Features

Shining a light

08 February 2019

Health visitors working in England, Northern Ireland, Scotland and Wales face a range of both unique and shared challenges that are impacting practice. Journalist Anna Scott highlights the reality across the UK.

Light People iStock

In the two months since Unite warned that the NHS faces a winter crisis while government ministers are distracted by Brexit, the UK’s departure from the EU has continued to dominate parliamentary and news schedules (Parliament UK, 2019; Unite, 2018a).

A 24% decline in the number of health visitors since October 2015, the large number of vacancies in crucial NHS roles due to poor levels of recruitment and retention, and the lack of progress in integration between health and social care, are among the factors spelling crisis for the health service, says the union (Unite, 2018a).

This warning comes a few months after the shadow secretary of state for health and social care described cuts to HVs totalling 8% as ‘savage’ and ‘another betrayal of our children’ (Unite, 2018b). Jonathan Ashworth MP has also promised more investment in health visiting, an additional mandatory HV check for children at three to four months and the reinstatement of the training bursary were his party to form the next government (Labour, 2018).

These figures and measures above apply to England only. But the rest of the UK has its own challenges. Northern Ireland, Scotland and Wales all have issues with workforce capacity. Specifically, Scotland has seen vacancies for HVs rise by almost 50% in a year (McArdle, 2018), while in Wales a 1.7% increase in the number of HVs was recorded between 2016 and 2017 (Welsh Government, 2017a).

‘The NHS is undergoing constant organisational, financial and structural change, when demand for public and community health services have never been greater,’ says Colenzo Jarrett-Thorpe, Unite national officer for health. ‘This is being felt in all four countries across the UK, but all four countries have different approaches to dealing with the current environment of health visiting.’ The main reason for this, says Janet Taylor, nurse manager, children’s services, South Eastern Health and Social Care Trust Belfast and chair of the CPHVA Executive, is ‘devolution, different governments, different budgets allocated, different leadership’.

 

The models

So the picture of health visiting across the UK varies considerably, but an important similarity remains. All four UK nations have the same practice ethos, goals and aspirations, and standards that inform the design and delivery of training programmes are approved in all countries by the NMC (2011).

What differs across all four is the number of times a child and family have a meaningful interaction with their HV, and how funding of health-visiting services is delivered and organised.

In England, the Healthy Child Programme 0 to 19 is led by HVs for the first five years of a child’s life (Public Health England (PHE), 2018). Regulations require all families with babies to receive five HV checks before the child reaches the age of two and a half (PHE, 2018).

While NHS England and clinical commissioning groups are responsible for commissioning services for the health and wellbeing of children aged 0 to 19 (PHE, 2018), local authorities have commissioned all health-visiting services since 2015 (NHS Employers, 2014).

The Healthy Child, Healthy Future programme in Northern Ireland covers children from pregnancy to 19 years old, and HVs are required to make nine visits to a family before a child starts school, one of which is made during pregnancy (Department of Health, Social Services and Public Safety, 2010). Services are commissioned by the Health and Social Care Board (HSCB), working in partnership with the Public Health Agency and five local commissioning groups (HSCB, 2018).

The Universal Health Visiting Pathway in Scotland consists of 11 home visits to all families, three of which include a formal review of the family and child’s health (Scottish Government, 2015). The 14 NHS boards covering Scotland are responsible for commissioning health-visiting services in their regions (NHS Scotland, 2018).

In Wales, health-visiting services comprise two flagship programmes. Healthy Child Wales sets out the core programme for all children aged 0 to seven that provides screening, vaccinations, and monitoring and supporting child development, and ensures nine visits to families before the child is four years old (NHS Wales, 2016). The Flying Start programme aims to cover 36,000 children living in some of the most deprived areas of Wales and offers one full-time HV for every 110 children (Welsh Government, 2017b).

The seven local health boards in the NHS in Wales are responsible for commissioning health-visiting services for their regions (Public Health Wales, 2013).

These differences – and the similarities – are reflected in the challenges faced by HVs across the UK, which are in turn felt by the children and the families these HVs serve.

 

England

Funding is a problem: nine years of cuts to local authority budgets (Local Government Association, 2017) have resulted in the loss of 2399 HV positions between October 2015 and June 2018 (NHS Digital, 2018). Student grants and bursaries for nursing, midwifery and allied health students have been replaced by standard student loans (Department of Health and Social Care, 2015).

In addition, the decision to move commissioning of health-visiting services from NHS to local authorities in October 2015 has ‘wiped out’ any gains from the HV implementation plan, according to Colenzo. ‘The drop in HV numbers has led to increasing caseloads, and HVs feeling they are unable to fulfil their public health duty and are simply dealing with firefighting rather than working with families,’ he adds.

HVs are also leaving the profession due to age/burn-out/professional concerns, says Sarah Reddington-Bowes, HV at Bristol Community Health and vice-chair of the CPHVA Executive and member for the South West.

‘Many colleagues are fighting privatisation impacts, such as down-banding, role change and capacity issues. Some employers lack the insight or don’t acknowledge the importance of the HV role due to financial constraints.’ Poor IT provision and outdated systems are also a problem for HVs, she adds.

The knock-on effect of this is that England has the lowest number of mandated visits to children and families by HVs, which can end up creating a ‘tick-box service rather than one that is needs-driven’, says Sarah. ‘The impact on our children and families is the availability of the HV. There may be a lack of meaningful support and families are again unable to identify the value of their HV,’ she says.

Wendy Nicholson, national lead nurse for children, young people and families, at PHE acknowledges that health-visiting services, like all services within health and social care, face challenges related to funding.

‘There are many changes, and it’s about being able to be flexible and adapt to the changing landscape,’ she says. ‘Clearly this requires a resilient workforce who are supported and encouraged, and this is why we have published guidance for employers, which outlines what support HVs should expect from their employer in terms of training, CPD and support for revalidation.’


 

Success stories

Leicestershire Partnership NHS Trust uses a secure text messaging service in Leicester, Leicestershire and Rutland, says Jo Chessman, public health nursing lead. It offers advice on all aspects of a child’s health and wellbeing, including healthy eating, emotional health, and parenting concerns. ‘It means parents are able to text an HV and receive a response within 24 hours. Parent feedback about this service has been hugely positive.’

‘Our Early Start service (a dedicated, intensive health-visiting service for vulnerable mothers) is also making a significant impact on the outcomes for families,’ continues Jo. ‘We have clear operating guidance underpinning our 0 to 19 public health offer, and this helps ensure consistency across all our Healthy Child Programme contacts.’

In Northern Ireland, as part of the Early Intervention Transformation Programme (EITP), HVs visit children at their 3+ review in the child’s nursery school setting, Janet Taylor explains.

‘We have childcare professionals working alongside HVs, gradually building up to that visit. The parents are invited in, and they have an all-round assessment of the child. It means there is more time before the child goes to school to identify any issues, whether behavioural, health, or developmental,’ she adds.

And while the outcome is yet to be measured, last November, education secretary Damian Hinds announced £18m worth of projects aimed at supporting the early development at home of children from disadvantaged families, including additional training to help HVs in England identify speech, language and communication needs early on (Department for Education, 2018).


 

Scotland

Recognition of the role of HVs has been demonstrated in Scotland with the boost of starting salaries for the profession from Band 6 to Band 7 under the Agenda for Change pay scale (Unite, 2018c).

‘It comes down to how a government spends its money, and in Scotland they are slightly more progressive,’ says Gavin Fergie, Unite’s lead professional officer for commercial development and Scotland and Wales, health sector. ‘The decision-making shows that devolution is more advanced than in the past. We’ve now used the additional tax-raising powers in Scotland, and the government is committed to putting that resource into health.’

One way this money is being invested is in the National Health and Social Care Workforce Plan, which commits to increase the number of HVs by 500 whole-time equivalents (WTEs) (Scottish Government, 2018). ‘This almost 50% increase is unprecedented and NHS boards are working towards this increase with at least 414.3 WTE additional HVs in post at 30 September 2018,’ says government senior policy officer Julie Robb.

Increasing the workforce has created the capacity to implement the Universal Health Visiting Pathway and its additional visits to families of pre-school children. However, there are difficulties. ‘Increasing any workforce will bring challenges as new HVs come on stream and look to consolidate their learning and implement the Universal Pathway,’ concludes Julie.

One of the main challenges is the shortage of practitioners to meet the needs of the service, despite the additional financial resources from government, says Gavin. ‘We hope that the new salary banding for HVs in Scotland will make health visiting a more attractive profession,’ he adds. ‘Perhaps if they are remunerated with more money, it will make up the human resources shortfall.’

Another issue is the provision under the Children and Young People (Scotland) Act 2014 for HVs to act as a Named Person for a pre-school aged child who needs support (Scottish Government, 2017). ‘This has definitely had an effect on health visiting since it has put more demands and expectations on the HV, although the information-sharing obligations have not yet been implemented,’ says Colenzo.

 

Wales

As in Scotland, the Welsh Government has provided additional financial resources to increase the number of HVs. Investment in HV education commissions has increased by 88% since 2014, according to a spokesperson from the Department of Health and Social Services.

And in November 2018, Welsh health secretary Vaughan Gething announced a £114m investment in 2019-20 in professional education and training for healthcare professionals, including HVs (Welsh Government, 2018). This is £7m more than 2018-19 and the fifth consecutive year of increased funding for health professional education (Welsh Government, 2018).

‘The Welsh Government is supporting a national workstream to look at skills-mix in health visiting, as well as developing an acuity tool to assist with determining the workforce required to develop the Healthy Child Wales Programme,’ he says.

Currently all health visitors in Wales are awarded a Band 6, but ‘there are plans to review the Band 5 role and to what degree they can support the health visitor programme with the aim of providing opportunities for career progression into health visiting’, the spokesperson adds.

However, like Scotland, Wales does not currently have enough practitioners to meet the needs of the health-visiting service. Some localities are experiencing recruitment difficulties and are failing to meet the standards and specific ratios for HVs to children set out in the Healthy Child Wales Programme (one HV to 250 children) and Flying Start (one HV to 110 children), the spokesperson says. ‘Where there are vacancies in health-visiting teams, some children and families in Wales are not receiving the full entitlement as set out by the Healthy Child Wales Programme at present. This is being monitored at a national level.’

Michelle Moseley, lecturer at the School of Healthcare Sciences (Primary Care and Public Health Nursing) at Cardiff University and CPHVA Executive member for Wales, says that as a result of staff shortages, some families are not receiving home visits. ‘Families are contacted at the pre-school review, for example, but if the parent does not raise any issues, they are not seen. They are contacted by letter and a checklist is completed. All identified children with specific health needs, those who are vulnerable, those where safeguarding issues are prevalent, are prioritised,’ she says.

 

Northern Ireland

There are similar concerns in Northern Ireland. Professor Charlotte McArdle, chief nursing officer, says: ‘The most significant challenge within the health-visiting service is workforce capacity.’

Like in Scotland, the health-visiting workforce is ageing. More than one-third (35%) of HVs in Northern Ireland is over 50 (Information Analysis Directorate, 2018). ‘Despite the unions saying better workforce planning was needed and that we were going to be seriously short of nurses, we are still seriously short of nurses,’ says Janet who works in Belfast. ‘And if you are short of nurses you don’t get those who go on to do health visiting.’

But unlike Scotland, Northern Ireland does not have an effective government in place. It’s now more than two years since deputy first minister Martin McGuinness resigned, triggering the collapse of the Northern Ireland Assembly (McCormack, 2019). ‘The lack of political leadership means plans and initiatives to push forward the public and community health agenda have fallen by the wayside,’ Colenzo says.

The stalemate also means HVs in Northern Ireland have not seen their pay increase, apart from the nominal 1% inflationary rise, according to Janet. ‘We are lagging way behind Scotland, England and Wales. We haven’t had a proper pay rise and no one will take a decision to give a pay rise,’ says Janet.

Alongside these pressures, a number of public health challenges are placing more demands on HVs in Northern Ireland, Professor McArdle says. These challenges include ‘the increase in childhood obesity, mental health issues, domestic abuse, child protection and looked-after children issues and, in some cases, the ability to deliver pre-school immunisations’.

As a result, the service does not have the capacity to deliver on the full Healthy Child, Healthy Future programme, and some children are not receiving all the health and development reviews that they should, Professor McArdle concludes.


Your views in a nutshell

‘We need to preserve the HV role. We are not social workers – our training and expertise is health- and needs-based’
Sarah Reddington-Bowes, HV, Bristol, and vice-chair of the CPHVA Executive

‘One of my concerns is how ongoing budget cuts have impacted on chances for career progression into specialist roles – despite being involved in several different areas, including my trust paying for me to complete specialist breastfeeding training, there’s no role for me to aim for/use the skills to the best effect’
HV, southern England

‘We need to look at how we integrate further with other services to have joint outcomes, KPIs, and so on, implementing integrated, placed-based care for the benefit of our communities!’
Donna Wilson, HV, north-west England

‘One of the major challenges we experience is working in a short-term commissioning environment where the service is only commissioned for two to three years at a time. It can mean regular changes to the way we deliver services, which is destabilising and can have a negative impact on staff morale and wellbeing. ST contracts also mean significant cuts in funding and consequent reductions to staffing and to the scope and extent of contacts with families’
Jo Chessman, public health nursing lead, Leicestershire

‘It’s not a case of looking at our staff and thinking that they need to work smarter or better. Our staff are working flat out. There is so much goodwill, knowledge, integrity and skills that are continually bridging the gap between what we can do and what we actually do’
Janet Taylor, nurse manager, Belfast, and chair of the CPHVA Executive


Shape of the profession

These kinds of challenges and demands were recently expressed by members in a Unite survey (2018). Most HV and school nurse members (80%) said they were always or frequently working more than their contracted hours in a typical week, and 72% of HVs either fairly or very seriously considered leaving their posts in the last year. The top three reasons for lower morale and motivation compared with the previous year were increased workplace stress, dissatisfaction of not being able to provide the quality of care to patients, and the ongoing threats to their job security. Meanwhile, most members experienced staff shortages in the past year and raised concerns about the levels of safe staffing (see Your views in a nutshell, left).

‘HVs care about the service they provide to children and families and are worried this is being compromised because of organisational and structural change in the way health visiting is being provided and organised,’ Colenzo says.

There’s also a change across the UK in the make-up of specialist and universal HVs, says Gavin. More specialisms were brought into the universal programme, and the shift up to a Band 7 role for HVs in Scotland reflects the more complex skill-set required, he says. ‘[It may be] that some of those specialist roles have been sacrificed because they are now in the universal programme. Also, some of the specialist roles were sacrificed in the UK due to budget cuts and haven’t been replaced since.’

In England, there are specialist HV roles in areas such as child protection, says Sarah, but dermatology, continence, infant feeding, NICU/paediatrics-linked roles are all added to the universal HV role. Wales has specialist HVs, particularly in perinatal mental health, safeguarding and special educational needs, says Michelle. And Northern Ireland’s specialists are also in mental health, according to Janet. ‘Staff want more training, as opposed to being generic,’ she adds.

 

The way forward?

‘Training and investment need to be part of the long-term strategy in supporting community health services’

‘There needs to be scope for professional judgement and autonomy rather than indiscriminate universalism or health visiting will change fundamentally, and it will be more challenging to recruit and retain highly skilled and dedicated staff,’ says Colenzo. ‘Training and investment need to be part of the long-term strategy in supporting community health services to ensure there are enough HVs to serve the community and that they are trained, nurtured and paid to reflect their value to society.’

A greater level of investment in public health is needed to resolve these problems, agrees Janet. ‘Investment in public health is so important, and we as a country don’t invest as much as other countries. We also need more services and pathways. We need to look more closely at the patients’ or clients’ journey, as opposed to thinking of all the different people that visit at different stages. For the client, there is one journey.’

But in England, local authority commissioning of health visiting needs to end and services need to be brought back into the NHS, according to Colenzo. ‘Local authorities are not to blame, but central government has starved our town halls and civic centres across England. In addition, commissioners do not understand what they are trying to commission and the role of HVs.’

The recent NHS long-term plan (NHS England, 2019) has stated that ‘the government and the NHS will consider whether there is a stronger role for the NHS in commissioning sexual health services, health visitors, and school nurses, and what best future commissioning arrangements might therefore be’.

Gavin says: ‘We need a national approach – we have that in Scotland, in Wales, in Northern Ireland. But we don’t have that in England, we have a postcode approach.’

However, this does not mean that health-visiting models should be more consistent across the four UK nations. ‘The model needs to meet the needs of the community; one size does not fit all,’ says Colenzo. ‘HVs in all four countries need to be out with children and families working with them to give those children the best start in life.’

 

Infographic

Image credit | iStock


 

References

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