Healthy Child Wales Programme: 2021
Statistics and further analysis on the percentage of eligible children receiving health visitor contacts through the Healthy Child Wales Programme for 2021.
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Introduction
The Healthy Child Wales Programme (HCWP) specifies nine contacts with health professionals at set points in time for children in Wales aged between 10 days and 3.5 years. Local health boards should offer these contacts to all children in Wales.
This annual report provides summary statistics on the contacts children received through the HCWP in 2021. It also provides longer term trend analyses, using quarterly data that is already available on StatsWales.
Data is sourced from the National Community Child Health Database, hosted by Digital Health and Care Wales (DHCW).
Data for the HCWP is collected using a paper-based system, which limits the accuracy of the data collected. In particular this process affects the 6-week and 8-week contacts. Data collected is of sufficient quality to show the broad picture of the programme but is likely to slightly undercount the number of contacts which took place. More details on the programme and data source are available in the quality and methodology section.
The COVID-19 pandemic substantially impacted the programme in 2020, though the majority of contacts were carried out ‘as normal’ in 2021. Specific details on how the programme was affected in 2020 are provided in last year’s statistical release.
Main points
Following the impacts of the COVID-19 pandemic in 2020, the number of HCWP contacts recorded in 2021 recovered to numbers seen prior to the pandemic, with more than 203,000 occurring across Wales.
Of all the contacts which should have been offered to all children aged between 10 days and 3.5 years during the year, 78% were recorded as being completed. This was 12 percentage points higher than in 2020 and the highest percentage since the programme began.
Contact completion rates continue to vary widely between each contact point. During the year 94% of children aged 10-14 days had their first contact recorded, compared to 67% of children who were eligible for the 3.5 year contact.
While the percentage of contacts completed was the highest on record in 2021, the percentage decreased in the last two quarters of the year at most contact points.
Over 58,000 contacts which should have been offered were not recorded as taking place. In nearly 7 out of 10 of these cases there was no appointment recorded on the system; in nearly 2 out of 10 cases the reason for the non-contact had missing or invalid data; while in a little more than 1 out of 10 cases, an appointment was made but the child was not brought.
The majority of all contacts (73%) were made within the programme’s specified age ranges, though there was some variation between contact points. Where a contact occurred outside of the age range, it was largely when the child was younger than the lower age threshold.
Annual summary of Healthy Child Wales Programme
| Contact | Eligible children | Received contact | % Received contact |
|---|---|---|---|
| 10-14 days | 28,636 | 26,909 | 94% |
| 6 weeks | 28,315 | 23,718 | 84% |
| 8 weeks | 28,231 | 21,181 | 75% |
| 12 weeks | 27,988 | 18,854 | 67% |
| 16 weeks | 27,945 | 18,910 | 68% |
| 6 months | 27,972 | 24,228 | 87% |
| 15 months | 29,149 | 23,653 | 81% |
| 27 months | 30,363 | 24,002 | 79% |
| 3.5 years | 32,507 | 21,634 | 67% |
| Total contacts | 261,106 | 203,089 | 78% |
Figure 1: Annual Healthy Child Wales Programme contact completion rate, 2017 to 2021
Description of Figure 1: A line chart which shows that the percentage of contacts completed has increased since the start of programme.
A child is eligible for a contact when they reach the age of each contact point. For example, a child becomes eligible for the 3.5 year contact when they reach 3.5 years old. A ‘completed contact’ is where an eligible child has a contact through the programme which is then recorded on the child health system. The ‘completion rate’ is the number of completed contacts divided by the number of contacts which should have been offered.
In 2021, over 203,000 contacts were received by eligible children, equivalent to 78% of all contacts which should have been offered. This is the highest contact completion rate of any year since the programme started and continues the longer term upward trend, following a decrease in 2020 (which was largely due to the COVID-19 pandemic).
The completion rate varied widely by contact point. Around 19 out of 20 contacts were received by children who should have been offered contacts when aged between 10-14 days, the highest completion rate of any contact. This compares to around 13 out of 20 contacts received by children who should have been offered contacts when they reached 3.5 years, the lowest completion rate of any contact.
Figure 2 shows time series’ of the contact completion rate, using quarterly data from the start of the programme at each contact point. See the quality and methodology section for an explanation of why quarterly and annual completion rates may differ.
Figure 2: Contact completion rates at each contact point, by quarter, October 2016 to December 2021
Description of Figure 2: Four line charts showing the percentage of eligible children receiving contacts at each point has increased since the start of programme. There was a marked fall during the pandemic for most contact points in 2020, however the completion rates at all contact points has since recovered.
Percentage of eligible children with recorded Healthy Child Wales contacts, by quarter on StatsWales
[Note 1] The actual percentage of eligible children receiving their contact at 8 weeks may be higher than the numbers presented because some health visitor contacts at 8 weeks may have been recorded on a 6 week contact form, see quality and methodology section for more detail.
[Note 2] Note that some children will be counted multiple times each quarter in the ‘total contacts’ chart. This is because it is a sum of all individual contacts and a single child may have been eligible for multiple contacts during a single quarter.
All contacts offered through the HCWP are voluntary, so personal choice affects the percentage of eligible children receiving a contact.
Overall, there is a longer-term upward trend in the percentage of eligible children receiving contacts. The impact of the COVID-19 pandemic is clear in 2020, but the programme recovered in 2021 and the percentage of children receiving contacts was at a broadly similar level to the quarters just prior to the pandemic.
Contacts at 10-14 days, 6 weeks and 6 months were prioritised in Welsh Government guidance issued at various times during the waves of the pandemic. The data for these contacts shows less of reduction in the percentage of children receiving contacts in 2020 than all other contact points.
While the overall percentage of children receiving contacts was higher than in any other year in 2021, the final two quarters show a slight downward trend for the majority of contacts.
Reasons for not receiving a contact
All eligible children across Wales should be sent an invite for all contacts either directly through the post (for contacts that align with immunisations, providing consent is provided) or via their health visitor or GP for all other contacts. Where no contact took place, the reason is recorded on the child health system.
Figure 3: Reason for no contact, all contacts combined, 2021
Description of Figure 3: Column chart show the majority of contacts which did not occur, did not have an appointment on record.
During 2021 there were just over 58,000 contacts which were not completed according to the child health system records. This will either be because:
- contacts were not offered by health boards because they did not have the capacity to offer it
- contacts were offered and not taken up by parents of eligible children
- contacts did occur, but the data collection form was not completed or added to the child health system
81% of incomplete contacts had information recorded on the system indicating why a contact was not recorded. The majority (68%) of contacts were not made because there was no record of an appointment being made. Where an appointment was made, the main reason why the contact did not happen was because the child was not brought to the appointment (12%).
Contacts within programme age range, 2021
While the HCWP is designed for children to receive a contact at specific ages, in practice each contact point has a minimum and maximum age threshold within which the contact should take place. These thresholds were determined by Heads of Health Visiting at local health boards and are shown in Table 2.
| Contact | Min age | Max age |
|---|---|---|
| Contact at 10-14 days | 10 days | 14 days |
| Physical examination at 6 weeks (GP led) | 6 weeks | 12 weeks |
| Contact at 8 weeks | 8 weeks | 12 weeks |
| Contact at 12 weeks | 12 weeks | 16 weeks |
| Contact at 16 weeks | 16 weeks | 20 weeks |
| Contact at 6 months | 26 weeks | 35 weeks |
| Contact at 15 months | 65 weeks | 78 weeks |
| Contact at 27 months | 117 weeks | 130 weeks |
| Contact at 3.5 years (pre-school) | 185 weeks | 208 weeks |
Figure 4: Percentage of contacts received within age range, below the minimum age, and above the maximum age, 2021
Description of Figure 4: A bar chart showing most contacts occurred within the specified age ranges.
Annual percentage of Healthy Child Wales Programme contacts received within age ranges on StatsWales
The majority of all contacts (73%) were made within the specified age range, though there was some variation between contact points.
When children had their contact outside of the age threshold, it was largely before the minimum age at all contact points, apart from the 10-14 day contact. The largest percentage of children not seen within the age range was at 3.5 years, where half of children had their contact before the lower age threshold.
Flying Start
Flying Start is a Welsh Government early years programme targeted at families who live in relatively disadvantaged areas. The programme complements the Healthy Child Wales Programme (HCWP) and offers enhanced health visiting services through additional visits at 24+ week gestation, from the baby’s birth to six weeks old, and between the ages of 9 to 12 months and 18 to 24 months.
Statistics summarising the activity within Flying Start programme areas as well as outcomes for children living in Flying Start areas are published annually: Flying Start: summary statistics.
Figure 5: Healthy Child Wales Programme contact completion rate for all contacts in the quarter, Flying Start and non-Flying Start residents, Oct to Dec 2016 to Oct to Dec 2021
Description of Figure 5: A column chart showing that the completion rate for HCWP contacts has been similar for children living in both Flying Start areas and non-Flying Start areas for the majority of the programme.
When the HCWP was first introduced, the HCWP contact completion rate was lower for children residing in Flying Start areas, compared to children residing in non-Flying Start areas. This was expected as both programmes became aligned to each other. Since mid-2017, there has been little difference between completion rates for children living in both areas.
In the last quarter of 2021, the percentage of eligible children receiving their contact was 73% in Flying Start areas and 74% in non-Flying Start areas.
Local health board summary
The HCWP is delivered by the seven local health boards in Wales. The contact completion rate differs by health board and data for the calendar year 2021 is shown in Figures 6 to 14.
Contact completion rate at each contact point, by health board, 2021
Figure 6: Contact at 10 to 14 days
Description of Figure 6: A column chart showing the completion rate for the 10 to 14 days contact was 90% or greater for all health boards.
Figure 7: Physical examination at 6 weeks (with GP)
Description of Figure 7: A column chart showing the completion rate for the 6 week GP appointment was close to the Wales average in most health boards, but markedly higher in Powys and markedly lower in Cardiff and Vale.
Figure 8: Weight and measurement at 8 weeks [note 1]
Description of Figure 8: A column chart showing that four health boards (Betsi Cadwaladr, Swansea Bay, Cwm Taf Morgannwg and Powys) had completion rates of greater than 80%; the rate in Hywel Dda was equal to the Wales average (75%); while the rate in Cardiff and Vale and Aneurin Bevan was below 70%.
[Note 1] The actual percentage of eligible children receiving their contact at 8 weeks may be higher than the numbers presented because some health visitor contacts at 8 weeks may have been recorded on a 6 week contact form, see quality and methodology information for more detail.
Figure 9: Weight and measurement at 12 weeks
Description of Figure 9: A column chart showing that four health boards (Cwm Taf Morgannwg, Swansea Bay, Betsi Cadwaladr, and Powys) had completion rates of greater than 77%; the rate in Hywel Dda and Cardiff and Vale was close to the Wales average (67%); while the rate in Aneurin Bevan was 32%.
Figure 10: Weight and measurement at 16 weeks
Description of Figure 10: A column chart showing that four health boards (Betsi Cadwaladr, Cwm Taf Morgannwg, Swansea Bay, and Powys) had completion rates of greater than 77%; the rate in Hywel Dda and Cardiff and Vale was close to the Wales average (68%); while the rate in Aneurin Bevan was below 30%.
Figure 11: Contact at 6 months
Description of Figure 11: A column chart showing the completion rate at 6 months was 90% or greater in three health boards (Swansea Bay, Cwm Taf Morgannwg and Betsi Cadwaladr); three other health boards (Hywel Dda, Powys and Aneurin Bevan) were close to the Wales average (87%); while Cardiff and Vale was the only health board with a completion rate of less than 80%.
Figure 12: Contact at 15 months
Description of Figure 12: A column chart showing the completion rate at 15 months was 80% or greater in four health boards (Betsi Cadwaladr, Cwm Taf Morgannwg, Aneurin Bevan and Powys); two other health boards had rates just below 80% (Swansea Bay and Hywel Dda); while Cardiff and Vale had a completion rate of 73%.
Figure 13: Contact at 27 months
Description of Figure 13: A column chart showing the completion rate at 27 months was 80% or greater in three health boards (Betsi Cadwaladr, Cwm Taf Morgannwg and Powys); two other health boards had rates just below the Wales average of 79% (Swansea Bay and Aneurin Bevan; while Hywel Dda and Cardiff and Vale had a completion rate of 73% or lower.
Figure 14: Contact at 3.5 years (pre-school)
Description of Figure 14: A column chart showing the completion rate at 3.5 years was close to 80% in two health boards (Powys and Betsi Cadwaladr); close to the Wales average (67%) in three health boards (Cwm Taf Morgannwg, Cardiff and Vale and Aneurin Bevan); and close to 50% in the remaining two health boards (Hywel Dda and Swansea).
Figures 6 to 14 show that the completion rates vary widely between contact point and health board providing the service.
While there is variation some health boards have consistently higher completion rates than others. Both Cwm Taf Morgannwg and Betsi Cadwaladr have completion rates greater than the Wales average at all contact points, while both Swansea Bay and Powys have completion rates greater than the Wales average at 6 of the 9 contact ages. Whereas Hywel Dda, Cardiff and Vale and Aneurin Bevan have completion rates above the Wales average at 3 or fewer contact points.
Data based on the child’s resident local authority is also published on StatsWales.
Quality and methodology information
The Healthy Child Wales Programme
Further information on the Healthy Child Wales Programme (HCWP) and the NHS Wales Data Dictionary.
Monitoring the programme and data source
The programme is supported by a child health system, delivered by Digital Health and Care Wales (DHCW). The system enables health boards to schedule HCWP contacts, provides a consistent data collection form for each contact, and a consistent digital infrastructure for data to be entered on. The data collected supports polices aimed at improving children’s health across Wales.
HCWP data is stored on the National Community Child Health Database (NCCHD) which consists of anonymised records for all children born, resident or treated in Wales and born after 1987. It brings together data from the child health system databases which are held by local health boards. Welsh Government and DHCW have worked together with health professionals to establish a dataset for those HCWP contacts with children between the ages of 10 days and 3.5 years. The data is collected by health visitors and other health professionals on paper forms which are submitted to administrative staff who manually enter data onto the child health system. The NCCHD is refreshed from local child health system databases every quarter (end January, April, July and October).
Note that only data extracted from the NCCHD is analysed here and that HCWP contacts before 10 days of age and after 3.5 years are not reported in this release. Other key components of the programme are reported elsewhere.
- Immunisation statistics (COVER statistics) are published by Public Health Wales.
- Infant feeding statistics are published in our annual Maternity and birth statistics statistical release.
Measuring coverage of the programme
In order to measure how the programme is being implemented for children living in Wales using the NCCHD, the following methodology has been used.
- Identified appropriate eligible children during the period for each contact. For example, in relation to the 10-14 day contact, we have looked at all children in Wales becoming 10 days old during the quarter.
- For these eligible children we have counted the valid records for each HCWP contact.
- Delayed reporting by one quarter to allow time for data to be recorded on child health system databases.
- Note that annual data is extracted at the same time as the last quarter in the year and data for the three previous quarters in the year are not revised. If there are late submissions of data for contacts which happened in the first three quarters of the year, then these will be counted in the annual data but not in the quarterly data from when they happened. As a result the annual completion rate is likely to be higher than the rates of the constituent quarterly rates.
Implementing the programme
Statistics in this release only relate to the following HCWP contacts:
- health visitor home contact at 10-14 days
- GP contact at 6 weeks
- health visitor service contact (growth assessment) at 8, 12 and 16 weeks
- health visitor service contact at 6 months
- health visitor service contact at 15 months
- health visitor service contact at 27 months
- health visitor service contact at 3.5 years pre-school
After the first home contact at 10-14 days, health visitor service contacts can occur either in the home or in clinics, although growth assessments contacts can also take place at GP practices. The physical examination takes place mostly in GP practices or in clinics.
Coverage
Statistics in the release relate to contacts by health professionals with children resident in Wales from birth to three and a half years old.
There are known data quality issues with the data collected through the Healthy Child Wales Programme. One of the issues is that the paper-based system can lead to an undercount in activity because it relies on the health professional completing the paper form correctly, submitting it to a child health administrator, who then uploads the data onto the child health system. This process can lead to incorrect data being input on to the form, forms being submitted late or not at all and manual imputation errors. While the large majority of contacts are recorded correctly, this process means data is not collected for all children in practice.
There are specific issues which affect the 6 and 8 week contacts. The 6 week contact is where physical examination of the eyes, heart, testes, hips and general health occurs and should be undertaken by a GP or paediatrician. Data recorded in NCCHD shows that around 80% of these contacts have occurred since the programme was introduced; however feedback from health boards suggests that all children are offered this contact and nearly all children receive the contact. Following an investigation into the data, it was apparent that some GPs recorded the contacts on their GP systems, but did not record the information on the Healthy Child Wales Programme data collection form, so it will not be present on the NCCHD.
Further to this, the 8 week contact with the health visitor often takes place simultaneously to the 6 week GP contact, but in order to be entered onto the NCCHD, separate data collection forms need to be submitted for each contact. This can result in a number of 6 week contact forms being submitted by the health visitor instead of the 8 week contact form. Therefore the number of 8 week contacts on the NCCHD is lower than the number of contacts occurring in practice.
Health visitor contacts which align with childhood vaccination appointments also suggest there is an undercount of activity recorded in NCCHD. Vaccination appointments (typically carried out by a general practice nurse) are usually arranged to happen at the same time and location as HCWP contacts with the health visitor, however vaccination rates are greater than the rate of eligible children receiving Healthy Child Wales Programme contacts.
Welsh Government officials are continually working with health boards and primary care colleagues to improve the quality of data recorded at all contacts and it is hoped that an electronic data collection system may be introduced in the future to help with this.
Data access, confidentiality and disclosure control
The extract supplied to Welsh Government by DHCW is anonymised so that it contains no personal identifiable information.
Statistics take into account our disclosure control guidance and follow ONS confidentiality guidelines for health statistics available from: ONS best-practice guidelines.
Revisions
The National Community Child Health Database is a live database and data is extracted from this database every quarter. There is usually a 4-month lag between the extract being taken and the reference period (for example, data extracted in April will be for the reference period Oct-Dec in the previous year). This is to allow child health departments to process all data collection forms for the reference period. Data is only extracted for the latest quarter, so data for all previous quarters are not routinely revised. If data for previously published periods were to be extracted at any point after their usual extraction date, numbers may differ slightly to the published data because there may have been some data collection forms processed very late.
Data for previous time periods is not revised unless errors are discovered. In the case of incorrect data being published, revisions would be made and users informed.
What are the potential uses of these statistics?
These statistics will be used in a variety of ways. Some examples of these are:
- advice to ministers
- to inform debate in the Welsh Parliament and beyond
- to make publicly available data on child health statistics in Wales
- monitoring service delivery
- public health research
- policy development
Users of this data
The main users of this data are likely to be:
- ministers and the Members Research Service in the Welsh Parliament
- local health boards and local authorities
- primary care organisations
- the research community
- students, academics and universities
- the general public
- private hospitals
- NHS organisations
- voluntary birth organisations
Relevance
The statistics provide an opportunity to monitor the implementation of the HCWP and provide an insight into the profile of the early years in Wales.
Users of the statistics are encouraged to contact Welsh Government to let us know how they use the data.
Key users have been contacted prior to release of this data and will continue to be liaised with as the statistical release develops.
The release will be adapted to respond to policy changes ensuring our statistics remain relevant.
Accuracy
There are known data quality issues with data collected through the programme, most of which are explained in the coverage section.
The data collection form records information on additional data items such as female genital mutilation (FGM), the age at which breastfeeding ceased, the age at which solid foods were introduced, and schedule of growing skills (SOGS). However none of these data items are currently recorded with sufficient accuracy and consistency to publish data.
Welsh Government and DHCW are continuously working with health boards to improve completeness and quality. Part of this work includes changing the data collection form to make it easier for health visitors to complete and potentially moving to an online data collection system, rather than using the current paper-based process which has many limitations.
Completeness
Notwithstanding the known data quality issues and impacts of the COVID-19 pandemic, data completeness is variable across some of the published data items, but is sufficiently high to produce official statistics with explanatory notes.
The current paper-based data collection process relies on the accurate completion of data collection forms by health care professionals, and timely processing and accurate imputation by child health system administrators.
Timeliness and punctuality
The NCCHD is refreshed from data derived from local child health systems every quarter.
There is often a lag in data collection forms being sent to child health system administrators so data is usually extracted from the system around 4 months after the reference period and is published by Welsh Government, as soon as resource allows but usually within 2 months of receiving the data.
To supplement the annual statistical release, quarterly data are published on StatsWales.
Accessibility and clarity
The statistics are published in an accessible, orderly, pre-announced manner on the Welsh Government website at 9:30am on the day of publication. An RSS feed alerts registered users to this publication. Simultaneously the releases are also published on the National Statistics Publication Hub. We also publicise our outputs on Twitter. All releases are available to download for free.
Open data tables are available via StatsWales every quarter.
We aim to use plain English in our outputs and all outputs adhere to the Welsh Government’s accessibility policy. Furthermore, all our headlines are published in Welsh and English.
Further information regarding the statistics can be obtained by contacting the relevant staff detailed on the release or via stats.healthinfo@gov.wales.
Comparability and coherence
Where there are changes to the source data provided, this will be shown in the statistical outputs. Where advance warning is known of future changes these will be pre-announced in accordance with Welsh Government arrangements.
Data collected from NCCHD adheres to national standards and are coherent within and across health organisations in Wales.
England has a Healthy Child Programme which is similar scheme to Healthy Child Wales.
Scotland has a Child Health Programme which differs somewhat from the Healthy Child Wales Programme.
Northern Ireland statistics on public health are available from the Northern Ireland Public Health Agency.
Well-being of Future Generations Act (WFG)
The Well-being of Future Generations Act 2015 is about improving the social, economic, environmental and cultural wellbeing of Wales. The Act puts in place seven wellbeing goals for Wales. These are for a more equal, prosperous, resilient, healthier and globally responsible Wales, with cohesive communities and a vibrant culture and thriving Welsh language. Under section (10)(1) of the Act, the Welsh Ministers must (a) publish indicators (“national indicators”) that must be applied for the purpose of measuring progress towards the achievement of the Well-being goals, and (b) lay a copy of the national indicators before Senedd Cymru. The 46 national indicators were laid in March 2016 and this releases includes 1 of the national indicators namely The percentage of live single births with a birthweight of under 2.5kg.
Information on the indicators, along with narratives for each of the wellbeing goals and associated technical information is available in the Well-being of Wales report.
Further information on the Well-being of Future Generations (Wales) Act 2015.
The statistics included in this release could also provide supporting narrative to the national indicators and be used by public services boards in relation to their local wellbeing assessments and local wellbeing plans.