Backlog and virtual visits are impacting health checks

• Covid-19 has led to development checks being postponed or done virtually, raising concerns about ‘invisible children’ and conditions being missed.
• No evidence that doing checks over the phone or virtually is ‘effective’.
• The pandemic has also impacted NHS dentistry, with many children unable to get their teeth checked.

The coronavirus pandemic has created a backlog of children’s developmental checks, and with the move away from face-to-face health visiting and GP appointments, there are concerns children will slip through the net.

Under the Healthy Child programme, all children in England should receive five mandated health visits and checks in their first two-and-a-half years. The aim of these is to identify health risks, the need for extra support and children’s broader development.

However, during lockdowns, some children missed development checks and were not seen by a health visitor due to a lack of PPE and the workforce being redeployed. This is on top of a historical shortage of health visitors and high staff turnover.

A University College London survey last year of 663 health visitors in England found that 41 per cent had between six and 50 team members redeployed from 19 March to 3 June, which the Royal College of Paediatrics and Child Health said should ‘never be allowed to happen again’.

The NSPCC, a member of the First 1001 Days Movement, said it was concerned about checks being missed and ‘hidden harms’. It pointed to official figures published in July that showed a steep rise in serious injuries or death in babies due to abuse or neglect during the pandemic.

The statistics revealed a 27 per cent annual increase – from 224 to 285 – in serious child-related incidents reported by councils between April and September 2020. The largest increases were seen in young children.

Parents whose children have missed development checks are urged to get in touch with their health visitor and/or GP.

Where checks were put on hold, there is now a backlog.

Nursery World can exclusively reveal that in parts of Essex, health visitors are working overtime to try to get through the backlog of 9-12 month checks.

Health visitor checks there are carried out under The Essex Child and Family Well-being Service, provided by Virgin Care in partnership with Barnardo’s, on behalf of the County Council.

Virtual checks

The county is continuing with virtual health visitor appointments like many areas across the country – a move that has attracted wide criticism.

Home-Start, a network of volunteers that supports families with young children through challenging times, said parents, staff and health visitors believed the move to bring some services online has failed to meet the needs of families.

Head of policy Becky Saunders explained, ‘The use of virtual appointments has meant parents have been unable to build up a relationship with their health visitor. The absence of a home visit means parents have been less likely to open up about any difficulties, while health visitors haven’t been able to identify developmental issues or safeguarding concerns so easily.’

A report by the non-profit organisation found that only one in ten parents of babies under the age of two saw a health visitor face-to-face last year. A total of 5,474 parents were surveyed for Babies in Lockdown between April and June 2020.

The number of referrals to Home-Start has fallen, meaning issues such as development delay may not be picked up early and support treatment started, warned Ms Saunders.

According to the Institute of Health Visiting (iHV), there is no evidence that carrying out reviews virtually or over the phone is effective. Health visitors surveyed by the iHV reported a rise in speech/communication delay among children, along with widening inequalities and increased safeguarding risks, since the change to how appointments are carried out.

The Institute told Nursery World that in some parts of the country, parents have just been sent the Ages and Stages Questionnaire (ASQ) through the post and not had a video or telephone call arranged for their child’s development check. Health visitors are prioritising children who score below a certain threshold, a method the institute called ‘flawed’, particularly as the ASQ has ‘low sensitivity’, meaning that it ‘misses children’.

According to the iHV, the questionnaire, which should be used as part of the health review, is not validated for use as a screening tool in the UK. The ASQ was originally introduced as a population measure to be part of a holistic face-to-face clinical assessment of health and development completed by a health visitor.

iHV executive director Alison Morton said, ‘Parents have faced a postcode lottery of health visiting support during the pandemic. Some services have carried on as normal; however, many children have missed out on important reviews or received these assessments using a video or telephone call, or just a questionnaire through the post.

‘There is currently no evidence on whether non-face-to-face reviews are effective, and serious concerns have been raised that children with developmental delay or vulnerability will be missed as it’s harder to spot the signs when children are not seen. We share the concerns raised by health visitors and parents that they are now being routinely introduced in some areas as a way to cut costs without consideration of whether they are safe or effective.’

Public Health England (PHE)’s chief nurse, Viv Bennett, explained, ‘Services are now working hard to catch up on reviews to see how babies are developing, and to support families to give every child the best start in life. The decision on how and where the checks take place will depend on local healthcare providers.’

There are no up-to-date figures on child development checks at six weeks, 9-12 months and at age two. The most recent figures were published by PHE before the pandemic in 2019.

PHE suspended its data collection in April 2020 so as not to ‘divert efforts from local Covid-19 planning and response’. It has now restarted collecting data for 2020-21, which will be published later this year.

The iHV said it would take time before the full extent of missed developmental delay, childhood conditions, safeguarding concerns or risk factors became evident.

As part of the First 1001 Days Movement, the NSPCC is urging the Government to invest more in the health visiting service and to ensure that babies and their parents are not forgotten in the Covid recovery plan.

The charity’s Fight for a Fair Start campaign – www.nspcc.org.uk/fair-start – calls upon the Government to rebuild the health visiting workforce in order to better support babies and their parents. It comes ahead of the Spending Review this autumn.

Vicky Nevin, the NSPCC’s senior policy and public affairs officer, said, ‘We want the Government to “urgently” rebuild the health visiting workforce so that all eligible families get a minimum of five mandated checks, delivered face-to-face by a consistent professional. With the upcoming changes to NHS structures and responsibility for children’s public health moving to the new Office for Health Promotion, now is the time to invest in delivering the Healthy Child Programme across the country.’ There are also concerns the Covid-19 pandemic will leave a legacy of poor oral health in children as dentists continue to turn away new NHS patients.

CASE STUDY

A first-time mum from London spoke to Nursery World about her and her partner’s experience of their daughter’s 9-12 month check.

She said, ‘We weren’t aware our daughter needed to attend the virtual 9-12 month check, so when the health visitor called, she was napping. Because she hadn’t seen my daughter, she said we had to come in person for her to be checked and weighed. I have no idea why we had the virtual appointment to begin with.

‘During the video call, we went through the Ages and Stages Questionnaire, looking at what skills my daughter has. At the end, the health visitor said she was “on target” for everything except for walking, where she was behind; however, she said that “when she learns to walk, it will be fine”. The whole experience was totally pointless!’

Oral health concerns

Since re-opening in June, dental practices across England have stopped taking on new NHS patients because of a backlog of routine appointments. At the height of the pandemic, the majority of practices were forced to close, meaning that patients could not attend for their routine checks.

The areas affected include York, central Bristol, Norfolk, Cumbria, Mid Sussex, parts of London, Essex and Hertfordshire.

This has left parents with children born during the pandemic or those who have moved struggling to get their children’s teeth checked.

Gemma Pudney, manager of Rascals Day Nursery in Gorleston, Norfolk, which has implemented an oral health programme within the setting, said she had been unable to get her one-year-old son registered at a dentist.

She told Nursery World she was hoping he could be seen when she went to her dental practice for a routine appointment, but was told that would not be possible.

The issue was highlighted in a report by Healthwatch in May, which said, ‘Some parents couldn’t access timely care for their young children, including babies who are teething.’

The consumer champion for health and social care found that some people could not get onto an NHS waiting list, and for those who could or were already a patient, the wait for an appointment varied between a few months and three years.

Due to additional Covid precautions, dentists are also unable to see as many patients as they normally would.

Dentists in England must now allow a ‘fallow period’ of 60 minutes after any procedure that might generate aerosol particles, such as using a drill.

Last year, the Local Government Association warned of an ‘epidemic of tooth decay on the horizon’ after lockdown.

The association said that with reports of children under five doing more snacking in their households during the lockdowns, the ‘nation’s poor record on oral hygiene is likely to have worsened’.

‘Real-term’ cuts

Figures show that tooth decay in five-year-olds has been rising in the past decade in the UK.

The Association of Dental Groups, which represents practices across the country, has raised concerns that many children had stopped going to the dentist or were unable to get appointments during lockdown, and over the interruption to community oral health programmes.

Its clinical director, Dr Sandra White, said, ‘For the last five years, NHS dental budgets have not risen with inflation – representing a real-terms cut in provision. Unless new services are commissioned, current contracts simply won’t meet all needs. Following Brexit, many providers now face a serious challenge in recruiting enough dentists to deliver NHS treatment across the country.

‘The problems are particularly acute in coastal and rural areas, as well as more deprived urban areas.’ Dr White added that nurseries could ‘play an important role in preventing dental decay’ through ‘healthy eating choices and supervised toothbrushing schemes’.

An NHS spokesperson said, ‘Dentists have been prioritising treatment for children and patients in urgent need, in part through the rapid establishment of 600 urgent dental centres across England - with millions of people getting the care they need throughout the pandemic.

‘Services are open and have been back at pre-pandemic levels since December and anyone with concerns about their dental health should contact their local dentist as they usually would or seek advice from NHS 111.’

CASE STUDY

Nursery toothbrushing scheme

Rascals Day Nursery in Norfolk said its toothbrushing scheme, which it started in March, has had a positive effect upon the oral health of its three- to four-year-olds.

The nursery implemented the Healthy Smiles public health programme within the setting after becoming aware of the difficulty parents in Norfolk face finding an NHS dentist for their children, a problem that has become more acute since Covid.

Nursery manager Gemma Pudney said, ‘Lots of our parents have been unable to get an NHS space for their child at a dentist. It is a real problem in Norfolk.

‘We are in a vulnerable area so paying for private dental care is not an option for many families.'

As the setting introduced the programme at the height of the pandemic - when children could only engage in dry brushing - extra safety measures were also taken, including staff wearing PPE and additional handwashing.

‘We’ve had brilliant results from the programme. Parents now report that their children are happy to clean their teeth at home and they no longer face a battle getting them to do so,’ said the nursery manager.

She added that over the years, some of the children in her care have had poor oral health and have needed ‘work done on their teeth’.

‘We’ve found that a lot of parents don’t realise you should take your child to the dentist as soon as they have teeth. They often wait until they are toddlers and then struggle to get their children seen. This means, many children have not had their teeth checked before starting school.’

FURTHER INFORMATION

Healthwatch: Dentistry during Covid-19 insight briefing