Connecting GPs with children at risk of poor health outcomes

We developed the GP Connect project to proactively identify LEAP children at risk of poor outcomes, so early help can be offered to these families.

This blog was originally published on the The National Lottery Community Fund website for the A Better Start programme.

Families and children with complex needs often have many supportive services in place, but those families sitting below this threshold may not be identified until problems escalate and their children are thought to be ‘at risk.’


The project aimed to identify these children via a computer search of codes on their GP notes. The intervention involved a tailored discussion between the family’s GP and Health Visitor (HV) to share knowledge about the family, assess their needs in more detail, and decide on an action plan of support.

To promote sustainability after the A Better Start programme finishes, we used services already in place in Lambeth e.g. GP services, health visiting services and early years services.

Identifying risk factors

A review of the literature was carried out to identify possible risk factors that may identify children at risk. However, many of these factors were not coded in GP notes, and there were administration issues of incomplete and incorrect coding.

A ‘late for immunisations’ code could however be searched for easily, and we wanted to investigate whether this could be used as a proxy indicator for identifying further childhood risk factors.

Engaging with GPs and health visitors

Engagement with GPs and HVs and their managers was achieved by attending both management and clinician meetings to discuss the project. Individual visits to each of the 17 GP practices in the LEAP area were also arranged, with the local children’s centre manager attending in order to increase knowledge and signposting by GPs to council-led children’s services.  

Seven LEAP-area GP practices expressed interest in participating in the pilot for six months. Practices performed a search to identify all children aged 0-3 in the LEAP postcode areas, who were three months or more late for any of their childhood immunisations. 20 children in total were discussed at the GP and HV meetings over a 6 month pilot period. GP Connect was based on the 4-6 weekly GP and HV monthly meetings which worked well for some, but not all practices.

Putting the plan into action

A bespoke template was created to capture risk factors and record them in one place. Some of these risk factors have been identified as being associated with Adverse Childhood Experiences. Information to be gathered included: number of accident and emergency visits; non-attendance at a hospital paediatric outpatient appointment; child protection register entries for child and any siblings; parental history of learning disability, alcohol/drug use, mental health issues or domestic violence; council housing as a proxy for possible poverty; at risk of social isolation; and positive family relationships.

A specific plan of action was then created and recorded. Possible actions included reminding about immunisation, HV or GP review, referral to paediatrician, referral to alcohol/drug services or to domestic violence support, referral to a children’s centre or referral to council early help assessment services. Participating GP practices were paid for time spent doing searches and filling in the bespoke templates.


The project will be evaluated in two ways: an anonymous electronic survey for all staff involved in the project to obtain views about the usefulness of this approach; and by an anonymised questionnaire and submission of anonymised templates asking about action plans for a small number of children. This will allow the study team a deeper level of understanding about whether the template helped to facilitate an appropriate action plan for each child.

We hope this pilot will encourage GPs to think about risk factors for poor outcomes in children and families, and signpost them to early help services and children’s centres sooner. This may enable families to use existing preventative and support services more, and may reduce the use of inappropriate services e.g. A&E. The GP and HV working relationship may be improved by encouraging regular face to face meetings and better understanding of each other’s roles. Ultimately the improved GP/HV relationship should benefit families by increasing joined up care across specialities, thereby supporting children before risk factors escalate.

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