Opinion

Harnessing a public health asset

Despite a rapid increase in birth rate, NHS-wide cuts mean that health visitor posts are being lost. Lisa Lewis asks what can be done to keep SCPHNs in public health.

Harnessing a public health asset

The health visiting service in England is facing another period of significant change, including uncertainty around the funding for training specialist community public health nurses (SCPHNs), apprenticeships and – perhaps most notably – the ramifications following its transfer to local authorities on 1 October 2015. This was arguably a natural transition, as public health and school nursing had already transferred.

However, the budgets for health visiting services that were also transferred across to the local authority were not ring-fenced. This occurred at the same time as large spending cuts in public health were announced, namely £200m in 2015-16, £77m in 2016-17 and £84m in 2017-18 (Unite, 2016).

Local authorities are proposing cuts to health visiting services despite Public Health England renewing the five mandated visits in March 2017. Harrow’s planned budget for 2018-19 proposed a 100% cut to the health visiting budget for 2018-19, and £1m cuts to Barnsley, Brighton and Waltham Forest. Sheffield had to make savings of £1.3m between 2016 and 2019, and Southwark and Lewisham cut between 40 and 60 health visiting jobs (Unite, 2016). These are just a few examples of cuts occurring all across England.

This is set against the backdrop of the recent significant public purse investment into educating health visitors (HVs). In 2010 the coalition government made a commitment to transform the health visiting service by increasing the workforce by 4200, and so began the Health visitor implementation plan in 2011. A large-scale publicity programme was launched to aid recruitment, and higher education institutions (HEIs) started offering two intakes a year to achieve the target number by the end of March 2015. Alongside this was a drive to recruit return-to-practise HVs. 

While there is no clear data available as to the exact cost of the implementation plan, a freedom of information request to the London Strategic Health Authority established that the average annual cost of training an HV between 2007 and 2012 was £38,401 per student (Ballinger, 2012). 

Taking into account the subsequent increase in tuition fees, inflation and the cost of promoting the implementation plan alongside indirect costs, one can only begin to make a conservative estimate that the overall investment is likely to have amounted to more than £150m.

 

Disappearing health visitors

While the target of 4200 new HVs was missed by only 271, data from NHS Digital (2017) shows that in real terms there was only an increase of 2507 from September 2011 and the end of the implementation plan. In the past year the numbers in post have dropped by a further 1050 despite the continued training of new starters. While there was always a predicted attrition rate owing to expected retirements within the workforce, it is unclear how the reduction relates to those of working age. What is eminently clear is that posts are continually being cut and some students qualifying this year do not have posts to go into, or are being offered Band 5 positions.

It is also of note that there were more than 11,000 registered HVs at the start of the implementation plan but only 7802 in post. Projected figures following the newly trained HVs entering the workforce were 12,292 full-time equivalents by March 2015 (Department of Health, 2013). So where have they all gone?

HVs sit on the third part of the NMC register with school nurses and occupational health nurses as SCPHNs, whose work with individuals and groups, and the decisions they make, can affect whole groups of people without necessarily involving direct contact (NMC, 2016).

The general working population is one of the less recognised groups that SCPHNs can have a positive impact on. The demographic is changing in terms of the change in retirement age and the subsequent ageing workforce. Sickness absence is a key challenge facing employers, with 1.8m employees having a long-term sickness absence of four weeks or more in a year equating to a cost of £9bn a year to the employers (Department for Work and Pensions, 2016). In 2016 an estimated 137.3 million sick days were taken; mental health issues accounted for at least 11.5% of these (Office for National Statistics, 2016).

Diane Romano-Woodward, president of the Association of Occupational Health Nurse Practitioners, acknowledges that with a large proportion of people’s time being spent at work there may be an opportunity to positively influence the population’s general health (O’Reilly, 2015).  

Viv Bennett, director of nursing at the Department of Health and chief adviser on public health, identifies that changes in the general workforce and the current demographic require a greater emphasis on health and wellness. She writes: ‘In future, the boundaries of traditional occupational health practice may also extend beyond the workplace to those who are economically inactive’ (Public Health England, 2016).

Within this context, SCPHN occupational health nurses (OHNs) will have an ever-increasing role in supporting and maintaining a healthy workforce. However, there is a shortage of OHNs, with employers struggling to recruit high-calibre candidates. This may be because of the small number of SCPHN OHNs who have been funded to complete the course, but also it may reflect the fact that occupational health nursing is not understood and does not factor in undergraduate student placements. 

Unfortunately, the situation is unlikely to improve with a number of HEIs cutting the SCPHN OHN pathway as it is not viable due to low student numbers.

 

Changing field of practice

Given changing commissioning of SCPHNs in the public sector, surely it makes sense to harness this valuable public health resource. The NMC allows for any SCPHN registrant to change their field of practice by completing a practice placement supported by a portfolio and assessed reflective account, which is facilitated by some HEIs offering the SCPHN programme.

The module requires a minimum 10-week placement in the appropriate field and a portfolio of evidence to demonstrate that the person has met the required learning outcomes in their new field. While there is consternation among OH professionals regarding this option, it should be set against the fact that OHNs and SHNs are often employed without any experience at all, as specific tasks can often only be learned on the job. An increasing number of SCPHNs are changing their field of practice to reflect the need in their area.

While there continues to be significant debate about the education of occupational health nurses, their ability to have an impact on the public health agenda cannot be ignored. In essence that there needs to be some separation of the issue of public health focus within occupational health and whether the SCPHN programme is fit for purpose for OHN education as this clouds the issue. 

SCPHNs from any pathway have a wealth of transferrable skills and have already demonstrated their ability to engage in higher education and new learning. Harnessing the resource will require a positive shift in thinking but in doing so there can only be a positive impact on public health outcomes by retaining current SCPHNs. 

The digital – or ‘third industrial’ – revolution creates a landscape of rapid change. Being responsive to this change and mindful of maximising the ever-limited resources available to health is surely a pragmatic approach to an untenable situation.

 

Lisa Lewis is senior lecturer in SCPHN at the University of the West of England.


References

Ballinger PJ. (2012) Freedom of information request to London Strategic Health Authority: health visitor training costs and numbers, 2006-2012. See: whatdotheyknow.com/request/health_visitor_training_costs_an (accessed 21 July 2017).

Department of Health. (2013) Public health functions to be exercised by NHS England. See: gov.uk/government/uploads/system/uploads/attachment_data/file/192978/27_Children_s_Public_Health_Services__pregnancy_to_5__VARIATION_130422_-_NA.pdf (accessed 21 July 2017).

Department for Work and Pensions. (2014) A million workers off sick for more than a month. See: gov.uk/government/news/a-million-workers-off-sick-for-more-than-a-month (accessed 21 July 2017).

NHS Digital. (2017) NHS workforce statistics: January 2017, provisional statistics. See: content.digital.nhs.uk/catalogue/PUB23803 (accessed 21 July 2017).

NHS England. (2013) The national health visitor plan: progress to date and implementation 2013 onwards. See: gov.uk/government/uploads/system/uploads/attachment_data/file/208960/Implementing_the_Health_Visitor_Vision.pdf (accessed 21 July 2017).

NMC. (2016) Standards of proficiency for specialist community public health nurses. See: nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-of-proficiency-for-specialist-community-public-health-nurses.pdf nmc.org.uk/registration/staying-on-the-register/scphn-registration (accessed 21 July 2017).

Office for National Statistics. (2016) Sickness absence in the labour market. See: ons.gov.uk/employmentandlabourmarket/peopleinwork/labourproductivity/articles/sicknessabsenceinthelabourmarket/2016 (accessed 21 July 2017).

O’Reilly N. (2015) Evolution of occupational health 2: OH stands at a crossroads. Occupational Health 67(10): 14.

Public Health England. (2016) Educating occupational health nurses: an approach to align education with a service vision for occupational health nurses. See: vivbennett.blog.gov.uk/wp-content/uploads/sites/90/2016/11/Educating-OHNs-final-Oct-2016-FinalNB071116.pdf (accessed 21 July 2017).

Unite. (2016) Health visiting in England. See: unitetheunion.org/uploaded/documents/Health%20visiting%20in%20England%20May%20201611-26805.pdf (accessed 22 July 2017).

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