Making prudent healthcare happen

Better health for all our children – prudent healthcare for future generations

  • Dr Shantini Paranjothy, Clinical Senior Lecturer, Cardiff University
  • Dr Aimee Grant, Research Fellow, Cardiff University
  • Dr Lisa Hurt, Research Fellow, Cardiff University

Summary

This article examines how a renewed focus on pregnancy and early years of child development can help NHS Wales deliver prudent healthcare. This is key to tackling health inequalities and helping people to take a proactive approach to protecting their own health, which are part of the citizen focus of prudent healthcare.

Welsh Government policy and NHS Wales organisations need to prioritise pregnancy and early years support to deliver health benefits and create a more equitable and healthier society in the long run. This means being open to new ways of working and investing in measurement and evaluation of child health, for example, tracking levels of obesity in children.

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Introduction

Prudent healthcare is,

“Healthcare which is conceived, managed and delivered in a cautious and wise way, characterised by forethought, vigilance and careful budgeting which achieves tangible benefits and quality outcomes for patients.”

(Bevan Commission, 2013)[2]

In a period of austerity, when public services are being cut and when there are increasing demands on services, it’s essential we use healthcare resources in the most effective and efficient ways.

There’s a compelling case for prevention across the life course. But intervention to promote health and well being in the early years (pre-conception to the seventh year of life) is essential to reduce the burden of disease throughout the life course.[3-5]

As well as promoting health equality during the early years, additional benefits of early interventions come from better to physical and mental health, educational outcomes and increased economic participation throughout the life course,[1,3,4,6] providing significant long-term savings. To maximise these benefits, we should be proactive in our early years interventions, rather than waiting for early signs of problems before we react.[3] Of all interventions, a focus on early years is likely to be the most effective investment to achieve prudent healthcare.

The principles of early intervention and prudent healthcare – to do no harm, carry out the minimum intervention and promote equity between professionals and patients – have largely been adopted by the Welsh Government, in their early years strategy,[5] maternity strategy[7] and guidance for Flying Start.[8] In addition, the Welsh Government’s healthcare strategy prioritises reducing health inequalities.[9] In order to deliver prudent healthcare, we will need to work to deliver the implementation of these plans through efficient interagency working.

We focus here on five key health challenges in considering how we might realise the vision of prudent healthcare in children’s health and wellbeing in Wales. The key challenges we have chosen are:

  • reducing the harm from tobacco
  • increasing breastfeeding
  • tackling childhood obesity
  • promoting good oral health
  • promoting good child development.

We chose these key challenges based on evidence in Wales for:

  • the numbers of children they affect
  • the unequal distribution of poor outcomes by levels of social deprivation
  • the severity of outcomes in childhood and later life
  • the potential for harm to affect future generations if current trends continue.
Smoke-free pregnancies

The prevalence of smoking in the female population and the variation of smoking levels between the most and least deprived areas, are important factors influencing maternal and child health outcomes. Wales has higher rates of smoking in pregnancy than any other UK country. Around a quarter (26 per cent) of mothers in the UK smoked directly before or during their pregnancy, but smoking levels before or during pregnancy were found to be highest in Wales (33 per cent). Across the UK, one in eight mothers (12 per cent) continued to smoke throughout pregnancy and were still smoking after the baby was born and mothers in Wales were found to be the most likely to smoke throughout their pregnancy (16 per cent).[12]

Risks of smoking in pregnancy

Smoking in pregnancy is associated with an increased risk of miscarriage, perinatal death and several conditions associated with a long-term risk of ill-health, including prematurity, low birth weight,[11] congenital anomalies in the baby,[12]and being overweight from ages three to thirty-three.[13] Data on children born in Wales between 2000 and 2008 shows the risk of hospital admission for respiratory conditions during childhood decreased with each successive week in gestation up to 40 to 42 weeks. Although the increased risk itself is small for late preterm infants (35 weeks-plus) the number of infants affected is large and so has an impact on healthcare services.[14]

How can we help pregnant women quit?

We have high-quality evidence about the effectiveness of interventions for promoting smoking cessation in pregnancy. Simply advising pregnant women who smoke and offering a brief intervention is not effective in facilitating successful quit attempts.[15] More intensive smoking cessation interventions, such as psychosocial interventions accompanied by nicotine replacement therapy (NRT), can reduce smoking in late pregnancy by three to six per cent.[16] Service evaluations from England and Scotland suggest flexibility around the site and setting and clinical staff delivering the intervention can improve engagement with the client, facilitate access to NRT and subsequently improve outcomes. In 2010–11, more than half stop-smoking services in England offered a specialist pregnancy quit smoking service and a third of services had a protected budget for supporting pregnant smokers.[17]

Health benefits and cost savings

Using the National Institute for Health and Care Excellence costing model[18]  we estimate as many as 23 of the 3,368 cases of complications for the mother and the baby could be avoided each year in Wales (with cost avoided to the NHS of £443,064), if the uptake of stop-smoking services for pregnant women increased from 11 to 25 per cent. In Wales we need to prioritise the systematic implementation of NICE guidance for quitting smoking during pregnancy[16] across all health boards.

Consideration should be given to how the NHS can work in a more integrated way to implement the evidence base on this key priority area, with a seamless approach to joint working across all NHS services and partner agencies. In particular the value of working with other organisations, such as Action on Smoking & Health (ASH) Wales, needs to be explored.

Example of good practice: Models for Access to Maternal Smoking cessation Support (MAMSS)Public Health Wales is working with four health boards to explore the feasibility of providing an effective specialist quit smoking services to pregnant women (Models for Access to Maternal Smoking cessation Support, MAMSS).  The pilots are being evaluated using a quasi-experimental design with results available in winter 2014–15. Further information on this is available online (Public Health Wales, 2014).[35]


Breastfeeding

The benefits of breastfeeding for the short and longer-term health and wellbeing of babies and mothers are well known.[1,19-21] If 45 per cent of women exclusively breastfed for four months in the UK, it is estimated that at least £17m could be saved in treatment costs annually for acute illness in infants, in addition to incremental benefits over the lifetime of each annual cohort of first-time mothers.[1]

Starting and stopping

Although around half of all mothers in Wales start breastfeeding, rates fall steeply in the first few weeks – around two-thirds of women who initiated breastfeeding stopped before six weeks and for most women this was earlier than planned.[22] Only one per cent of mothers in Wales currently exclusively breastfeed for six months, which is the World Health Organization recommended duration.[10] There are marked inequalities in breastfeeding rates – mothers who are younger (under 20), of white British ethnicity, and of lower socio-economic status are less likely to start or continue breastfeeding beyond six weeks.[10]Professional support for breastfeeding is already universally available in Wales but this has not had much impact on breastfeeding initiation or maintenance in areas with high levels of social deprivation.

Innovative approaches are needed

New approaches to support women who are at highest risk of failing to initiate and continuing breastfeeding[22] are urgently needed. Interventions to normalise breastfeeding are also urgently required.[23] Media campaigns are successful in promoting health changes, although there is limited evidence to support this approach regarding breastfeeding.[24] Alongside this, proactive, mother-centred support should be available soon after birth to ensure initiation is successful in women who want to breastfeed. This should take into account known barriers to breastfeeding (including physical, societal and emotional) and be rigorously evaluated. New models for providing this type of support should be explored.

Example of good practice: Motivational interviewing based peer support for breastfeedingCardiff University, funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA), is currently developing and testing a breastfeeding support programme delivered by peer supporters. Peer support can potentially be a cost-effective way of providing more intensive support when and where it is needed most. The project will be robustly evaluated.


Healthy diet and weight in infancy

The recent child measurement programme in Wales reported 26 per cent of Wales’ four to five-year-olds are overweight or obese.[25] Causes of obesity in children are many and complicated – there are links with maternal smoking and formula feeding[1,14] and, continuing into early childhood, poor diet and lack of exercise are the major contributory factors.

Addressing maternal smoking and breastfeeding will therefore go some way to help address obesity in infancy and early childhood. Ideally, these need to be backed up with interventions to promote healthy eating and exercise in children, but at present there is a lack of evidence-based interventions. However, it would be prudent, given that we must deal with this major public health issue urgently, to press forward with experimental approaches for developing and testing new interventions. Through continuous monitoring and surveillance we must highlight the issue of childhood obesity with parents. We can offer them advice and support for establishing healthy diets and becoming more active through physical activity regimes accessible through the various ongoing early years initiatives across Wales.

Good oral health

The prevalence of dental caries has fallen over the past 40 years. Caries are still seen in almost a half of UK children and adolescents, although the incidence varies markedly by deprivation level.[26] This is an important public health problem because poor oral health is associated with pain, absence from school, reduced educational attainment,[27] sleep deprivation as well as dental caries.[26] Recent evidence suggests the number of children requiring the removal of decayed or infected teeth under general anaesthetic may be increasing, with some children undergoing multiple surgeries.[26]

In Wales, good dental health is promoted by the Designed to Smile programme. This programme offers dental screening in schools throughout Wales, provides fluoride varnish and fissure sealant to children where appropriate, gives free toothbrushes and toothpaste for children to use at home and promotes supervised daily brushing in schools and nurseries. The effectiveness of this initiative will be evaluated in due course. Consideration should be given to implementing new evidence-based strategies, such as providing fluoride supplements.[28]

Example of good practice: Seal or varnishCardiff University, funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA), is evaluating the clinical and cost-effectiveness of providing fluoride varnish and fissure sealant to children in reducing carries in the medium term. The research will be completed in 2016 and will inform future policy development.

 

Enhancing early child development including social and emotional wellbeing

Early child development – including physical, social and emotional, language and cognitive domains – has consistently been shown to be associated with many aspects of wellbeing into adulthood, including physical and mental health, competence in literacy and numeracy, criminality, and economic participation.[29-31] Investment in early child development is therefore prudent. Services which have a proven benefit in enhancing early child development and social and emotional wellbeing, to optimise child health, wellbeing and developmental resilience[6] now deserve investment to deliver prudent healthcare.

Marmot review

The Marmot review recommended increasing the proportion of expenditure allocated to the early years and reducing adverse outcomes in pregnancy and infancy by prioritising pre and postnatal support to families.[29] It also highlighted the advantages of intervention delivery based on ‘proportional universalism’, stating:

“To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage.”

(Marmot et al. 2010)[29]

This concept was developed in the Allen report which reviewed the evidence for early interventions with the aim of identifying programmes to enhance readiness for school (0 to five), readiness for secondary school (five to 11) and readiness for life (11 to 18). Most evidence-based programmes in the early years were for targeted high-risk groups and many of the universal programmes lacked a robust evidence base and did not address global child development, including social and emotional wellbeing.[3]

What do we know works?

There is high-quality systematic review evidence available or planned for the effects of many specific interventions to promote child development in the early years, including parent-training and centre-based educational programmes. However, these reviews do not always provide a full picture of interventions relevant to public health policy and practice in Wales. Either they do not fully capture the programme models that are currently the cornerstone of our local early years programmes (universal health professional support, mainly provided by health visitors, which is at its most intensive in the first two years of a child’s life), or they fail to provide a comprehensive examination of child development outcomes in the very early years (up to and including three years of age). They fail to articulate the inter-relationships between child development and social and emotional wellbeing and they do not describe the theoretical basis for interventions and relate this to the effect of the intervention.

There is a clear need to examine the effect of enhanced health professional contact with parents and children from the antenatal period to two years. We need to review child development and social and emotional wellbeing outcomes in children from three months to three years and inform the development of comprehensive, evidence-based policies for early years services in Wales.

Next steps: advancing a prudent child health agenda in Wales
1. Practical ideas to engender change

To make a difference in these areas of child health using the prudent healthcare agenda, we need to prioritise investment and increase focus on preventative measures in the early years. In areas like childhood obesity, where there is a lack of evidence for what works, prudent healthcare requires us to highlight the size of the problem, and then scale up efforts to develop, test and evaluate the potential impact of new interventions, with an emphasis on timely large-scale implementation.

2. Policy change to facilitate healthy pregnancies and healthy early years

The Welsh Government should continue to implement a progressive programme of public health legislation. Using healthcare modelling approaches we need to identify the interventions which will have the most impact on population health outcomes and ensure these are implemented systematically at scale and pace. Current programmes should be rigorously evaluated if they do not have strong evidence, using Randomised Controlled Trials or quasi-experimental designs.

3. Widening access to existing evidence-based interventions

Currently, pathways to an intervention are often reliant upon health professionals. Alongside this valuable formal pathway, lay health workers have been found to be effective in promoting breastfeeding and vaccination uptake.[33] The use of community health champions to support healthy behaviour and access to interventions should therefore be considered in community groups, schools, youth clubs, children’s centres and social services. These community health champions should receive brief training to refer people for advice or treatment and regular support from a health professional.

4. Addressing multiple health risk behaviours

In Wales, multiple health risk behaviours in pregnancy and childhood co-exist. To maximise the potential impact, interventions should be developed or adopted to address multiple health risks as a matter of priority.

5. A principle of proportional universalism should be adopted

Alongside universal interventions, additional support should be targeted to those who have greatest need, in order to reduce health inequalities.[5,30]

6. A robust integrated surveillance platform should be created

The purpose of an early years surveillance system would focus attention and give priority to early years, drive forward improvement in early years inequalities and track progress, identify areas of good practice and identify gaps to be addressed, support coordination and evaluation of programmes. The development of such a system, using the range of routinely-collected health and social care data in Wales would allow progress towards outcomes to be measured, in both the long term and short term.[1,3,33]


 References

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  2. Bevan Commission. Simply Prudent Healthcare: achieving better care and value for money in Wales [Internet]; 2013 [cited 2014 August 01]; Available at http://www.bevancommission.org/sitesplus/documents/1101/Bevan%20Commission%20Simply%20Prudent%20Healthcare%20v1%2004122013.pdf.
  3. Allen G. Early intervention: the next steps, an independent report to Her Majesty’s government by Graham Allen MP: The Stationery Office. 2011.
  4. Field F. The Foundation years: preventing poor childern becoming poor adults. The Report of the Independent Review on Poverty and Life Chances. HM Government. December 2010. http://webarchive.nationalarchives.gov.uk/20110120090128/http://povertyreview.independent.gov.uk/media/20254/poverty-report.pdf [accessed 15.09.2014]
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  7. Welsh Government. A Strategic Vision for Maternity Services in Wales [Internet] 2013c [cited 2014 September 02]; Available at http://wales.gov.uk/topics/health/publications/health/strategies/maternity/?lang=en
  8. Welsh Government. Flying Start strategic guidance. Cardiff: Welsh Government; 2013b.
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  10. Health and Social Care Information Centre. Infant Feeding Survey 2010 [Internet] 2012 [cited 2014 June 04]; Available at http://www.hscic.gov.uk/catalogue/PUB08694.
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  12. Hackshaw A, Rodeck C, Boniface S. Maternal smoking in pregnancy and birth defects: a systematic review based on 173 687 malformed cases and 11.7 million controls. Hum Reprod Update 2011;17, 589-604.
  13. Oken E, Levitan E, Gillman M. Maternal smoking during pregnancy and child overweight: systematic review and meta-analysis. Int J Obesity 2007; 32, 201-210.
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  31. Irwin LG, Siddiqi A, Hertzman C. Early child development: a powerful equalizer. Final report to the WHO Commission on social determinants of health, Geneva; 2007.
  32. Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, Van Wyk BE, Odgaard-Jensen J, Johansen M, Aja GN, Zwarenstein M. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev, 3. 2010.
  33. Lyons RA, Ford DV, Moore L, Rodgers SE. Use of data linkage to measure the population health effect of non-health-care interventions. The Lancet 2014;383, 1517-1519.
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Watch Dr Shantini Paranjothy talk more about this article, click the video.

“The benefits of breastfeeding for the short and longer-term health and wellbeing of babies and mothers are well known. If 45 per cent of women exclusively breastfed for four months in the UK, it is estimated that at least £17m could be saved in treatment costs annually for acute illness in infants, in addition to incremental benefits over the lifetime of each annual cohort of first-time mothers.”

Making it happen

  1. Consideration should be given to how the NHS can work in a more integrated way to implement the evidence base on supporting pregnant women quit smoking, with a seamless approach to joint working across all NHS services and partner agencies.
  2. New approaches to support women who are at highest risk of failing to initiate and continuing breastfeeding are urgently needed.
  3. We must deal with the major public health issue of childhood obesity urgently, and press forward with experimental approaches for developing and testing new interventions. Through continuous monitoring and surveillance we must highlight the issue of childhood obesity with parents.
  4. We need to review child development and social and emotional wellbeing outcomes in children from three months to three years and inform the development of comprehensive, evidence-based policies for early years services in Wales.

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Prudent Healthcare - collaboration leads to increased sustainability in patient care. #ConnectNHS pic.twitter.com/C33lMtboqH