Puld. ft!th., Land. 0978) 92, 224-230
Relating Child Health Services to Needs by the Use of Simple Epidemiology Richard J. Madeley M.B., B.S., M.Sc., M.F.C.M.
Specialist #7 Community Medicine, Hea/th Care Planning, Epidemiology, and Preventive Medicine, Nottinghamshire A.H.A. (T), Huntingdon House, Huntingdon Street, Nottingham The publication last year of the Court Report, 1 and the many reactions to it, have focused attention on the problem of child health. Despite the differences in outlook that have become apparent during the course o f the past year it seems to be generally accepted that though many factors, especially social and economic, are 9.f great importalnce there is no doubt that good child health services relevant to'the needs o f the community can have an impact o n child health. This paper describes an attempt in the Nottingham area to use health services in the most effective and efficient manner possible based upon the results .of simple research, using easily available data. Those infants dying in the post neonatal period in the City o f Nottingham in the years 1974-6 have been compared with ~the control group o f children born on the same day but who have not died. There is a gross excess o f deaths in certain Wards o f the City which have been identified by the Nottinghamshire County Council as socially deprived. Other differences between the two groups have been demonstrated, thus allowing risk factors to be demonstrated. By appropriate statistical methods these individual factors have been converted into a scoring system, to be scored in the maternity unit, which identifies children and families in need of extra help during the first few months o f life. ApproximatelylO~ o f babies will fall into a high risk category. These babies will then be intensively followed up by health visitors: Their names will also be made available to general practitioners and casualty Officers. The scoring system itself is unique in that it uses area o f residence as an important weighting factor, thus reflecting the effect o f social conditions on child health. This system has been thoroughly discussed with representativas of the midwives, health visitors, general practitioners and paediatricians. Their response has been enthusiastic. The system will come into operation on 1 January 1978. As a result, it is hoped that, at a .timeof acute financial stringency, results can be obtained by a more effective and e~cient use o f existing resources. Introduction T h e recently published R e p o r t o f the Committee o n Child Hefilth Services " F i t for t h e F u t u r e " , has analysed certain problems i n t h e field o f child health in Britain, especially in inner urban areas. I n 1975, against t h e background o f slowly i m p r o v i n g figures nationally, the Infant Mortality Rate in N o t t i n g h a m South Health District rose from t6/1000 to 20/1000 live births. P r e l i m i n a r y analysis o f the pattern o f these deaths showed t h a t the deterioration was accounted for b y a worsening o f the position :in the inner wards o f Nottingham city. A m o r e detailed analysis was therefore undertaken. This p a p e r summarizes the most important findings, and the suggestions that h a v e been made f o r improving the situation. 0038-3506/78/050224+07 $01.00/0
@ 1978 The Society of Community Medicine
Relating chiM health services to needs
225
Methods Information about the 72 children (aged 1 month-I year) who died in Nottingham in 1974-6 was obtained from (a) the death notification sent to the Area Medical Officer; (b) birth notifications; (c) Health Visitors' records; (d) obstetric records of the mother and (e) Observation ("at-risk") register. Two controls were chosen for each death. This was done by Iaking birth notifications on each side of that of the dead child, by random numbers. Information about the controls was obtained from the same sources as for the deaths, with the exception of death notifications. Coverage was complete in the case of death and birth notifications, and the Observation register. Health Visitors' records were obtained for 66 deaths (92~°~,) and 1 15 controls (80%). The obstetric records of the mother were obtained for 60 deaths (83 o/) and 123 controls (85 %), Chi-squared tests were carried out between the death and control groups. In this way the degree of importance of a particular item as a risk factor could b e determined. Those items where a difference significant at the 10 % level or higher was obtained, were investigated further using the method of step-wise discriminant analysis, described by Emery & Carpenter. °- This process converts the degree o f risk into a numerical value.
Results
The most striking single finding was the grouping o f post-neonatal deaths in certain parts of the city. This distribution does not merely reflect the childhood population of Nottingham, as can be seen from comparing the number of deaths and controls in each ward (Table I). Other measurements o f child health show the same distribution. These include admissions to hospital, admissions to the special care baby unit, admissions to hospital because of failure to thrive, admissions for non-accidental injury. ~ Further analysis o f t h e deaths revealed other factors, many of which have been described elsewhere. 4-~ The babies who died had significantly lower birth weights than ehe control groups. Their mothers were younger, likelier to be unmarried and likelier to bottle feed. They were likelier to have more brothers and sisters, conceived at more frequent intervals. Their fathers were likelier to be in manual occupatioas. Forty-nine o f the 7/2 deaths (69%) were classified as being due to respiratory infections or sudden death in infancy. Sixty-eight deaths (95 %) of them occurred before the end :of the seventh month. Most :of the deaths occurred during the winter months. In 1975, the Nottinghamshire County Council published a report oh social deprivation within the county, known as the Deprived A r e a Study) In this, an index of deprivation was calculated for each ward of the city o f Nottingham, by means o f a Principal Component Analysis. The items used chosen for this analysis are shown in Table 2. There was a striking re|ationship between deprivation and post-neonatal mortality (Table
3, Fig. 2). An analysis o f the wards with the greatest child health problems, showed that there was no greater provision of services in these more needy areas. For example the ratio of Health Visitors to population was lower in these wards than in suburban districts. Also, in the ward with the worst results, Radford, there are no fewer than 30 G.P.s witll more than I00 patients, leading to considerable fragmentation of care.
R. J. M a d e l e y N
2
Key" to
e
2345-
St AJbons Byron P0rlland Mapperley Forest
6
St. Anns
I-
3 '0
15
Words
-
7 - ManverS
14
13
\
~' 10
"J9
"
"
8
8 - Tren! 9 -Bridge I 0 - Lenton I i - Universily 12- Clifton 13 - Abbey 14- Wolloton 15E3roxtowe ~6 -.Robin HOOd 17 - Roclford 18- Morket
12
Figure i. Address of post-neonatal deaths 1974-6. Each dot represents a post-neonatal death. "fABLE 1. Breakdown of post-neonatal deaths 1974-6 b y ward of deaths
No.
Ward Radford Lenton Market Bridge Clifton St Arms R o b i n Hood Broxtowe Byron ~:Vollaton Trent Portland St Albans Manvers University Mapperley Forest Abbey
Total
13 11 7 7 3 2 3 3 7 5 3 2 2 1 1 I 1 0 72
Rate per 1000 17.6 15-0 15.0 1.1.7 11 ~3 10.0 9.0 9"0 5.8 6"3 5.6 5.0 4-8 3.0 2-1 1-8 1-4 ~
No. of controls I1 1I 7 9 4 3 5 5 18 |2 8 6 7 5 7 8 1t 2
144
Relathlg child health services to needs
227
T^BLE 2. Indices of deprivatiora
Income
households with no car families with children receiving free school meals
Emplo)wlent
economically aclive males semi-skilled economically active males° unskilled long term unemployed
Housing
6 7 8 9 10
households without exclusive useofhot water, fixed bath or inside W.C. Vohouseholds sharing a dwelling Vohouseholds in privately rented accommodation ~o households in Local Authority and N.C.B. rented accommodation Vohouseholds with more than 1.5 persons per room
EducatioJl
11
persons in employment without qualifications--"A" levels, O.N.C. or S.C. 70 E.S.N. children aged 5-15
12
Sacio-cu#ural
Crime
t3 14 15 16 17
population with both parents born in New Commonwealth single parent families with dependent children persons of pensionable age Vohouseholds with children statutorily supervised aged 5-17 ~0households with ~zhildren in care, aged 5-17
18 19 20
adults convicted o f assault/wounding ~0adults convicted o f burglary]theft adults convicted o f breach of the I~eaee
T^ULE 3. Rank Order--data for Figure 2
Ward
Deprivation study
Radford Lenton Market Bridge Clifton St Anr~s Robin Hood Broxtowe Byron Wollaton Trent :Portland St Albans Manvers University Mapperley Forest Abbey
4 5 1 3 12 2 10 7 I1 16 9 14 13 8 17 15 6 18
Post-neonatal mortality 1 22} 4 5 6 71
7t 9 10 11 12 13 !4 15 16 17 18
R, J. Madeley
228 181
g
17
0/
16 15
•
/
/
14
5
•
9-
. /
81-
,i/ ,.
I
1
I
2 3
I
l
I
4 5
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•
t
I
6 7 8
I
I
l
•
/
o o
1
J I
!
I
I
I
9 I0 il 12 13 14 15 16 17 18
Post- neonotol mortality- Rank order
Figure 2. Relations~p between depr~vadon and mortality. Using Spcarman's ranked correlation coefficient, r = 0'690, P < O ' 0 I .
Discussion It is particularly important, a t a time of financial stringency both in the N.H.S, and nationally, that resources are used in the most effective manner possible. From the data described it is possible in Nottingham t o define at birth a group o f infants who are particularly likely to be in need o f help in the first year of life. Factors, likelier to be possessed by the children in the death, group than controls can, by the technique of stepwise discriminant analysis, be converted into a scoring system (Table 4). Those babies scoring more than (+500) on this scoring system are considered to be in need of extra help. They represent approximately 10% of total births (see Table 5). TABLE 4. Scoring system Starting score + 1000 (a) Born in M a r k e t / R a d f o r d & Lenton (b) Birthweight 2000 g 2000-2499 g 2500-2999 g 3000-3499 g 3500+ (c) Breast fed baby (d) Age (e) Second stage o f labour less than 15 rain
+200 +425 +215 -t-215 -425 -400 - 3 0 × a g e in years +400
Babies ending with a score Of more than + 500 points under this system were assigned to the high-risk category.
Relating child health services to needs
229
TABI~E5. Semitivity of scoring .system Number of babies scoring more 1hun 500 Controls Deaths
Score > + 500 (High risk) < +500 (Low risk) ,
,,,,,,,,,,
,
,
i3 (9 V,) 131 (91 ~) 144 (IOOZ)
38 ( 3 ~) 34 (47%) 72 (100%) 5
o
f,
Sensitivity = Percenlage of true positives identified-----53 ~. Specificity= Percenlage of false positives excluded = 91%. Increasing the number o f controls in the high risk category t o 15 ~o, by altering the weighlings, increases the number of,deaths predicted to 58% ,
,
,
, ..........
,,,
i
,
*
J
t
Risk group
Controls
Deaths
High Low
2 2 : ( 1 5 ~) 122 (85%) 144 (100%)
42 (58 :o) 30 (42%) 72 (100%) o /
Sensiti~,ity= 58 Y/o. Specificity=,85 %.
Thus a risk group of I 0 Yo wou|d correctly identify 55 % of deaths. In practice, the application of a scoring system to the cases and controls from which it is obtained, can be over-optimistic. The reduction in performance that occurs is usually of the order of 5~o, caused primarily by misclassification errors: .~° The identification of this group opens up the possibility of concentrating resources upon it in an attempt to improve child health. Some observers feel Chat any such attempt is likely to be futile, for example--"When the cilize~s' problem is an education problem, a health problem, an employment problem, a housing problem, then remedial action concentrating on any one of the many aspects o f these problems is unlikely to succeed. The really intractable nature of multiple deprivation is that to solve one problem is but to succumb to another and, since public action is always conceived in a fragmented fashion, resulting programmes have not been relevant to the circumstances o f the inner city". H Whilst such sentiments are in a way understandable, they unfortunately offer a perfect excuse for doing nothing. What will be interesting t o see is the extent to which a more sensitive medical care system can achieve results irrespective o f decisions 'taken by other social agencies. The strategy Will mean increased surveillance of those babies identified by the scoring system, without .usurping ~[he role o f the ,family. This will :immediately involve more frequent visits by health visitors in o~der to lo0k out for trouble, and to help build up the confidence of the mother. It is envisaged that each child will be visited in the home every fortnight for t~e first few weeks. Continuous assessment o f the progress of the baby will be made, and if all goes well it will be visited less often. Doctors will also need to be invotved---G.P.s, Community Child Health Doctors, Hospital Paediatricians and Casualty Officers./VI:ost deaths occur in the community, and there is evidence in Nottingham, as elsewhere, that many of the families most in need of help go direct to casualty.
230
R. J. Madeley
T.he factors lying behind these deaths are extremely complex, often with a large number of contributing factors, as has been described in several studies of the problem. Prevention will therefore not be a simple matter. I t probably involves a change o f attitude amongst those involved, leading to more appreciation o f t h e factors involved in a particular situation than an attempt to pin a diagnostic label on it. The scheme has been particularly welcomed by health visitors and their Divisional Nursing Officers in that it enables them to plan the allocation of health visitors to the more needy areas of Nottingham. It also is ofhelp to the individual health visitor in the allocation of her time. The costs of the programme will be very small since no additional establishment of health visitors or any other staff is necessariJy implied. The only costs incurred are in the printing o f forms. Methods of evaluation are under active consideration at the moment though many people in Nottingham feel that the whole exercise will be of immense value as an exercise in health education for all concerned, irrespective o f any other considerations. Acknowledgements Thanks are due to Dr H. I. L~ockett, Area Medical Officer, Nottinghamshire A.H.A. (T), Professor D. Hull, Professor of Child Health, Notthlgham Medical School, and Dr A. D. Clayden, Senior Research Fellow, Department of Community Health, Nottingham Medical School, now Senior Lecturer, Department of Community Health, Medical School, I~eds University for their help and advice. References 1. R.eport of the Committee on Child Health Services (1976). Fitfor the Future. London: H.M.S.O. 2. Carpenter, R. & Emery, J. L. (1974). Identification and follow-up of infants at risk of sudden death in infancy. Nature 250, 729. 3. Wynne, J. & Hull, D. (1977). Why are children admitted 1o hospital ? British MedicalJournalii, 1t40. 4. Morris, J. N. & Heady, A. (1955). Social and biological factors in infant mortality. Lancet i, 348. 5. Department of Health and Social Security (19"70). Confidential enquiry into post-neonatal deaths. Reports on Pab/ic Health and Medical Subjects No. 125. London: H.M.S.O. 6. Ki~hards, I. D. G. & Mclntosh, M-T. (1972). Confidential enquiry into 226 consecutive infant deaths. Archii~esqf Disease in Childhood 47, 697. 7. Ministry of Health (1965). Enquiry into sudden death in infancy. Reports on Public Health and Medical Subjects No. 113. London: H.M.SiO. 8/NOttinghamshire County Council (1975). The County Deprived Area Study, 1975. 9. Hills, M. J. (1966). Allocation rules and their error rates.~Royal Statistical Society B28, 1. I0. Lachenbruch, P. A. (1968). Mi~lassification in discriminant analysis. Biometrics 24, 823. 11. Shelter (1972). Another Chmicefor the Cities. SNAP 69/72.
Relating Child Health Services to Needs by the Use of Simple Epidemiology Richard J. Madeley M.B., B.S., M.Sc., M.F.C.M.
Specialist #7 Community Medicine, Hea/th Care Planning, Epidemiology, and Preventive Medicine, Nottinghamshire A.H.A. (T), Huntingdon House, Huntingdon Street, Nottingham The publication last year of the Court Report, 1 and the many reactions to it, have focused attention on the problem of child health. Despite the differences in outlook that have become apparent during the course o f the past year it seems to be generally accepted that though many factors, especially social and economic, are 9.f great importalnce there is no doubt that good child health services relevant to'the needs o f the community can have an impact o n child health. This paper describes an attempt in the Nottingham area to use health services in the most effective and efficient manner possible based upon the results .of simple research, using easily available data. Those infants dying in the post neonatal period in the City o f Nottingham in the years 1974-6 have been compared with ~the control group o f children born on the same day but who have not died. There is a gross excess o f deaths in certain Wards o f the City which have been identified by the Nottinghamshire County Council as socially deprived. Other differences between the two groups have been demonstrated, thus allowing risk factors to be demonstrated. By appropriate statistical methods these individual factors have been converted into a scoring system, to be scored in the maternity unit, which identifies children and families in need of extra help during the first few months o f life. ApproximatelylO~ o f babies will fall into a high risk category. These babies will then be intensively followed up by health visitors: Their names will also be made available to general practitioners and casualty Officers. The scoring system itself is unique in that it uses area o f residence as an important weighting factor, thus reflecting the effect o f social conditions on child health. This system has been thoroughly discussed with representativas of the midwives, health visitors, general practitioners and paediatricians. Their response has been enthusiastic. The system will come into operation on 1 January 1978. As a result, it is hoped that, at a .timeof acute financial stringency, results can be obtained by a more effective and e~cient use o f existing resources. Introduction T h e recently published R e p o r t o f the Committee o n Child Hefilth Services " F i t for t h e F u t u r e " , has analysed certain problems i n t h e field o f child health in Britain, especially in inner urban areas. I n 1975, against t h e background o f slowly i m p r o v i n g figures nationally, the Infant Mortality Rate in N o t t i n g h a m South Health District rose from t6/1000 to 20/1000 live births. P r e l i m i n a r y analysis o f the pattern o f these deaths showed t h a t the deterioration was accounted for b y a worsening o f the position :in the inner wards o f Nottingham city. A m o r e detailed analysis was therefore undertaken. This p a p e r summarizes the most important findings, and the suggestions that h a v e been made f o r improving the situation. 0038-3506/78/050224+07 $01.00/0
@ 1978 The Society of Community Medicine
Relating chiM health services to needs
225
Methods Information about the 72 children (aged 1 month-I year) who died in Nottingham in 1974-6 was obtained from (a) the death notification sent to the Area Medical Officer; (b) birth notifications; (c) Health Visitors' records; (d) obstetric records of the mother and (e) Observation ("at-risk") register. Two controls were chosen for each death. This was done by Iaking birth notifications on each side of that of the dead child, by random numbers. Information about the controls was obtained from the same sources as for the deaths, with the exception of death notifications. Coverage was complete in the case of death and birth notifications, and the Observation register. Health Visitors' records were obtained for 66 deaths (92~°~,) and 1 15 controls (80%). The obstetric records of the mother were obtained for 60 deaths (83 o/) and 123 controls (85 %), Chi-squared tests were carried out between the death and control groups. In this way the degree of importance of a particular item as a risk factor could b e determined. Those items where a difference significant at the 10 % level or higher was obtained, were investigated further using the method of step-wise discriminant analysis, described by Emery & Carpenter. °- This process converts the degree o f risk into a numerical value.
Results
The most striking single finding was the grouping o f post-neonatal deaths in certain parts of the city. This distribution does not merely reflect the childhood population of Nottingham, as can be seen from comparing the number of deaths and controls in each ward (Table I). Other measurements o f child health show the same distribution. These include admissions to hospital, admissions to the special care baby unit, admissions to hospital because of failure to thrive, admissions for non-accidental injury. ~ Further analysis o f t h e deaths revealed other factors, many of which have been described elsewhere. 4-~ The babies who died had significantly lower birth weights than ehe control groups. Their mothers were younger, likelier to be unmarried and likelier to bottle feed. They were likelier to have more brothers and sisters, conceived at more frequent intervals. Their fathers were likelier to be in manual occupatioas. Forty-nine o f the 7/2 deaths (69%) were classified as being due to respiratory infections or sudden death in infancy. Sixty-eight deaths (95 %) of them occurred before the end :of the seventh month. Most :of the deaths occurred during the winter months. In 1975, the Nottinghamshire County Council published a report oh social deprivation within the county, known as the Deprived A r e a Study) In this, an index of deprivation was calculated for each ward of the city o f Nottingham, by means o f a Principal Component Analysis. The items used chosen for this analysis are shown in Table 2. There was a striking re|ationship between deprivation and post-neonatal mortality (Table
3, Fig. 2). An analysis o f the wards with the greatest child health problems, showed that there was no greater provision of services in these more needy areas. For example the ratio of Health Visitors to population was lower in these wards than in suburban districts. Also, in the ward with the worst results, Radford, there are no fewer than 30 G.P.s witll more than I00 patients, leading to considerable fragmentation of care.
R. J. M a d e l e y N
2
Key" to
e
2345-
St AJbons Byron P0rlland Mapperley Forest
6
St. Anns
I-
3 '0
15
Words
-
7 - ManverS
14
13
\
~' 10
"J9
"
"
8
8 - Tren! 9 -Bridge I 0 - Lenton I i - Universily 12- Clifton 13 - Abbey 14- Wolloton 15E3roxtowe ~6 -.Robin HOOd 17 - Roclford 18- Morket
12
Figure i. Address of post-neonatal deaths 1974-6. Each dot represents a post-neonatal death. "fABLE 1. Breakdown of post-neonatal deaths 1974-6 b y ward of deaths
No.
Ward Radford Lenton Market Bridge Clifton St Arms R o b i n Hood Broxtowe Byron ~:Vollaton Trent Portland St Albans Manvers University Mapperley Forest Abbey
Total
13 11 7 7 3 2 3 3 7 5 3 2 2 1 1 I 1 0 72
Rate per 1000 17.6 15-0 15.0 1.1.7 11 ~3 10.0 9.0 9"0 5.8 6"3 5.6 5.0 4-8 3.0 2-1 1-8 1-4 ~
No. of controls I1 1I 7 9 4 3 5 5 18 |2 8 6 7 5 7 8 1t 2
144
Relathlg child health services to needs
227
T^BLE 2. Indices of deprivatiora
Income
households with no car families with children receiving free school meals
Emplo)wlent
economically aclive males semi-skilled economically active males° unskilled long term unemployed
Housing
6 7 8 9 10
households without exclusive useofhot water, fixed bath or inside W.C. Vohouseholds sharing a dwelling Vohouseholds in privately rented accommodation ~o households in Local Authority and N.C.B. rented accommodation Vohouseholds with more than 1.5 persons per room
EducatioJl
11
persons in employment without qualifications--"A" levels, O.N.C. or S.C. 70 E.S.N. children aged 5-15
12
Sacio-cu#ural
Crime
t3 14 15 16 17
population with both parents born in New Commonwealth single parent families with dependent children persons of pensionable age Vohouseholds with children statutorily supervised aged 5-17 ~0households with ~zhildren in care, aged 5-17
18 19 20
adults convicted o f assault/wounding ~0adults convicted o f burglary]theft adults convicted o f breach of the I~eaee
T^ULE 3. Rank Order--data for Figure 2
Ward
Deprivation study
Radford Lenton Market Bridge Clifton St Anr~s Robin Hood Broxtowe Byron Wollaton Trent :Portland St Albans Manvers University Mapperley Forest Abbey
4 5 1 3 12 2 10 7 I1 16 9 14 13 8 17 15 6 18
Post-neonatal mortality 1 22} 4 5 6 71
7t 9 10 11 12 13 !4 15 16 17 18
R, J. Madeley
228 181
g
17
0/
16 15
•
/
/
14
5
•
9-
. /
81-
,i/ ,.
I
1
I
2 3
I
l
I
4 5
•1
•
t
I
6 7 8
I
I
l
•
/
o o
1
J I
!
I
I
I
9 I0 il 12 13 14 15 16 17 18
Post- neonotol mortality- Rank order
Figure 2. Relations~p between depr~vadon and mortality. Using Spcarman's ranked correlation coefficient, r = 0'690, P < O ' 0 I .
Discussion It is particularly important, a t a time of financial stringency both in the N.H.S, and nationally, that resources are used in the most effective manner possible. From the data described it is possible in Nottingham t o define at birth a group o f infants who are particularly likely to be in need o f help in the first year of life. Factors, likelier to be possessed by the children in the death, group than controls can, by the technique of stepwise discriminant analysis, be converted into a scoring system (Table 4). Those babies scoring more than (+500) on this scoring system are considered to be in need of extra help. They represent approximately 10% of total births (see Table 5). TABLE 4. Scoring system Starting score + 1000 (a) Born in M a r k e t / R a d f o r d & Lenton (b) Birthweight 2000 g 2000-2499 g 2500-2999 g 3000-3499 g 3500+ (c) Breast fed baby (d) Age (e) Second stage o f labour less than 15 rain
+200 +425 +215 -t-215 -425 -400 - 3 0 × a g e in years +400
Babies ending with a score Of more than + 500 points under this system were assigned to the high-risk category.
Relating child health services to needs
229
TABI~E5. Semitivity of scoring .system Number of babies scoring more 1hun 500 Controls Deaths
Score > + 500 (High risk) < +500 (Low risk) ,
,,,,,,,,,,
,
,
i3 (9 V,) 131 (91 ~) 144 (IOOZ)
38 ( 3 ~) 34 (47%) 72 (100%) 5
o
f,
Sensitivity = Percenlage of true positives identified-----53 ~. Specificity= Percenlage of false positives excluded = 91%. Increasing the number o f controls in the high risk category t o 15 ~o, by altering the weighlings, increases the number of,deaths predicted to 58% ,
,
,
, ..........
,,,
i
,
*
J
t
Risk group
Controls
Deaths
High Low
2 2 : ( 1 5 ~) 122 (85%) 144 (100%)
42 (58 :o) 30 (42%) 72 (100%) o /
Sensiti~,ity= 58 Y/o. Specificity=,85 %.
Thus a risk group of I 0 Yo wou|d correctly identify 55 % of deaths. In practice, the application of a scoring system to the cases and controls from which it is obtained, can be over-optimistic. The reduction in performance that occurs is usually of the order of 5~o, caused primarily by misclassification errors: .~° The identification of this group opens up the possibility of concentrating resources upon it in an attempt to improve child health. Some observers feel Chat any such attempt is likely to be futile, for example--"When the cilize~s' problem is an education problem, a health problem, an employment problem, a housing problem, then remedial action concentrating on any one of the many aspects o f these problems is unlikely to succeed. The really intractable nature of multiple deprivation is that to solve one problem is but to succumb to another and, since public action is always conceived in a fragmented fashion, resulting programmes have not been relevant to the circumstances o f the inner city". H Whilst such sentiments are in a way understandable, they unfortunately offer a perfect excuse for doing nothing. What will be interesting t o see is the extent to which a more sensitive medical care system can achieve results irrespective o f decisions 'taken by other social agencies. The strategy Will mean increased surveillance of those babies identified by the scoring system, without .usurping ~[he role o f the ,family. This will :immediately involve more frequent visits by health visitors in o~der to lo0k out for trouble, and to help build up the confidence of the mother. It is envisaged that each child will be visited in the home every fortnight for t~e first few weeks. Continuous assessment o f the progress of the baby will be made, and if all goes well it will be visited less often. Doctors will also need to be invotved---G.P.s, Community Child Health Doctors, Hospital Paediatricians and Casualty Officers./VI:ost deaths occur in the community, and there is evidence in Nottingham, as elsewhere, that many of the families most in need of help go direct to casualty.
230
R. J. Madeley
T.he factors lying behind these deaths are extremely complex, often with a large number of contributing factors, as has been described in several studies of the problem. Prevention will therefore not be a simple matter. I t probably involves a change o f attitude amongst those involved, leading to more appreciation o f t h e factors involved in a particular situation than an attempt to pin a diagnostic label on it. The scheme has been particularly welcomed by health visitors and their Divisional Nursing Officers in that it enables them to plan the allocation of health visitors to the more needy areas of Nottingham. It also is ofhelp to the individual health visitor in the allocation of her time. The costs of the programme will be very small since no additional establishment of health visitors or any other staff is necessariJy implied. The only costs incurred are in the printing o f forms. Methods of evaluation are under active consideration at the moment though many people in Nottingham feel that the whole exercise will be of immense value as an exercise in health education for all concerned, irrespective o f any other considerations. Acknowledgements Thanks are due to Dr H. I. L~ockett, Area Medical Officer, Nottinghamshire A.H.A. (T), Professor D. Hull, Professor of Child Health, Notthlgham Medical School, and Dr A. D. Clayden, Senior Research Fellow, Department of Community Health, Nottingham Medical School, now Senior Lecturer, Department of Community Health, Medical School, I~eds University for their help and advice. References 1. R.eport of the Committee on Child Health Services (1976). Fitfor the Future. London: H.M.S.O. 2. Carpenter, R. & Emery, J. L. (1974). Identification and follow-up of infants at risk of sudden death in infancy. Nature 250, 729. 3. Wynne, J. & Hull, D. (1977). Why are children admitted 1o hospital ? British MedicalJournalii, 1t40. 4. Morris, J. N. & Heady, A. (1955). Social and biological factors in infant mortality. Lancet i, 348. 5. Department of Health and Social Security (19"70). Confidential enquiry into post-neonatal deaths. Reports on Pab/ic Health and Medical Subjects No. 125. London: H.M.S.O. 6. Ki~hards, I. D. G. & Mclntosh, M-T. (1972). Confidential enquiry into 226 consecutive infant deaths. Archii~esqf Disease in Childhood 47, 697. 7. Ministry of Health (1965). Enquiry into sudden death in infancy. Reports on Public Health and Medical Subjects No. 113. London: H.M.SiO. 8/NOttinghamshire County Council (1975). The County Deprived Area Study, 1975. 9. Hills, M. J. (1966). Allocation rules and their error rates.~Royal Statistical Society B28, 1. I0. Lachenbruch, P. A. (1968). Mi~lassification in discriminant analysis. Biometrics 24, 823. 11. Shelter (1972). Another Chmicefor the Cities. SNAP 69/72.
