26th November 2010, Volume 123 Number 1326

Pat Tuohy

The publication1 of the early results from the Hawke’s Bay implementation of the Before (B4)School check in this issue of the Journal marks a milestone for the Well Child/Tamariki Ora programme. The publication illustrates both a willingness and opportunity to evaluate our Well Child/Tamariki Ora programme, as part of a commitment to continuously improve quality.
The results indicate that many more children are now better prepared for learning, due to the early identification and referral for problems identified by the nurses undertaking the checks. There is almost universal parent support for the programme, which provides information and reassurance that in most cases their child is doing well, and allows the parent to talk with a trained health professional about any concerns they might have about their child’s readiness for school.
The B4School check is a comprehensive preschool health check for 4-year-old children which was designed to replace the 5-year-old school entry check. The purpose of the B4School check is to “identify and address any health, behavioural, social or developmental concerns which could affect a child’s ability to get the most benefit from school”. The programme was piloted in Whanganui and Counties Manukau District Health Boards, and was fine-tuned before it was rolled out nationally in 2008.
Alongside the development of the B4School check, the Ministry undertook a systematic review of the needs of whānau/families and children to determine how best a Well Child programme might address the present and emerging issues faced by modern parents and caregivers.
We consulted widely on the findings and found that although there was a general consensus that the current system had served us well, some changes needed to be made. These changes were intended to reflect the increasing recognition of the “new morbidity” for children.2 The American Academy of Pediatrics identified the epidemiological shift away from acute infectious diseases towards chronic illness and disability and behavioural difficulties as the major conditions now facing children and families.
The Ministry’s review also identified the emerging evidence around the importance of pregnancy, parental mental health and the child’s first years of life for a healthy life course trajectory. The changes also recognised the importance of improving the quality of the Well Child/Tamariki Ora service.
The B4School check introduced validated, evidence based behavioural and developmental questionnaires, fully manualised assessments for growth, vision and hearing screening and surveillance, and collection of clinical information for every child seen into a national database.
The New Zealand Well Child/Tamariki Ora programme has over 50 providers, who provide home visiting and clinic based services to the 300,000 New Zealand children under the age of 5 years. The nurses and kaiawhina of the Plunket Society see around 85 to 90% of these children, and a range of smaller Māori and Pacific Tamariki Ora providers care for the remainder.
Well Child nurses and general practitioners are the health professional groups who have the most contact with New Zealand’s whānau/families, mothers and children. However, the major interface between these complementary facets of primary and community care for children and their whānau/families was the occasional referral, or chance meeting in another forum.
This fragmentation of primary and community care for mothers and children has meant that the considerable investment of people, time and money in these services has not been leveraged to maximise the benefit to New Zealand families. As a result of the significant numbers of B4School checks now being delivered through PHO based primary care, general practitioners and Well Child/Tamariki Ora nurses are beginning to work more closely, and the concept of broader team-based care is now beginning to emerge.
As anticipated, the concerns about unmet needs raised in the pilots have emerged in this publication. Although increases in waiting times are seen for some specialties, these have generally been managed in a constructive and innovative fashion. Although waiting times may create anxiety and concern among parents and professionals, most children are now getting a service in a timely fashion. Before the B4School implementation some were not being identified as even having a need.
The paper from Wills et al1 in this Journal describes the journey that the Hawke’s Bay District Health Board took when implementing this complex, professionally demanding programme for 4-year-old children. The high degree of professionalism, enthusiasm and innovation by the child health professionals in Hawke’s Bay demonstrated the value they placed on the programme.
The DHB’s decision to contract a PHO based provider to deliver the B4School check gave an opportunity for general practice to make strong professional relationships with a range of community based Well Child providers. It also enabled general practitioners to develop their role in the provision of a universal Well Child/Tamariki Ora programme.
The other key decision made by the DHB was the implementation of a Clinical Advisory group, chaired by the Director of Paediatrics. This group provided clinical governance, and enhanced intersectoral collaboration by bringing together the major child health, education and wellbeing groups from across the Bay. The collaborative nature of the Clinical Advisory group led to high levels of parental acceptance of the programme.
If the B4School check and the new Well Child programme are implemented nationally with as much commitment as in Hawke’s Bay, then the lifetime opportunities for all New Zealand children can only be improved.

Author Information

Dr Pat Tuohy, Chief Advisor – Child & Youth Health, Population Health Directorate, Ministry of Health, Wellington


Dr Pat Tuohy, Chief Advisor – Child & Youth Health, Population Health Directorate, Ministry of Health, PO Box 5013, Wellington 6145, New Zealand.

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Competing Interests



  1. Wills R, Morris Matthews K, Hedley C, et al. Improving school readiness with the Before School Check: early experience in Hawke’s Bay. N Z Med J. 2010;123(1326). http://www.nzma.org.nz/journal/123-1326/4434
  2. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child Family Health. Pediatrics and the psychosocial aspects of child and family health. Pediatrics. 1982;70:126-127