Review of the Healthy Child Wales Programme: summary

OB3 Research was commissioned by the Welsh Government to undertake review of the Healthy Child Wales Programme (HCWP).

The Healthy Child Wales Programme (HCWP) is the national framework that sets out the universal offer of child health contacts, screening, surveillance and health promotion for all children and families in Wales. It was launched in 2016 and covers the period from the transition from maternity services through infancy, early childhood and into the early school years, establishing a minimum schedule of planned contacts delivered primarily by health visiting and school nursing services.

The review’s aims were to assess the perceived impact of the HCWP and to examine whether its current delivery is fit for purpose and supports the programme’s objectives.

The work programme for the research involved:

• an inception stage
• a desk review of relevant child health policy, international comparative child health programmes and published HCWP data
• the development of research instruments, including survey tools and discussion guides
• fieldwork with strategic stakeholders, health visitor leads, health visiting staff and other health professionals involved with the HCWP, parents and guardians

Our conclusions are set out below in relation to the 8 identified objectives of the HCWP review.

Review the original goals and objectives of the HCWP

The original goals of the HCWP remain appropriate and widely supported. HCWP continues to provide a national, universal framework that establishes clear expectations for health visiting contacts from birth to 3.5 years. The consistency it provides is valued across policy, management and frontline delivery and is seen as central to ensuring equity of access for families across Wales.

The HCWP’s original goals of universal early years support, early identification and intervention, and reducing inequalities remain valid and relevant, and are strongly endorsed by stakeholders. The programme is seen as a flagship framework that provides a safety net and consistent offer, with early contacts (10-to-14 days and 6 weeks) delivered well and valued.

The evidence demonstrates that there is a growing mismatch between the formal objectives of HCWP and the realities of health visiting practice. Health visitors consistently report that HCWP captures only a portion of their workload, with substantial time devoted to complex, unscheduled and often intensive work that sits outside the programme’s formal structure. As a result, HCWP can feel overly task-focused and does not accurately reflect or capture the breadth and complexity of the health visiting role. The consequence is professionals feeling increasingly over-burdened and this is further driven by workforce capacity constraints, rising family complexity, and rigid compliance pressures.

Workforce capacity is the single biggest constraint identified in the review. Health visitors described increasing caseloads, administrative burden, and emotional strain, with risks to morale and sustainability. The programme’s increasing rigidity was seen to erode professional judgement and reduce effectiveness. Without addressing workforce pressures, further expansion of HCWP expectations (including new tools or assessments) risks undermining quality and continuity.

There is a risk that the programme’s metrics and expectations do not accurately represent the services delivered or where pressures are most acute. Key preventative, safeguarding and mental health work, for example, is invisible in national data.

While HCWP remains the right framework, with sound, universal objectives, it requires modernisation to keep up with the pace of change and remain achievable in practice. Specifically, HCWP requires clearer articulation of how universal contacts sit alongside wider health visiting activity. Without this, there is a risk that national oversight focuses on completion of contacts rather than on whether families’ needs are being effectively met, limiting the programme’s ability to drive meaningful improvement.

The HCWP needs to integrate more flexibility into contact timing and content to allow professional judgement and a proportionate response. Its scope also needs to be refreshed to reflect contemporary priorities such as mental health, healthy weight, additional learning needs and domestic abuse and a greater focus on outcomes (what changes as a result of contacts) rather than the ‘tick box’ exercise of counting contacts.

Compare HCWP with similar programmes internationally

HCWP is broadly aligned with early years public health programmes in comparable countries. Like many international models, it combines universal provision with targeted responses to additional need, and is underpinned by a preventive, early-intervention ethos. At the same time, international examples illustrate that different policy choices are possible. Some countries place greater emphasis on statutory or near-statutory entitlement, clearer minimum standards for delivery, or more intensive contact in the earliest years of life. Others structure their core contacts around fewer, more developmentally focused reviews, supported by stronger multidisciplinary integration.

HCWP is not a fixed or inevitable model. Wales has scope to adjust how the programme is delivered without undermining its core principles. International evidence suggests that changes to contact timing and integration with other services could strengthen HCWP’s impact, but it also highlights that such changes require careful consideration of workforce capacity and system readiness. The implication is that any future reform of HCWP should be seen as a strategic policy choice, informed by evidence rather than constrained by the existing model.

HCWP is also not an outlier in facing some of the issues raised during this review such as the challenges of outcome attribution, accurate data collection and sharing of records across multi-disciplinary teams.

Where HCWP differs, most is in the timing and number of contacts and the strength of integration with adjacent early years services (midwifery, early education, speech and language therapy, paediatrics). The Nordic countries provide Wales with some useful examples of how this could be strengthened in a community-based model in line with the ethos of A Healthier Wales. There is also some evidence from the international comparison that Wales is more heavily reliant on performance monitoring of contact completion, with weaker links between data and continuous, local improvement.

Explore perceptions of the impact of HCWP

It is important to highlight the challenge of attributing any observed impacts solely to HCWP, given that many valued aspects reflect established health visiting practice; as a result, the findings are better interpreted as indicating where HCWP has added value to existing health visiting practice rather than attributing impacts to the programme alone.

HCWP can have a meaningful and positive impact for families when it is delivered as intended. Feedback from parents demonstrate how they value early home visits, ongoing relationship with a named health visitor, and access to professional advice and reassurance. Health visitors describe the important role HCWP plays in enabling this early engagement, building trusting relationships and identifying concerns that might otherwise remain hidden.

Parents value HCWP when it works well but reported some confusion about later contacts, inconsistent communication and a variable experience of delivery depending on locality. Parents would benefit from having a better understanding of the programme and a more flexible offer, as these changes would result in greater engagement and fewer appointments being missed.

HCWP is perceived as impactful for spotting needs early, protecting children, supporting parents’ mental health, and providing preventative health advice. Impact is at its strongest where contacts are delivered flexibly and tailored to need but weaker where delivery is compliance‑driven.

Impact is inconsistent and highly dependent on local delivery and system capacity. Families’ experiences vary between areas, with some reporting reduced contact or limited follow-up. A recurring theme across the evidence is the gap between identifying need and securing timely support. In many cases, HCWP contacts successfully identifies concerns, but onward access to assessment or intervention is often unavailable or delayed, reducing the practical benefit of early identification.

HCWP does not consistently achieve its intended impact for some specific groups of children and families, particularly children with higher levels of need living outside Flying Start areas, families experiencing housing instability or high mobility, and children with additional or emerging needs such as those who are looked after or have potential neurodevelopmental or additional learning needs. For these groups, limited contacts and barriers to accessing timely support constrain the preventative value of the programme.

Children with higher needs but living in areas not covered by Flying Start were repeatedly highlighted as at risk of reduced impact. The evidence indicates that Flying Start enhances engagement and timely interventions, particularly in deprived communities, but postcode-based eligibility creates inequities. Looked after children, and those with potential neurodevelopmental or additional learning needs also often did not receive the additional support required or the identification of their needs did not align well with the HCWP schedule. Many stakeholders favoured a needs-led model that builds on HCWP universal contacts and allows additional support to be triggered through professional opinion and experience. This would help address inequities for high need families outside Flying Start areas while protecting the non-stigmatising nature of universal provision.

Health visitors identified mobility and housing instability as major barriers to continued engagement. Families moving frequently, between health boards, temporary accommodation or across borders, were more likely to miss multiple contacts, fall between systems, and experience delays in referrals.

Parents (both mothers and fathers) also often lacked the follow-on support required for perinatal mental health needs or other issues identified by health visitors.

Working parents reported practical barriers to attending later contacts, especially the 27‑month and 3.5‑year reviews, leading to missed opportunities for early identification. Families with limited knowledge of child development or limited ability to advocate for themselves were also viewed as more likely to disengage or be overlooked without flexible, persistent outreach. Parents consistently asked for clearer communication about what HCWP offers and when contact points will occur.

HCWP’s impact is constrained not by its ability to identify need, but by the wider system’s capacity to respond. Identification without intervention increases the risk of parental anxiety and professional frustration without improving outcomes. Strengthening HCWP therefore requires closer alignment between the programme and the services to which it refers, rather than further emphasis on identification alone.

The review highlights that transitions (from maternity or to school nursing) are pivotal but inconsistently managed, with risks of “cliff edges” for children with emerging or lower-level needs. Integration is strongest where relationships and co-location exist but remains fragile elsewhere due to fragmented systems and unclear accountability. Improving clarity and delivery of these transitions would reduce duplication of effort, ensure information is transferred between services and improve family experience.

The outcomes achieved by the HCWP are not reflected in national data currently as the reporting is focused on whether contacts occurred, not what happened or changed as a result. Key activity around safeguarding, perinatal mental health, enhanced support, and multi‑agency work is all under‑reported. The HCWP would benefit from some light-touch outcome and quality indicators (around actions taken, needs identified, referrals, follow‑up and resolution), and enable local feedback loops so teams can see and use their data more effectively.

Review the content and timing of HCWP contact points

HCWP is most effective in the early postnatal period. Completion rates are highest for the earliest contacts, and these visits are highly valued by both families and practitioners. In contrast, completion rates decline for later contacts.

The evidence consistently highlights the period between 15 and 27 months as a point of vulnerability. This is a phase of rapid developmental change, yet the long gap between contacts increases the risk that emerging speech, language, behavioural or social concerns are identified later than optimal. The universal 3.5-year contact is the most contested element of the programme, with widespread concerns about its deliverability, attendance and added value for families with no identified needs.

The implication is that the current contact schedule does not always align with developmental need or service realities. Maintaining the existing schedule without adjustment risks missing opportunities for earlier intervention while continuing to invest resources in contacts that add less value. Reviewing and recalibrating contact timing therefore represents one of the clearest opportunities to increase the effectiveness of HCWP without expanding the overall scale of the programme. Therefore, whilst the universal logic remains robust the schedule needs rebalancing around the following contact periods:

Antenatal and early postnatal

Evidence suggests antenatal contacts, while part of the HCWP, are not consistently delivered; strengthening this engagement, reducing duplication with midwifery contacts at 10-14 days, and maintaining the 6-week contact with discretion and better alignment with other services could improve effectiveness.

8-, 12-, 16- weeks, 6 months

There is an opportunity to be more flexible and streamline the 8-, 12-, and 16- week visits and/or use a skill mix for lower‑risk families, separate early feeding support from later developmental assessment and close the perceived long gap between 6 and 15 months with an additional, well‑timed review.

15 and 27 months

The evidence suggests that there is appetite to replace the 15‑month contact with a better‑timed developmental checkpoint (around 18 months) and retain the 27‑month review due to its high clinical value but allow greater timing flexibility or add an interim review to avoid missed early intervention windows.

3.5 years

This was widely viewed as low value and duplicative with nursery/school settings and would be better aligned with school entry via structured transitions to school nursing.

Assess changes affecting the relevance of HCWP

Current population and policy trends make HCWP more, not less, relevant. The rising prevalence of speech, language and communication needs, an increased recognition of perinatal and parental mental health issues, an increase in more serious safeguarding issues, and persistent inequalities in child health outcomes all reinforce the importance of a strong universal early years offer.

HCWP continues to align with Welsh policy priorities (prevention, early intervention, equity, ALN and mental health). However, additional policy expectations since its inception have expanded faster than its capacity to deliver. The evidence also indicates that the HCWP guidance has not been consistently updated to reflect these emerging challenges. Key priorities such as perinatal mental health, fathers’ engagement, early language development, healthy weight, and toilet training are addressed unevenly across areas and are not always clearly embedded within programme guidance or training. This in turn contributes to variation in practice and reduces the programme’s ability to respond systematically to contemporary risks.

Without a clearer and more explicit alignment with current priorities, HCWP could become less effective over time, even as the need for early intervention increases. Refreshing programme guidance to reflect these challenges would strengthen its relevance and consistency but it must also be accompanied by consideration of workforce capacity and referral pathways.

Explore access to and use of digital technology and data

There are major weaknesses in the data systems underpinning HCWP. Reliance on paper-based forms and manual data entry leads to under-recording, delays, and inconsistencies. This in turn, undermines confidence in reported completion rates and limits the usefulness of data for performance management or service improvement purposes. The variation in recording practices across areas further complicates interpretation of national data.

The practical consequence is that both national and local decision-making are constrained by incomplete or unreliable information. Managers lack access to timely, accurate data to target improvement activity, and frontline staff receive limited feedback on how all the data they collect are used or how their service compares with others which reduces opportunities for learning and improvement.

Improving data quality and usability is therefore not only a technical issue but a fundamental requirement for effective governance and accountability within HCWP. The digital infrastructure is a critical constraint and is not fit for purpose. Paper and hybrid processes, variable practices, and non‑integrated systems drive under‑recording and duplication of effort. CYPrIS is often seen as a reporting tool, not a clinical support system and cannot provide the type of data that local management and health visitors require.

There is a dire need for a single-entry, integrated Wales-wide digital platform which is aligned to clinical workflows and has built-in interoperability with midwifery, GP services, speech and language therapy and paediatric systems. The addition of clinically useful fields (around actions, needs, and outcomes) would further provide frontline dashboards that could support local decision‑making, not just national reporting.

Explore the feasibility of implementing Prosiect Pengwin tools

Prosiect Pengwin (Cardiff Metropolitan University) aligns well with HCWP objectives and contact points and is viewed positively by many strategic and operational stakeholders. There is recognition that improved tools for identifying speech, language and communication needs could add value, particularly given current pressures in this area.

However, awareness among frontline staff is very limited, and there are unresolved questions about training requirements, workload implications for health visitors and the capacity of referral services. The views gathered on its feasibility also vary, particularly in relation to the ages at which the tools would be used (and this is further complicated if feedback about preferred changes to certain contact points are implemented).

Whilst Prosiect Pengwin has potential to enhance HCWP, this can only be achieved if implemented carefully. An initial pilot, followed by a gradual roll-out, is recommended to ensure benefits are realised without creating additional pressure on the workforce or on already stretched speech and language services.

Summarise strengths, weaknesses, and overall implications

HCWP has a solid foundation: it is universal, widely supported, and effective at reaching and engaging families early. It builds trusted relationships with families and undertakes an important preventative public health role and has the capacity to identify and escalate concerns and needs.

Its limitations do not lie in its core concept, but rather in how it is working operationally within a constrained system. The variability in delivery, workforce pressures on health visitors and other key professionals surrounding them (midwifery, school nursing, speech and language), suboptimal contact timing, weak data infrastructure and inconsistent integration with wider services all limit its impact.

HCWP is a valuable programme which provides a useful platform to adapt for improvement. Making some targeted reforms which are focused on timing, data, governance, and system integration could lead to meaningful improvements, and ultimately improved outcomes for the young children which the programme seeks to serve. Conversely, maintaining the programme in its current form without adjustment runs the risk of perpetuating uneven outcomes and missing opportunities for early intervention at a time when pressures on families and services are ever increasing.

If the contact schedule is adjusted to fit children’s developmental needs, and designed with more flexibility, HCWP will be better positioned to achieve its aims. Strengthening workforce and partner capacity is also essential so that early identification can be followed by timely support. With modern digital systems, including a single, integrated platform that captures clinically useful data, the programme could become a flagship example of Wales’ commitment to supporting future generations.

We make the following recommendations for the Welsh Government to consider.

Recommendation 1

Welsh Government should reaffirm the HCWP as Wales’s universal, progressive early years health visiting framework, while leading a programme of modernisation to reflect current workforce capacity, increasing family complexity and contemporary policy priorities. The universal nature of HCWP should be retained as the foundation of equitable access, but the programme should be refreshed so that it operates as a more flexible framework rather than a rigid schedule of contacts. This modernisation should explicitly recognise the breadth of health visiting practice, including unscheduled and complex work, and ensure that HCWP remains deliverable.

Recommendation 2

Welsh Government, working with health boards and professional stakeholders, should undertake a national refresh of the HCWP contact schedule. This refresh should aim to reduce duplication with other services, close developmental gaps and align contacts more closely with key stages of child development. It should include restoring and formally recognising antenatal health visiting contact, streamlining early infancy contacts where duplication with other services exists, introducing a more developmentally meaningful toddler review around 18 to 24 months, and reducing, replacing or redesigning the universal 3.5-year contact as a more targeted or transition-focused offer aligned to school entry. The outcome should be a refined national schedule with clearer intent for each contact, greater flexibility in timing windows and explicit guidance on when and how input should be intensified for families with higher levels of need.

Recommendation 3

Welsh Government and health boards should seek to ensure that enhanced input is driven more consistently by assessed family need rather than geography alone. This should include reviewing how eligibility for enhanced support is operationalised, reducing reliance on postcode-based criteria where possible, and supporting health visitors to exercise professional judgement in allocating additional input. Strengthening assessment-led provision in this way would reduce inequities between areas and ensure that families with similar levels of need receive comparable levels of support.

Recommendation 4

Health boards, supported by Welsh Government, should adopt a strategic national approach to sustain the health visiting workforce. This should:

• support recruitment, retention, and bank capacity, reducing reliance on goodwill
• minimise administrative burden to maximise clinical time
• promote skill-mix models where they enhance delivery, without replacing qualified health visitors in complex work
• ensure guidance explicitly protects professional autonomy and reinforces progressive universalism based on assessed need
• seek to adequately resource multi-agency pathways so that the needs identified through HCWP can be acted upon

Recommendation 5

Welsh Government should establish a clear national governance structure for HCWP including a programme steering group and named leads for specific areas that require attention such as data and workforce. Roles and responsibilities of Public Health Wales, health boards, and local authorities should be clarified, and expectations for reporting, and escalation of performance concerns clearly set out. Clear governance would reduce ambiguity, support consistent local decision-making, and ensure coherent implementation of policy changes. A short communications package should accompany implementation to ensure shared understanding among health boards and partner organisations and minimise operational confusion.

Recommendation 6

Welsh Government and DHCW, working with health boards, should transform HCWP data and digital infrastructure so that it supports practice as well as improved reporting. This should include developing a single, integrated, Wales-wide digital system for health visiting that aligns with clinical workflows and is interoperable with maternity, primary care, education, and social care systems. The system should enable digital, point-of-care recording, reduce duplication and manual data entry, capture enhanced activity including safeguarding and mental health work, and support a shift towards outcome- and quality-focused data. Digital transformation should be phased, co-designed with users, and supported by training to ensure adoption and sustainability.

Recommendation 7

Welsh Government should rebalance national HCWP performance monitoring so that contact completion remains important but is complemented by light-touch measures of outcomes achieved. Performance frameworks should move beyond counting contacts alone to include indicators that reflect the effectiveness of contacts and the contribution of HCWP to improved outcomes for children and families. Unnecessary data items that are not used in reporting or analysis, for example, data on female genital mutilation, age at cessation of breastfeeding, age solid foods were introduced, and completion of SOGS, which are not currently published due to poor data quality, should be discontinued to reduce administrative burden on health visitors. Consideration should also be given to using qualitative case studies to provide richer insight into how HCWP contributes to outcomes, helping to more accurately reflect and attribute programme impact.

Recommendation 8

Welsh Government, health boards, and local authority partners should strengthen HCWP’s role as a central early years’ programme by improving integration, transitions, and multi-agency pathways. This should include clearer and more consistent antenatal to postnatal transitions from midwifery to health visiting, strengthened and standardised handover from health visiting to school nursing, and improved clarity and consistency of referral pathways into speech and language therapy, paediatrics, and early years services. HCWP should also be more explicitly aligned with relevant national frameworks and programmes, including immunisation, the First 1,000 Days and Talk With Me, to support coherent delivery across the early years system.

Recommendation 9

Welsh Government should proceed cautiously with Prosiect Pengwin and not move to national rollout within HCWP until key enabling conditions are in place. Instead, a phased and evaluated implementation approach should be adopted, to include an initial pilot in one area, contingent on workforce capacity and protected time, clear role boundaries and training for health visitors, sufficient speech and language therapy capacity to respond to increased identification, developmentally appropriate assessment points, and improved digital recording systems. Decisions about wider rollout should be based on evaluation evidence demonstrating feasibility, acceptability, and impact over time.

Recommendation 10

Health boards, supported by Welsh Government, should improve communication with parents and families about HCWP. This should include providing clear, accessible information on the purpose and timing of contacts, offering better reminders and flexible appointment options, and promoting greater continuity of relationship with a health visitor where possible.

Report author: Heledd Bebb, Nia Bryer, Heledd Bebb, Myfanwy Davies and Tanwen Grover

Views expressed in this report are those of the researchers and not necessarily those of the Welsh Government.

For further information please contact:

Health Research Branch
Social Research and Information Division
Knowledge and Analytical Services
Welsh Government
Cathays Park
Cardiff
CF10 3NQ

Email: Research.HealthAndSocialServices@gov.wales

Social research number: 66/2026
Digital ISBN: 978-1-83745-688-8