Guidance

Early years high impact area 5: Improving health literacy, managing minor illnesses and reducing accidents

Updated 19 May 2021

Applies to England

On average, annually 55 children under the age of 5 die due to an unintentional injury, 370,000 children attend the emergency departments and 40,000 children are admitted to hospital as an emergency. Each year over 300 infants die suddenly and unexpectedly, many in circumstances with recognised risk factors such as unsafe sleeping arrangements.

Illnesses such as gastroenteritis and upper respiratory tract infections, along with injuries caused by accidents in the home, and poor oral health are the leading causes of attendances at emergency departments and hospitalisation amongst under-5s.

Unintentional injuries are also a major cause of morbidity and premature mortality for children and young people in England. Unintentional injuries for the under-5s tend to happen in and around the home.

They are linked to a number of factors including:

• child development
• the physical environment in the home
• the knowledge and behaviour of parents and other carers (including literacy)
• overcrowding and homelessness
• the availability of safety equipment
• consumer products in the home

Five causes account for 90% of unintentional injury hospital admissions for this age group and are a significant cause of preventable death and serious long-term harm.

These are:

• choking, suffocation and strangulation
• falls
• poisoning
• burns and scalds
• drowning

Understanding other local causes can help focus local action. Furthermore, hazards change, especially as new products such as hair straighteners or liquid detergent capsules emerge, and the risks will vary according to the developmental age of the child. Recently, concerns have been raised about harm caused by swallowing powerful button batteries and the dangers of cot bumpers and sleeping pods.

Around 1 in 11 children utilise hospital outpatients and 1 in 10 to 15 are admitted overall, with emergency hospital admission rates for unintentional injuries among the under-5s, 38% higher for children from the most deprived areas compared with children from the least deprived areas. Data showing local authorities’ child injury rates that are similar to those for England may mask significant inequalities between smaller geographical areas, for example districts or wards, which need addressing through child injury prevention actions.

Dental extractions are one of the most common reasons for anaesthesia in under-5s and tooth decay is a leading cause of parents seeking medical help and advice.

Research shows the average NHS short-term financial cost of a hospital admission for 2 days or more for a burn, poisoning or fall in the under-5s (the 3 most common causes of hospital admissions in this age group) ranges from £2,500 to £3,000. The NHS cost of an admission for up to one day ranges from £700 to £1,000 and for an emergency department attendance without admission from £100 to £180.

These figures do not include costs for NHS or social care for longer term follow-up of more severely injured children and will therefore underestimate the true costs of these injuries.

In 2014, all age NHS dental treatment costs were £3.4 billion with an estimated additional £2.3 billion in the private sector. In the financial year 2015 to 2016, the cost of tooth extractions in hospital was approximately £50.5 million among children aged 0 to 19 years. Among the under-5s, the cost was £7.8 million.

The personal costs of an injury can be devastating to a child or family and can have major effects on their long-term education, employment, emotional wellbeing and family relationships. The majority of unintentional injuries are preventable, making them a public health priority.

Sudden unexpected death in infancy (SUDI) is defined as an unexpected death of a child which was not anticipated, a significant possibility 24 hour before the death, or where there was a similarly unexpected collapse leading to or precipitating the events which led to the death. SUDI refers to all unexpected deaths up to one year of age at the point of presentation. As such it is a descriptive term rather than a diagnosis. At the conclusion of an investigation, the deaths will be divided into those for which we have a clear diagnosis, including those related to underlying medical causes, accidents and homicides, and those for which we do not have a diagnosis.

In the UK, over 300 babies die suddenly and unexpectedly every year. Health visitors have a unique role in the prevention of SUDI as they contact parents in the antenatal period and up to 14 days after delivery to undertake a new birth visit. Health visitors will provide evidence-based information to parents on safer sleep which can prevent and reduce the risk of SUDI.

There has been a 70% reduction in the number of SUDI deaths since the early 1990s. This is largely due to the discovery that babies are much safer when placed on their back to sleep. Encouraging parents to stop smoking during and after pregnancy also reduces the risk of SUDI. SUDI occurs more in the younger and more vulnerable families due to the factors connected to health inequality such as low income, poor accommodation, smoking and the misuse of drugs .

There is benefit in considering how targeted multi-modal interventions that provide a safe infant sleep space with comprehensive face to face safe sleep education can be embedded in wider whole family initiatives to promote infant safety, health and wellbeing and where possible involving practitioners from all agencies working with families with children at risk.

The role of health visitors

Health visitors, as public health nurses, use strength-based approaches, building non-dependent relationships to enable efficient and effective working with parents and families to support behaviour change, promote health protection and to keep children safe.

Health visitors also undertake a holistic assessment in partnership with the family, which builds on their strengths as well as identifying any difficulties. It includes the parents’ capacity to meet their infant’s needs, the impact and influence of wider family, community and environmental circumstances. This period is an important opportunity for health promotion, prevention and early intervention approaches to be delivered. Working with parents and families, health visitors identify the most appropriate level of support and intervention for their individual needs.

Healthy Child Programme

The Healthy Child Programme offers every family a programme of screening tests, immunisations, developmental reviews, information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.

The Healthy Child Programme is universal in reach. It sets out a range of public health support in local places to build healthy communities and to reduce inequalities. It also includes a schedule of interventions, which range from services for all through extra help to intensive support.

The Healthy Child Programme is personalised in response. All services and interventions need to be personalised to respond to families’ needs across time. For many families this will be met by the universal offer. More targeted, intensive or specialised support and evidence-based interventions should be provided early to meet ‘predicted, assessed and expressed need’ to improve outcomes.

Improving health and wellbeing

The high impact areas will focus on interventions at the following levels and will use a place-based approach:

• individual and family
• community
• population

The place-based approach offers new opportunities to help meet the challenges public health and the health and social care system face. This impacts on the whole community and aims to address issues that exist at the community level, such as poor housing, social isolation, poor or fragmented services, or duplication or gaps in service provision. Health visitors as leaders in public health and the Healthy Child Programme: Pregnancy and the first 5 years of life programme are well placed to support families and communities to engage in this approach. They are essential to the leadership and delivery of integrated services for individuals, communities and population to provide RightCare that maximises place-based systems of care.

Individual and family

Health visitors are accessible to all parents and provide a trusted source of knowledge, advice and information, and are often the first point of contact for parents who are unsure on the best course of action when their child is unwell. They can support families to be more confident increasing parental self-efficacy and empowering the family to make the changes required to improve home safety. Health visitors play an important role in the primary care team and can help to reduce unnecessary visits to emergency departments and pressure on primary care. If a child sustains an unintentional injury, the health visitor can follow up this attendance to offer preventative solutions, which could prevent further or repeat attendances.

Health visitors work using a health promoting approach, with a focus on prevention and self-efficacy rather than treatment or cure. For example, promoting breastfeeding, safer sleep, responsive infant feeding, hygiene awareness, immunisations, oral health, providing support for parents to give up smoking and messages such as Choose Well and Smoke Free can reduce attendances at the emergency departments and prevent hospital admissions.

They can play an essential role in educating parents, children and family members in the importance of good food hygiene, hand hygiene, particularly targeted hygiene such as after using the toilet, before preparing food or eating and when family members are unwell. They can also play an important role in improving parental health literacy to manage minor illnesses, including information relating to antimicrobial resistance and the appropriate use of antibiotics, and compliance with medications and equipment.

appropriate use of antibiotics.

The health visitor’s role is invaluable in improving uptake of immunisations. They work with other professionals, for example general practice nurses, to maintain a high uptake of the national childhood immunisation programme, including the flu vaccination programme for children. This programme provides vital protection to children and young people and results in indirect protection to those around them, including infants, older people, and those in clinical risk groups.

They will encourage access to local health services, including registration with a GP and local dentist and the promotion of going to a dentist as soon as the first tooth erupts via the dental check by one campaign.

Health visitors can provide advice, support, and signpost new parents on a range of common childhood illnesses, such as fever, cough and colds, vomiting and diarrhoea and oral health problems. This builds parental confidence and knowledge on self-management and when to seek help enabling them to manage childhood illnesses at home, access appropriate support and services and reduce unnecessary emergency department attendances.

Healthier Together is a useful tool that can be used during consultations for patients with self-limiting infections such as coughs, colds or flu. It includes information on illness duration, self-care advice, warning symptoms and advice on when to consult a GP or NHS 111.

Services provided by health visitors are not intended to provide first line treatment or diagnostic services for acutely unwell children. However, they do have the knowledge to support parents to make the decision about the most appropriate course of action to take. Health visitors can advise and guide on the signs and symptoms of more serious diseases such as meningitis, bronchiolitis and chicken pox and can raise awareness of when to seek urgent medical treatment.

Health visitors play an important role with families, helping parents to recognise early signs of illness and provide advice or support to allay fears and concerns, for example about sepsis, a rare but serious illness. They can work with families in the home or in settings such as early years services, and in the event of a local disease outbreak, they will work with general practice nurses, the wider primary health care team and local public health teams.

As community nurse prescribers or independent prescribers, health visitors can support the management of diabetes, epilepsy, skin conditions and asthma, therefore stabilising symptoms through the correct use of medication and through patient education. They can also provide brief interventions and referral to specialist services if required.

Health visitors have opportunities to support accident prevention in high-risk groups, for example those living in hostels or who may be homeless, and to help families anticipate and respond appropriately to changing circumstances and out-of-routine situations, such as a new partner, parental physical or mental ill health, or visiting relatives. Exploring child development with parents within and beyond the home provides a foundation for the prevention of unintended injuries.

They can review the severity and frequency of attendances at emergency departments or other minor ailment centres to assess if parenting capacity or other environmental factors are affecting a child’s wellbeing or are indicators of safeguarding concerns. Appropriate follow-up can be arranged and, or signposting to services that are able to support safety in the home environment.

If further support for home safety is required, a safety plan with interventions to reduce the risk of further incidents and, or identify and respond to multiple incidents could be discussed. Parental education and building confidence or self-efficacy are a vital part of the work of health visitors in supporting parents to reduce unintentional injuries.

Community

The health visitor will also lead and support delivery of preventative programmes for infants and children through the Healthy Child Programme: Pregnancy and the first 5 years of life. This programme includes regular advice on oral health at each of the mandated reviews, accident prevention and links to safety schemes and wider community resources. They can signpost to local authority-commissioned oral health programmes such as fluoride varnish and supervised tooth brushing programmes in early years services and nurseries.

Health visitors can also work with early years services to ensure that safety messages are promoted across early years services and are tailored to the needs of the local population, for example, ethnic minority families, young parents and homeless families.

Poor housing and overcrowded conditions can lead to increased numbers of accidents. Health visitors can work with local authority housing options and homelessness services to identify and target homeless families, or those at risk of homelessness in temporary accommodation or hostel accommodation to ensure appropriate safety measures are in place. This includes safer sleeping for babies and help to develop pathways out of homelessness and to improved health, wellbeing and wealth outcomes.

Health visitors can Make Every Contact Count to raise health issues, offering awareness-raising, health education and immunisation opportunities to prevent ill health and protect from disease.

Population

Health visitors make links and work with the local authority and multi-agencies on wider determinants of health, such as housing, health and safety. Their role supports the development of local pathways aimed at keeping children out of hospital and they have an important role to play in primary and secondary prevention.

Health visitors lead the Healthy Child Programme: Pregnancy and the first 5 years of life, and provide leadership at a strategic level to contribute to the development and improvement of policies, pathways and strategies to support delivery of high quality, evidence-based, consistent care for children and families for improving health literacy.

At a population level, this data will provide a measure of children’s development and wellbeing as part of the Public Health Outcomes Framework and generate information which can be used to plan services and contribute to the reduction of inequalities in children’s outcomes.

Using evidence to support delivery

A place-based or community-centred approach aims to develop local solutions that draw on all the assets and resources of an area, integrating services and building resilience in communities so that people can take control of their health and wellbeing, and have more influence on the factors that underpin good health.

The All Our Health framework brings together resources and evidence that will help to support evidence-based practice and service delivery, Making Every Contact Count and building on the specialist public health skills of health visitors.

Most health and care professionals focus on interventions that tend to be delivered on an individual basis. However, health visitors and school nurses focus on individuals, families and communities’ approaches. It is critical that all professionals consider the importance of population health as an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population.

Social prescribing complements such approaches, enabling public health nurses and other health and care professionals to refer people to a range of local, non-clinical services. School nurses recognise that children and young people’s health is determined primarily by a range of social, economic and environmental factors. Social prescribing seeks to address individuals needs in a holistic way, taking greater control of their own health.

Measures of success or outcome

High quality data, analysis tools and resources are available for all public health professionals to identify the health of the local population. This contributes to the decision making process for the commissioning of services and future plans to improve people’s health and reduce inequalities in their area, including child and maternal health profiles, measure of access and service experience. Health visitors and wider stakeholders need to demonstrate impact of improved outcomes. This can be achieved using local measures.

Access

Measures include:

• universal reviews of the Healthy Child Programme
• percentage of births that receive a face-to-face New Birth Visit within 14 days by a health visitor
• percentage of children who received a 6 to 8 week review by the time they were 8 weeks old
• percentage of children who received a 12 month review by the time they turned 12 months
• percentage of children who received a 12 month review by the time they turned 15 months
• percentage of children who received a 2 to 2 and a half year review

The above are reported monthly via Community Services Dataset (CSDS).

Effective delivery

Measures include:

• evidence of implementation of locally devised pathways for example on accident prevention
• evidence of interagency training on the prevention of accidents, safer sleep messages, promoting oral health and managing minor illness
• health visiting teams to review all routine hospital attendances for children aged 0 to 5 and identify children who require further assessment or intervention
• health visiting teams to follow up where concerns are highlighted or in accordance with local procedures, for example repeat emergency department attendances, families where there are known vulnerabilities, delayed presentation of injury, inconsistent explanation, serious head injuries, burns and fracture or dental injuries
• neglect and trauma to the teeth or bruising of a non-mobile child, or where parenting was noted as an integral factor to the accident
• referral to partner agencies to provide and fit home safety equipment in low-income families, for example Royal Society for the Prevention of Accidents and the fire service
• signpost parents to online resources and apps to improve parental confidence in managing minor illnesses – for example, Wessex Healthier Together app, Start4Life, NHS Choices
• empower parents to assess their own home safety issues and support to take action to address them
• health visiting services being accessible to parents who are worried about diseases such as meningitis and sepsis and information to address vaccine hesitancy
• health visiting services that identify and raise awareness of when to seek urgent medical attention

Measuring impact

Measures include:

• attendances at any emergency department by a child under 5 years resident in the area in the Early years profiles
• local data can be obtained and set out to monitor the top 10 primary admissions to hospital
• hospital admissions for dental caries in child health profiles
• percentage of children aged 5 years with one or more obviously decayed, missing (due to decay) or filled teeth, collected through the National Dental Epidemiology Programme for England – this indicator is included in the Early years profiles and Public Health Outcomes Framework
• rate of hospital admissions for unintentional injuries and deliberate injuries (0 to 4 years) via trusts’ routine reporting, reported in the Public Health Outcomes Framework and the Early years profiles

Other outcome measures include:

• uptake of dental check by one
• dental access rates for 0 to 2 years
• increased immunisation uptake
• proportion of pregnant women who smoke at the time of delivery as reported through the Maternity Services Data Set
• breastfeeding prevalence at 6 to 8 weeks after birth – number of infants who are totally or partially breastfed at 6 to 8 week review is reported through the Community Services Data Set
• improved early access to medical treatment for urgent situation

User experience

Measures include:

• feedback from NHS Friends and Family Test and service user experience questionnaires on satisfaction, increased knowledge of managing minor illnesses, accident prevention and intended behaviour change
• development of an evaluation tool to measure impact of health visiting service in reducing accidents and increasing parents’ confidence in managing minor illnesses in the community

Other measures can be developed locally and could include measures such as initiatives within health visitors’ building community capacity role, such as developing peer support, engaging fathers, joint developments with parent volunteers and early years services.

Connection with other areas

The high impact area documents support delivery of the Healthy Child Programme and 0 to 5 agenda, and highlight the link with a number of other interconnecting policy areas such as the maternity transformation programme, childhood obesity, speech, language and communication, immunisations, troubled families, mental health and social mobility action plan. The importance of effective outcomes relies on strong partnership authority including early years services, and voluntary sector services.

Best Start in Life has been identified as a priority as part of Public Health England’s (PHE) 5-year strategy, which runs from 2020 to 2025. Best start in life is a priority for the government and as such is included in the Prevention Green Paper (Advancing our Health: prevention in the 2020s).

Improving services for children and young people is part of the NHS Long Term Plan. The Child Digital Strategy and Maternity Programme are currently developing and implementing infrastructure to improve access and timeliness of data with the aim to know where every child is and how well they are. This includes the development and implementation of a Digital Parent Child Health Record. This programme supports the ambitions and modernisation of the Healthy Child Programme.

Collaborative working

Early years services play a key role in supporting improved outcomes for children and families as part of the integrated planning, delivery, monitoring and reviewing approach. Partnerships can use information from Joint Strategic Needs Assessment (including Early Years Foundation Stage Profile data, health data, information about families, communities and the quality of local services and outcomes from integrated reviews) to identify and respond to agreed joint priorities. Children and Family Centres provide a good focus for coordination on this.

Other options include:

• using the Public Health Outcomes Framework indicator reported and benchmarked by PHE and local commissioning
• information sharing agreements in place across all agencies
• integrated commissioning of services or local agreements to improve service pathways and coordination of care
• collation of local data by top 10 primary diagnoses
• commission partnership preventive support programmes to avoid hospital admissions based on local data
• primary care and community services to support out of hospital care
• demonstrating value for money and return on investment

Improvements

These include:

• improved accessibility to services, as families are aware of how to contact their named health visitor
• integrated IT systems, interoperability and information sharing across agencies
• development and use of integrated pathways including primary care and community services to avoid admissions and demonstrate a reduction in inequalities in unintentional injuries
• systematic collection of user experience – for example, NHS Friends and Family Test to inform action
• increased use of evidence-based interventions with incorporated local evaluation methods and links to other early years performance indicators
• improved partnership working – for example, maternity, school nursing and early years services
• consistent, evidence-based information on accident prevention for parents and carers – for example, blind cord safety
• identification of repeat attendance for non-elective admissions
• development of systems to capture interventions to reduce injuries
• development of evaluation tools to measure impact of health visiting service in reducing unintentional injuries

Professional or partnership mobilisation

These include:

• multi-agency training to identify common themes and advice on appropriate unintentional injury prevention
• continued multi-agency safeguarding training
• effective delivery of universal prevention and early intervention programmes
• improved understanding of data within the Joint Strategic Needs Assessment and at the local health and wellbeing board to better support integrated working of health visiting services with existing local authority arrangements to provide a holistic, joined up and improved service for young children, parents and families
• identification of skills and competencies to inform integrated working and skill mix
• health visitors to be aware of how the Child Protection Information System works in hospitals
• understanding barriers to primary care access

Associated tools and guidance

Policy

Chief Medical Officer: Our Children Deserve Better: Prevention Pays Department of Health and Social Care (DHSC), 2013

Child oral health: applying All Our Health

Delivering better oral health: An evidence-based toolkit for protection, PHE, 2014

Early Years Foundation Stage Profile: 2020 handbook, Standards and Testing Agency, 2020

Fever in children, NHS Choices

Healthy Child Programme: Pregnancy and the first 5 years of life, DHSC, 2009

Healthy Child Programme: Rapid review to update evidence, PHE, 2015

Improving oral health: An evidence-informed toolkit for local authorities, PHE, 2014

Preventing unintentional injuries: A guide for all staff working with children under 5 years, PHE, 2017

Reducing unintentional injuries in and around the home among children under 5 years, PHE, 2018

Social Mobility Program, Department for Education (DfE), 2019

Working Together to Safeguard Children, DHSC, 2018

Research

Antibiotic awareness: Treating your infection leaflets, PHE, 2016

Antibiotic Guardian

Child Accident Prevention Trust

Children’s food: Safety and hygiene, NHS Choices

Digital Child Health, NHS Digital, 2020

Place-based systems of care: A way forward for the NHS in England, Ham and Alderwick, NHS England, 2015

Health Matters: Child dental health

How to prevent germs from spreading, NHS Choices

Improving outcomes for patients with sepsis: A cross-system action plan, NHS England, 2015

HSIB issues recommendations to prevent ‘devastating’ deaths from button and coin cell batteries, Healthcare Safety Investigation Branch, 2019

NHS Long Term Plan, NHS England, 2020

Reducing antimicrobial resistance, e-Learning for Healthcare

Royal Society for the Prevention of Accidents (RoSPA)

A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm, National Child Safeguarding Practice Review Panel, 2020

Why Children Die, Royal College of Paediatrics and Child Health, National Children’s Bureau and British Association for Child and Adolescent, Public Health, May 2014

Think sepsis: a film for all healthcare workers involved in the care of sick children, Health Education England, 2016

Think sepsis

Guidance

A Framework for supporting teenage mothers and young fathers, PHE-Local Government Association (GLA), 2016 and 2019

Colds, coughs and ear infections in children, Your Pregnancy and Baby Guide, NHS, 2020

Promoting emotional health and wellbeing and positive mental health of children and young people, DHSC and PHE, 2014

Reduce the risk of sudden infant death syndrome (SIDS), NHS England, 2018

Safeguarding in general dental practice, PHE, 2019

Sepsis in children: Advice for health visitors and school nurses, PHE, 2017

NICE guidance

Brief interventions and referral for smoking cessation, NICE public health guideline [PH1], 2006

Bronchiolitis in children: Diagnosis and management, NICE guideline [NG9], 2015

Diarrhoea and vomiting caused by gastroenteritis in under 5s: Diagnosis and management, NICE clinical guideline [CG84], 2009

Fever in under 5s: Assessment and general management, NICE clinical guideline [CG160], 2019

Head injury: Assessment and early management, NICE clinical guideline [CG176], 2014

Oral health, Local authorities and partners, NICE public health guideline [PH55], 2014

Oral health promotion, general dental practice, NICE guideline [NG30], 2015

Postnatal care up to 8 weeks after birth, NICE guideline [CG37], 2006

Preventing unintentional injury in under-15s, NICE quality standard [QS107], 2016

Reducing differences in the uptake in immunisation, NICE guideline [PH21], 2009

Smoking: stopping in pregnancy and after childbirth, NICE public health guideline [PH26], 2010

Unintentional injuries in the home: Interventions for under-15s, NICE public health guideline [PH30], 2010

Unintentional injuries: Prevention strategies for under-15s, NICE public health guideline [PH29], 2010