We have used routinely available consultation data to explore GPs’ contribution to the preventive care of pre-school children, and to examine the impact of the changes to the child health surveillance system that were implemented in Scotland from 2005.
Prior to the changes to the CHS system, GPs made a substantial contribution to the provision of child health reviews, particularly those offered at 6–8
weeks and 8–9
months (and to a lesser extent 39–42
months) of age. Following the changes, GPs have continued their involvement in the 6–8
week review but provision of other standard reviews has essentially ceased. This finding is broadly in line with what would have been expected from the policy recommendations, although it is worth noting that policy is by no means always implemented as intended [16
]. Our findings also show that, since 2005, GPs have had minimal involvement in provision of the selective 24
month review. This is perhaps not surprising as GPs historically had little involvement with the universally provided 21–24
month review, but it does suggest that GPs now have minimal input into proactively assessing children’s development after early infancy.
Despite extensive code lists, relatively few additional (non-child health review) GP consultations with pre-school children for other aspects of preventive care were identified. Changes over time in the number of GP consultations involving childhood immunisations appear to reflect occasional changes in GP provision of routine immunisations in individual practices rather than any specific effect of the changes to the CHS system on GP involvement in this aspect of children’s care. Consultations coded as involving child protection were noticeably rare, particularly in light of evidence that unhelpful parenting, neglect, and abuse are very common and have serious implications for children’s outcomes [18
]. In general, changes to the CHS system appear to have had minimal, if any, impact on GPs’ provision of these wider aspects of preventive child health care. In particular, there is no evidence that withdrawal of ‘routine’ child health reviews has led to an increase in the number of non-child health review consultations for pre-school children that are focused on preventive care. Our results cannot comment on whether or how the characteristics of pre-school children receiving preventive consultations have changed over time however.
This study involved 30 practices from across Scotland that together serve over 11,000 pre-school children. The PTI information system is well established and subject to ongoing data quality assurance procedures [15
]. PTI practices are asked to code all the clinical findings/activity relevant to each consultation as precisely as possible using as many Read codes as necessary and GPs usually assign the Read codes themselves during the course of their consultations. The Read code lists used in this analysis were carefully specified to reflect the range of preventive child health care that GPs may be involved in and all recorded codes were included in the analysis. The codes assigned to a consultation will be those considered necessary by a GP for safe and effective care hence may not reflect all aspects of the consultation. It is likely that some opportunistic health promotion activity will not have been recorded and therefore not reflected in this analysis. Consultations that had provision of preventive care as a substantive component should have been identified however and the trends (or lack of them) identified are likely to be genuine.
This study has specifically examined changes over time in the preventive care delivered to pre-school children by GPs. Preventive health care provided by GPs is only one element of the complex system of services that aims to protect and promote young children’s health and development however, with Health Visitor and early education/childcare services amongst others also being important. A separate national information system, Child Health Surveillance Programme – Pre School (CHSP-PS) collects information on completed child health reviews from Health Visitors but this system does not record information on all contacts between HVs and young children [14
]. The PTI system did collect information on all Health Visitor consultations with the practices’ patients from 2003/04 but this data collection stopped in 2005/06 hence PTI data cannot provide information on how the totality of HV consultations with pre-school children changed after the changes to the CHS system [15
It is known from the CHSP-PS data that HVs also ceased universal provision of child health reviews after 6–8
weeks after implementation of the 2005 policy [14
], hence our results reflect a genuine withdrawal of these later universal reviews rather than just a shift in their delivery from GPs to HVs. Since implementation of the revised CHS system, HVs have provided the selective 24
month review to around 25% of children, although GPs have had minimal involvement in this review as noted above.
The changes to the Scottish CHS system were explicitly designed to free up existing HV time to focus available resources on children most in need of preventive care. The lack of data on care apart from routine child health reviews provided by Health Visitors means that the overall impact of the changes to the CHS system on the amount, content, and distribution of HV care (and how this relates to changes in GP provision of preventive care) therefore cannot be directly assessed. Some local areas are starting to use electronic HV case record systems which may in time make more detailed analysis of HV activity, and hence a more complete assessment of the preventive care provided to young children, feasible.
The configuration of the child health surveillance system has been the subject of longstanding debate [5
]. The question of how many universal reviews are required, and at which ages, to form an effective and efficient service through which to reliably deliver early identification of health and developmental problems and provide universally relevant health promotion advice and parenting support, and from which to target additional support to families most in need, continues to exercise policy makers. Some elements of the child health programme (for example neonatal hearing screening, immunisation, and certain aspects of the CHS reviews such as provision of advice on reducing the risk of sudden infant death syndrome) are supported by high quality evidence, but in general robust evidence that directly answers detailed service organisation questions is lacking. The HFAC reports are therefore explicitly based on drawing together multiple stands of different types of evidence along with consensus professional opinion to provide the best possible recommendations given the evidence available. It is notable that the revised CHS system implemented in Scotland from 2005 onwards has delivered a considerably reduced schedule of pre-school child health reviews compared to that recommended in HFAC4.
This study did not set out to investigate the impact of the changes to the CHS system on young children’s outcomes although ultimately securing equitable positive health and developmental outcomes for children is the goal of the preventive care system. There is some evidence that the changes to the Scottish CHS system implemented from 2005 have compromised the early detection of some developmental problems. An audit in one NHS Board area suggested that the age of children referred to speech and language therapy increased considerably after the changes, and a separate pilot project looking at reinstating universal developmental reviews for toddlers found a large number of children with previously undetected developmental delays [20
]. This evidence is clearly limited (and it is not possible to comment on whether changes in GP provided care have made a specific contribution to the changes seen) but comprehensive data on the detection of childhood developmental problems are lacking, making more definitive assessments difficult. Nevertheless, in response to concerns about the impact of the CHS changes on the overall functioning of the preventive care system, the Scottish Government has recently recommended the introduction of a new 24–30
month child health review for all children, although this is yet to be fully implemented [21