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BUCKINGHAMSHIRE COUNTY COUNCIL: PUBLIC HEALTH (OCT 2015) 1

BUCKINGHAMSHIRE Early Years Needs Assessment:

Summary By Health Visitor Team Localities

Overview

The early years of a child’s life have life-long consequences on health and life chances. Children flourish in safe, secure, loving and stimulating environments where they are able to form strong bonds with their carers. There are many factors which can adversely affect children in their early years and have a profound effect on their future life, but deprivation is the single biggest driver. Variations in the health and development outcomes for early years (under 5 year olds) within Buckinghamshire may reflect differences in health needs related to factors such as ethnicity and deprivation. There are five health visiting (HV) localities in Buckinghamshire. This summary has been produced to provide an understanding of variation in health and development outcomes among children under 5 years of age, by HV locality, alongside capacity and delivery of the Healthy Child Programme.

Map of Buckinghamshire showing GP practices by Health

Visiting Localities

Executive Summary

5,966 live births were registered in Buckinghamshire to women usually resident in Bucks(2014/15)

32,190 children aged 0-4 years, registered with GPs in Bucks (GP register, April 2015)

Almost 1 in 2 births in Wycombe (52.3%) and in Aylesbury (43.2%) were born to mothers who live in most deprived areas in 2005.

Crude infant mortality rate and 1-4 year old mortality rates do not differ significantly from England rates.

7% of all births in Bucks weighed under 2.5kg (low birth weight); two-thirds of these babies were born pre-term.

Proportion of older (40+ years) mothers are higher and younger (<20 years) mothers were fewer in Bucks than England, but this significantly varies by HV locality.

76.3% of mothers initiated breastfeeding in Bucks compared to 74.3% in England(2014/15)

86% of mothers had a maternal mood assessment, but this varied from 67% to 91% between HV localities. Overall, there were 8 care plans per 1,000 new births for post-natal depression (PND).

More than 12,000 A&E attendances among 0-4 year olds in 2014/15 with a rate of 382.2 per 1,000.

540 hospital admissions for accidental/deliberate injuries among 0-4y olds with a rate of 16.8 per 1,000(2014/15).

62% of children achieve a good level of development at 4/5 years, but only 38% of those eligible for free school meals achieve a good level of development.

Rates of Looked After Children and Child Protection Plan are highest in Aylesbury and Wycombe locality.

Overall ratio i.e. HV:case load (0-4 year olds) ratio is 1:330 excluding FNP nurses, and 1:310 including all FNP nurses. This widely varies by health visitor locality

Uptake of mandated newbirth and 6-8 weeks visit was relatively high. However, uptakes of 6-8 weeks visits vary significantly by HV locality. Aylesbury and Chiltern &S Bucks locality show lower uptake compared to others.

Family Nurse Partnership (FNP) coverage was a third (31%) of eligible women and is increasing. Higher numbers of clients were from Aylesbury and Wycombe HV locality.


Demography

Population: o In 2014-15, 5,966 live births were registered in

Buckinghamshire to women usually resident in Bucks (ONS 2015). 5,757 new births records were extracted in 2014/15 from the Buckinghamshire Healthcare Trust’s community health information system (RiO) to analyse the health visitor process and outcome measures.

o 32,190 children aged 0-4 years, registered with GPs in Bucks (GP register, April 2015) (Fig. 1)

o Number of 0-4 year olds GP registered population vary by HV locality(Fig 1)

Ethnicity: o Nine of ten (89%, n=5634) birth records on the

RiO database had ‘ethnicity’ field completed that could be mapped against HV Localities in Bucks. Two thirds (66%) were White British (incl. White Other), 23% from other ethnic backgrounds and the rest (11%) were incomplete (RiO, 2015).

o Among those with records, Wycombe HV area has the highest number of BME (Black and minority ethnic) births (40%), followed by Aylesbury (27%) and the lowest in North Bucks (Fig 2; RiO, 2015).

Deprivation: o The average deprivation score (IMD 2015) for HV

localities using LSOA level deprivation scores is higher in Aylesbury (13.5), Wycombe (12.9) followed by North Bucks (8.8), Chiltern & South Bucks (7.5) and Ridgeway & Marlow (7.4) [Higher the score = higher the deprivation].

o A quarter of under 5 year olds (25%) live in the most deprived areas (DQ5=Deprivation Quintile 5) in Bucks based on local deprivation context.

o Almost 1 in 2 births in Wycombe (52.3%) and in Aylesbury (43.2%) were born to mothers in most deprived areas in 2005 (Fig 3)

Note: Deprivation classification is based on child’s resident postcode

o 1 in 10 (11%) of families of 0-4 year olds (3,575 families) were in receipt of Child Tax Credit, Income Support or Job-seekers Allowance (2012 snapshot; HMRC 2014).

Family structure: o In 2013, there were 3,523 (14.5%) children aged

0-4 in single parent families in Buckinghamshire. Wycombe DC (16.2%) has the highest followed by Aylesbury DC (15.4%); South Bucks DC (13.9%) and Chiltern DC (9.6%).

o 221 (3.8%) sole registrations of births in Buckinghamshire in 2013 (ONS, 2014).

Risk Factors & Outcomes

Mortality: o Number of deaths among under 5 year olds are

very small with year to year variations in rates. o 3-year average (2012-14) crude infant mortality

rate in Bucks was 3.8 (95% CI 3.0-4.8) per 1,000 live births (n=68) (Fig 4).

o As the numbers are small, the infant mortality

rates for localities were not significantly different from England rates with the exception of Ridgeway and Marlow.


o 5-year average (2010-14) crude death rate for 1-

4 year olds was 17.3 (95% CI 11.0-26.0) per 100,000 under 5 population (n=23) in Bucks with no significant difference compared to England rate (Fig 5) (ONS 2015).

Birth weight: o 7.0% of all births (2014/15) in Bucks were

grouped as low birth weight (<2.5kg), (RiO,

2015i) (Fig 6) compared to 7.4% in England (2013). Overall in Bucks, 8% of all births were premature and 65.2% of low birth weight babies were born premature (SUS, 2015)

o Fig 6 shows the LBW (%) for all births by deprivation quintile (DQ) compared to the Buckinghamshire average (2014). The LBW (%) was three percentage points higher in the most deprived quintile (DQ5) compared to other areas (Fig 6).

Age of mothers:

o In Bucks, 2.6% (n=157) were young (<20years of

age) mothers and 6.1% (n=367) were older mothers (40 + years) among mothers who delivered in 2014 (ONS, 2015)

o Fig 7 shows significant variations in the age of the mother at birth by HV localities, 2014 (Fig 7).

Smoking: o 8.0% of women in Bucks (11.4% in England)

were recorded as smokers at the time of delivery in 2014/15. Smoking figures showed a declining trend in Bucks and in England during last year (Fig 8) (HSCIC, 2015).

Breastfeeding: o 76.3% of mothers initiated breastfeeding in

Bucks compared to 74.3% in England in 2014/15 and is similar to the previous year i.e.2013-14 (PHOF)

o At 6-8 weeks, 59.5% of mothers with a record of 6-8 week assessment were breastfeeding (49.7% data completion; RiO-2015; Fig 9). The latest England data (2013/14 PHOF) reported 45.8% of mothers were breastfeeding at 6-8 weeks (equivalent Bucks data not published).

o Breastfeeding data for mothers in Bucks have frequently not met the validation criteria for PHE national publication.

o Available local data shows that the breast feeding rates at 6-8 weeks vary by HV locality (Fig 9)

Note: Caution is advised when comparing breastfeeding data with England due to different data quality, sources and years.

Maternal mood: o Assessment: 86.4% (n=4900) of eligible women

had a maternal mood assessment in 2014/15. Repeat assessments were conducted for 1.7% (n=81) women (Fig 10).


o Outcome: Outcome data cannot be robustly extracted from RiO database. Some relevant data were recorded for 66.6% of assessments (i.e. entries other than NULL) and “no concerns” recorded in 20.1% (note this does not mean there were concerns in the remaining assessments). Evidence shows that around 5% – 14% of women are estimated to suffer from post-natal depression which equates to an average of 80-90 women per 1000 new births estimated to suffer from PND.

o Fig 10 shows the variations in maternal mood assessment and care plan rate by HV locality.

o Intervention:

o Maternal mood outcomes were recorded as “GP”, “refer”, “healthy minds” or “listening visits” in the concluding remarks of 44 (0.9%) assessments.

o 47 women had care plans for postnatal depression (8.3 per 1,000 births, Fig 10).

Hospital attendances and admissions: o A&E attendances: 12,304 (382.2 per 1,000) A&E

attendances in 2014/15 among 0-4 year old Bucks GP registered children (SUS, 2015).

o Fig 11 shows the significant differences in A&E attendances by HV locality. Aylesbury has the highest and Wycombe the lowest.

o Admissions for accidental or deliberate injuries: 540 admissions (16.8 per 1,000) among 0-4year olds Bucks registered children for accidental or deliberate injuries in 2014/15 (APC, 2015;Fig 12).

o Fig 12 shows variations in hospital admissions

rate for accidental or deliberate injuries among 0-4 years olds by HV locality.

Child development: o 62.0% (95% CI 60.8-63.2) of all pupils achieved a

‘good level of development’ at Early Years Foundation Stage 2013/14(Fig 13). However, this was significantly lower among children eligible for free school meals (38.0%, 95%CI 33.6-42.5) (DfE, 2014).

o Fig 13 shows significant variations by HVL.

o 67.1%ii of eligible 2-year olds taken up funded

nursery/childminder places in Bucks (Fig 14). This uptake widely varies by HV locality (Fig 14).

Child weight: o In Buckinghamshire, 17.9% of 4-5 year olds are

obese or overweight in 2013/14 (National child measurement programme) with some variations by HV locality (Fig 15). This was significantly lower compared to England average in Bucks and in three Health Visitor Localities.


Health Visiting Service

Health Visiting Service: o The HV service is contracted to provide a skill-

mix team and funded for 97.5 WTE health visitors and 6.4 WTE FNP nurses (2014/15).

o The overall current HV:case load (0-4 year olds) ratio is 1:330 excluding FNP nurses, and 1:310 including all FNP nurses. Fig 16 &17 shows the distribution of HV staff as at Aug 2015 and caseload determinants.

Universal Offer: (RiO, 2015) o Antenatal Visit: 7.0% (n=397) of 2014/15 births

had an antenatal visit in Bucks. Antenatal visit uptake is improving (42% of visits took place in Q1 of 2015/16).

o New birth visit: All babies had a new birth visit. 85.9% (4,871) new birth visits were conducted within 14 days (2014/15).

o 6-8 week visit: 93.8% (5,318) of new birth had a record of 6-8 weeks visit on RiO in 2014/15

o Fig 18 shows visits and review by HVL.

Universal Plus and Partnership Plus: (RiO, 2015) o Safeguarding: There were 160 care plans (for

122 children (< 5 yr) for safeguarding in 2014/15. o Family support and parenting skills: There were

649 care plans for parenting and family support (20.2 per 1,000 0-4 year olds) in 2014/05.

o Fig 19 shows variations by HVL.

Child protection: o As at September 2015, among under 5 year olds,

there were 81 looked after children (LAC), 150 with Child Protection Plans (CPP) and 345 Children in Need (CIN) in Buckinghamshire, including 42 unborn children (BCC, 2015).

o Fig 20 shows variations by Health Visitor Locality.

o The most common reasons (accounting for 86% of cases) for both <1 year olds and 1-4 year olds to enter into care were abuse/neglect followed by family dysfunction (BCC, 2015).


Family Nurse Partnership

o 194 women were recruited to FNP between November 2012 and October 2015. Clients remain in the programme for up to 2.5 years i.e. average 65 clients per year.

o On average, a third (31%) of the estimated eligible population recruited to FNP since Nov 2012 (Fig 21) and is increasing.

Childrens’ centres (CC)

o 35 children’s centres across Bucks (2015). o 62.7% of 0-4y olds registered with CC’s. o 22.9% of 0-4 year old children are engaged

(attend at least 3 times a year) with children’s centres (BCC Collate, 2015)

o Fig 22 shows some variations by Health Visitor Locality.

Recommendations

1. Re-aligning HV staff capacity based on need and workload if needed on a regular basis. 2. Explore reasons for variations in health visiting service uptake (e.g. universal offer) between groups of the

population and different health visiting teams should be explored and appropriately addressed. 3. Notifications by stakeholders to FNP should be improved (even where there is no capacity) to gain a full

picture of demand. 4. Reduce the gap in the percentage of children reaching a ‘good level of development’ at 4/5 years between

most and least deprived areas. 5. Implement evidence based interventions to address overweight and obese during the early years especially

targeting deprived areas. 6. Data Quality and monitoring needs to be improved in order to understand important process and outcomes

measures related to the health visiting services more accurately. _________________________________________________________________________________________

DATA SOURCES AND LIMITATIONS: Several published and unpublished data sources have been used from local and

national datasets such as Health and Social Care Information Centre (HSCIC), Office for National Statistics (ONS), RiO system, Secondary Uses Services (SUS) etc. The dates / years for indicators used are different depending on the source of data and information availability. Data from Buckinghamshire Healthcare Trust community RiO system (cited as RiO, 2015) used by Health Visitors for day to day operations such as recording client details and case notes has been used to acquire data on outcomes (e.g. breastfeeding) and process indicators (e.g. universal offer visits) where recorded and available. Data completion is variable. Data on child protection, children’s centres, two-year funding and Early Years Foundation Stage profile results was shared by BCC Children’s Social Care & Learning team. To create a map to show HV localities, LSOA based resident populations of the GP practices was matched to the HV locality provision based on the GP practice. This made it possible to identify the majority of GP registered population in each locality boundary which was based on LSOAs. The map created uses LSOA boundaries to create each HV Locality with individual GP practices in each HV locality mapped as points on the map.

i Health visitor recorded data extracted from RiO are reported as this was more complete than SUS data which does not include information from Heatherwood and Wexham Park Hospital Trust. ii Figures have been estimated by applying data at the Children Centre level to health visiting areas.


APPENDIX

Category Indicator AylesburyChiltern & S

BucksNorth Bucks

Ridgeway &

MarlowWycombe Bucks England Year Sources

GP registered 0-4 year olds 7,260 9,882 3,042 5,476 6,530 32,190 3,378,814 April 2015 GP registrations

GP registered 0-2 year olds 4,259 5,480 1,659 3,072 3,825 18,295 1,965,162 April 2015 GP registrations

GP registered <1 years 1,331 1,625 533 896 1,228 5,613 600,062 April 2015 GP registrations

GP registered 1-2 years 2,928 3,855 1,126 2,176 2,597 12,682 1,365,100 April 2016 GP registrations

GP registered 3-4 years 3,001 4,402 1,383 2,404 2,705 13,895 1,413,652 April 2017 GP registrations

0-4 year as % of GP registered population 7.3% 5.5% 4.8% 5.4% 6.8% 6.0% 5.9% April 2015 GP registrations

Ethnicity - White incl. W Other 61% 72% 83% 77% 48% 66% 2015 RiO

Ethnicity - Non-White 27% 19% 6% 12% 40% 23% 2015 RiO

Ethnicity - No record 13% 9% 11% 10% 13% 11% 2015 RiO

Fig 3. Births by DQ Deprivation Quintil (DQ) DQ1 16.0% 24.2% 7.9% 17.9% 5.0% 15.2% 2014-15 RiO

DQ1=Least deprived DQ2 11.0% 16.7% 22.1% 21.7% 11.8% 15.3% 2014-15 RiO

DQ5=Most deprived DQ3 23.8% 18.2% 38.4% 16.6% 11.4% 19.6% 2014-15 RiO

DQ4 6.1% 24.9% 31.2% 28.3% 19.5% 20.0% 2014-15 RiO

DQ5 43.2% 16.0% 0.4% 15.6% 52.3% 29.9% 2014-15 RiO

Fig 4. Infant Mortality RateAverage crude infant mortality rate

(IMR), per 1,000 live births 2012-145.7 2.8 2.9 1.7 4.7 3.8 4.1 2012-14 ONS

Fig 5. Mortality rate in 1-4

year olds

Crude 1-4y death rate per 100,000

population (average 2010-2014)27.0 14.5 8.0 13.1 18.9 17.3 15 2012-14 ONS

Fig 6. Low Birth Weight % LBW and born term 1.4 2.4 3.1 2.7 3.1 2.4 7.0 2013 ONS

% LBW and born preterm 5.6 4.4 6.3 3.8 3.5 4.6 2013 ONS

Fig 7. Mother's age Mothers <20y 46 15 14 10 33 122 2014, 2014-15 ONS, SUS

% mothers <20y 3.5% 1.6% 3.1% 1.6% 2.7% 2.6% 3.7% 2014, 2014-15 ONS, SUS

Mothers >= 40y 55 75 36 45 50 270 2014, 2014-15 ONS, SUS

% mothers >=40y 4.1% 7.9% 8.0% 7.1% 4.1% 6.1% 4.2% 2014, 2014-15 ONS, SUS

Fig 8. Smoking At the Time Of Delivery (SATOD) Trend-See below 2013-14 - Q1 2015-16 HSCIC

% breast feeding of those with data 49.4 64.9 58.7 64.0 55.2 59.5 2014-15 RiO

% of all births 15.36 25.60 29.94 29.99 24.66 26.22 2014-15 RiO

Fig 10. Maternal mood

assessment (MMA)% of women having a MMA 67.5% 76.6% 91.1% 92.3% 90.3% 86.4% 2014-15 RiO

Care plans for PND per 1,000 births 2.2 2.5 15.1 6.6 15.2 8.3 2014-15 RiO

Fig 11. A&E AttendancesRate of A&E attendances (per 1000 0-

4 year olds)493.1 365.1 349.8 293.6 242.9 382.2 2014-15 SUS

Fig 12. Hospital admissions Rate of admission for accidental and

deliberate injury in 0-4y per 100018.9 14.2 14.1 13.5 19.4 16.8 14.10

2014-15

2013-14

SUS 2014-15

Eng 2013-14

PHE

Fig 13. Early Years

Foundation Stage

Programme (EYFSP)

% achieving a good level of

development61.6 66.3 70.3 69.8 54.2 63.8 60.4 2013-14 DfE

Fig 14. Take up of 2 year

old funding

Percentage of eligible 2 year olds

taking up funded nursery places 76.4 69.3 69.2 59.6 62.3 67.1 Apr-Jul 2015 BCC, CYPS

Fig 15. National Child

Measurement Programme

% of 4-5 year olds overweight or

obese20.9 16.5 20.9 16.9 16.0 17.9 2013-14 NCMP

% HV staff (excl team lead and FNP) 20.1% 34.5% 13.3% 18.4% 13.7% 2014-15 RiO

Caseload: % of Bucks new births 24.2% 28.1% 9.4% 16.1% 22.2% 2014-15 RiO

Caseload: % of Bucks 0-4y olds 22.6% 30.7% 9.5% 17.0% 20.3% 2014-15 RiO

Caseload: % of Bucks 0-4y in DQ5 35.6% 16.3% 0.0% 6.1% 42.0% 2014-15 RiO

Caseload ratio per total HV skill mix

staff (WTE) 261 242 168 245 318 248 Apr-15

Caseload ratio per HV incl. FNP 288 366 328 296 386 310 Apr-15

Caseload ratio per HV excl. FNP 313 383 350 308 435 330 Apr-15

New birth visits inside 14 days 86.2% 84.8% 89.1% 88.8% 83.9% 85.9% 2014-15 RiO

6-8 week visits 71.2% 89.2% 100.0% 97.2% 93.5% 93.8% 2014-15 RiO

Safeguarding care plans 3.3 5.0 3.6 4.7 4.4 5.0 2014-15 RiO

Parenting skills and family support

care plans10.9 18.1 38.5 13.3 15.8 20.2 2014-15 RiO

Looked after children 4.7 1.3 1.6 1.1 3.1 2.5 Mar-15 BCC, DfE

Child Protection Plans 6.1 3.3 4.9 2.4 4.9 4.7 Mar-15 BCC, DfE

Children in Need 12.4 7.9 11.8 6.4 14.4 10.7 Mar-15 BCC, DfE

% of all FNP clients in Bucks 31.0% 19.0% 9.0% 11.0% 30.0% 2014-15 RiO

FNP clients as % of notified women 44.0% 47.0% 40.0% 38.0% 52.0% 45.0% 2014-15 RiO

FNP clients as % of estimated

eligible women35.3% 28.0% 21.5% 21.0% 43.6% 31.4% 2014-15 RiO

Average annual number of FNP

clients offered20 12 6 7 19 65 2014-15 RiO

Not registered 2824 3945 1118 2041 2320 12248 Sep-14 - Aug 15 BCC

Registered 1840 2640 857 1255 1728 8320 Sep-14 - Aug 15 BCC

Reg & Accessing 1181 1370 520 595 1048 4714 Sep-14 - Aug 15 BCC

Reg & Engaged 1840 2047 827 1012 1785 7511 Sep-14 - Aug 15 BCC

2013-14 to 2014-15 HSCIC

Q1 13/14 Q2, 13/14 Q3, 13/14 Q4, 13/14 Q1, 14/15. Q2, 14/15. Q3, 14/15 Q4, 14/15. Q1, 15/16

England 12.0 11.7 12.0 12.3 11.5 11.5 11.4 11.1 10.7

NHS Aylesbury Vale CCG 9.8 7.6 8.2 8.4 9.2 8.7 9.2 6.8 6.0

NHS Chiltern CCG 7.0 7.4 7.4 8.4 7.9 9.2 7.2 6.9 5.8

Fig 8. % Women smoking at

the time of delivery

(SATOD) Trend 2013-14 and

2014-15

Fig 1. Population

Fig 2. Ethnicity of new births

HEALTH VISITOR LOCALITY PROFILES - SUMMARY DATASET

GP

reigistrations,

HV team data

Fig 17 Caseload ratio of 0-4

y olds per HV staff in

Bucks

SATOD data is published by the Health and Social Care Information Centre at CCG level quarterly and not available at HV

locality level

Fig 22. Proportion of <5

year population registered,

accessing and engaged

with children's centres

Fig 21. FNP notification,

eligibility and offer

Fig 19. Rate of care plans

for support to families and

children per 1,000 under 5

year olds

Fig 18. Percentage of

eligible births receiving

each mandated, universal

offer visit

Fig 16. HV Caseload and

staff distribution

Fig 9. Breast feeding at 6-8

weeks

Fig 20. Rate of LAC, CPP

and CIN per 1,000 under 5

year olds


ABBREVIATIONS

A&E Accident and Emergency APC Admitted Patient Care BCC Buckinghamshire County Council

CC Childrens’ Centre CCG Clinical Commissioning Group

CI Confidence Interval CIN Children in Need CPP Child Protection Plan

CYPS Children and Young People’s Service DfE Department for Education DQ Deprivation Quintile Eng England

EYFSP Early Years Foundation Stage Programme FNP Family Nurse Partnership

GP General Practice HMRC Her Majesty’s Revenue and Customs HSCIC Health and Social Care Information Centre

HV Health Visitor HVL Health Visitor Locality IMD Index of Multiple Deprivation LAC Looked After Children

LBW Low Birth Weight LSOA Lower Super Output Area MMA Maternal Mood Assessment

MYE Mid-Year Estimates NCMP National Child Measurement Programme

ONS Office for National Statistics PHE Public Health England

PHOF Public Health Outcomes Framework PND Post Natal Depression

Q1 Quarter 1 RIO Community Health Information System

SATOD Smoking at the Time Of Delivery SUS Secondary Uses Services

WTE Whole Time Equivalent

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