to look creatively at the ways in which we can bring services into the community, including more clinics in schools and better links with nursery groups.

'It is quite a challenging agenda to make sure that we do not lose what works well while broadening our reach to those who haven't benefited from the service as well as they might in the past, ' explains Ms Fickling.

Further information

Health For All Children (4th edition) by David Hall and David Elliman. Oxford University Press.£17.95 www. health-for-all-children. co. uk

Scottish implementation guidance and consultation www. scotland. gov. uk/consultations/health/hfac-00. asp

Key points

This is a year of change for children's services, with reports, proposals and new clinical guidelines.

Some primary care trusts have been accused of using the focus on the core programme as a way of cutting services.

A royal college report may clash with the imminent national service framework.