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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

About 1 in 4 children in England may be missing their 2-2½ year development check. Research found that children from deprived backgrounds, and those in local authority care, were less likely than other children to have these checks recorded.

This study looked at all contact with health visitors, including other assessments and counselling. It found that children from deprived backgrounds had most face-to-face contact with health visitors, but were least likely to have a development check recorded. The researchers say it is possible that the children had the development check, but that it was not recorded.

The importance of early years development is well-known. The Healthy Child Programme in England states that all children aged 2-2½ should have a health check by the health visiting team. Not all children receive these checks, and, before this study, it was not known whether certain groups are more likely to miss out.

This research was based on data from 2018-2019 gathered by NHS Digital from English local authorities. The quality of the data is still being evaluated, but the researchers call for NHS Digital and government partners to improve its quality. This would allow researchers to look at why certain groups of children are not receiving health checks and help policymakers address the reasons.

More information on development reviews is available on the NHS website.

What’s the issue?

Children who are developmentally behind their peers when they start school, struggle to catch up by the time they are 16. Their whole lives may be affected. Identifying these children at age 2-3 means they and their families can be offered extra support, to help them start school on a level footing with other children.

The Healthy Child Programme in England states that all 2-2½ year olds should have a development review. This is usually carried out by a health visitor (specialist nurse) or another member of the health visiting team. The review assesses a child’s readiness to learn, and their physical, social and emotional development. It identifies any need for additional support.

In 2020 the Children’s Commissioner found that most local authorities do not have data on whether children in their care have received their 2-2½ year review. Research suggests that these vulnerable children are more likely than others to miss out on reviews.

The researchers explored which groups of children were least likely to receive the review. They looked at whether children who did not have a review had other contact with health visitors (other assessments, counselling, or support).

What’s new?

The study was based on NHS Digital data. It included 181,000 children in the 33 (of 152) local authorities in England for which data was sufficient. Researchers looked at whether children's ethnicity and deprivation influenced their chance of receiving a health check.

They also looked at the influence of vulnerability (children in care, for example). Only 13 local authorities had enough data on whether children were in care.

The study found that, overall, 3 in 4 (74%) children had a 2-2½ year health review. In addition:

  • slightly fewer children from the most deprived backgrounds (72%) had a check recorded than those from the least deprived backgrounds (78%)
  • in the 13 local authorities with sufficient data, children in care were much less likely to have a check recorded (44%) than other children (69%)
  • when other contact with health visitors (including letters and phone calls) was included, children from the most deprived backgrounds had more contacts (80%) than children from the least deprived (78%); children in care had a similar number of contacts to other children.

Ethnicity did not appear to make a difference to the chance of receiving a 2-2½ year health check.

The researchers noted that, overall, 1 in 4 (24%) children had no record of either a review or other face-to-face contact with the health visiting team when they were 2-3 years old. Slightly more (29%) children in care had no record of any contact with health visitors in the same period. Researchers could not tell from the data whether children were seeing other professionals or were ‘invisible’ to services.

Why is this important?

This is the first study to investigate health checks alongside other contacts with health visiting teams. It suggests that some children with the highest needs (deprived or in care) may be seeing health visitors but not receiving their development check. The researchers say too much data was missing for them to draw firm conclusions.

Many vulnerable children had no record of any health check or contact with health visitors. The researchers say this is concerning, given the likelihood of health and welfare needs in these children.

The study highlights issues with national health visiting data held by NHS Digital (Community Services Dataset). The researchers say that data held by local authorities seems to be more complete. This suggests that data may be lost as information is pulled together into the community services dataset.

What’s next?

The research team call for improvements to the data “as a matter of urgency”. Better data on which children have had checks, and the reasons why others have not, would give policymakers a better understanding of what is happening. This information could drive recommendations.

Health visiting aims to protect all children and promote child and family health. But without additional resources and without sufficient staff, health visiting teams may need to find new ways of working. For example, they may need to carry out health reviews in different settings, such as pre-schools. Or they may need to prioritise certain groups. More research is needed to identify these groups and test new ways of working.

The children in this study were similar to the general population in their levels of deprivation but were less ethnically diverse. Further research could explore in more detail whether ethnicity influences health checks.

You may be interested to read

This summary is based on: Fraser C, Harron K, Barlow J and others. Variation in health visiting contacts for children in England: cross- sectional analysis of the 2-2½ year review using administrative data (Community Services Dataset, CSDS). BMJ Open 2022;12:e053884.

Earlier research from the same team: Woodman, J and others. “Which children in England see the health visiting team and how often?” Journal of Health Visiting 2021;9:7:282-284.

How to help children who have had adverse experiences: Woodman J, Mc Grath-Lone L, Clery A, and others. Study protocol: a mixed-methods study to evaluate which health visiting models in England are most promising for mitigating the harms of adverse childhood experiences. BMJ Open 2022; 12:e066880.

Funding: This research was funded by the NIHR Policy Research programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.

NIHR Evidence is covered by the creative commons, CC-BY licence. Written content may be freely reproduced provided that suitable acknowledgement is made. Note, this license excludes comments made by third parties, audiovisual content, and linked content on other websites.

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