The sticking point

06 September 2019

An action plan to help your client when the odds are stacked against you is more important than ever, writes journalist Erin Dean, especially with harder-to-access services and CP staffing issues. 

Earlier this year, eight out of 10 child and adolescent mental health services (CAMHS) providers in the community said they were unable to meet current demand in England (NHS Providers, 2019). Almost 30% of in-patient CAMHS services told the survey they couldn’t provide all the care needed.

These are not the first figures to show the strain on children’s mental health services, and the problem is not just limited to England, as hundreds sit on waiting lists for specialist support across the UK (ISD Scotland, 2019; BBC, 2019).

Meanwhile, in March, a coalition of more than 60 organisations wrote to the government calling for action to end the ‘postcode lottery’ of access to speech and language services for the 1.4 million UK children who need support (I CAN, 2019). And in Northern Ireland, children with heart conditions, allergies and skin conditions are waiting as long as four years for a hospital appointment (Smyth, 2019).

As community practitioners, accessing the services and support needed by your clients in a timely manner is of course essential. But how can you help when services are full and busy and thresholds to access services get higher and higher? This is not the only scenario that leaves CPs, for want of a better word, ‘stuck’ and unsure of where to turn.

The critical period

John McLaren, senior representative for Unite-CPHVA at NHS Borders, has seen it get harder for community staff when it comes to accessing CAMHS as well as social services support across Scotland.

More than 10,600 children and young people were waiting to be seen by CAMHS in Scotland in March, more than 400 of whom had been waiting for more than a year (ISD Scotland, 2019). In Northern Ireland, figures from the Health and Social Care (HSC) Board show 487 patients missed the CAMHS target of waiting no longer than nine weeks in March (BBC, 2019).

These long waits can be critical, as a survey of parents by mental health charity YoungMinds (2018) said that around three-quarters of young people waiting for CAMHS become more unwell before they can access treatment.

High caseloads

‘Families are sometimes waiting up to a year for an assessment with CAMHS, and health visitors will still be expected to support these families on an ongoing basis, without the support they need,’ John says.

‘We also hear time and time again about the threshold rising for social service referrals, and while referrals are being considered, or have been rejected, HVs are carrying much more complex, difficult cases, with families who are just a hair away from falling apart. This is very difficult for HVs, and I can remember the sleepless nights I had when I was practising, worrying about some of the families on my caseload.’

Another concern for many of you is how to find the time to do the work required. One issue is caseloads for HVs and district nurses. These are particularly bad in England where district nurse numbers have also fallen sharply, dropping by almost 43% over the past decade (QNI, 2019).

Unite-CPHVA recommends a ratio of one HV to every 250 clients. But the union has heard reports of HVs in England with more than 800 clients, says Colenzo Jarrett-Thorpe, Unite national officer for health.

‘Across England, HV caseloads appear to be above the CPHVA recommended limit,’ says Colenzo. ‘With high caseloads it is impossible to provide the service HVs want to. Cuts to budgets need to be reversed in order to protect services for children and families or the damage will be felt for a generation.’

Recent Public Health England (PHE) 2018-19 preliminary figures revealed that only 77% of children received the 12-month HV review in England by the age of one (PHE, 2019), with the number at 75% for the previous year (PHE, 2018).

Staffing shortfall

But staffing is a countrywide lottery. The number of HVs in England has fallen by 30% since 2015 (NHS Digital, 2019). But HV numbers have been fairly stable in Wales (Welsh Government, 2019) and Northern Ireland (NI HSC, 2018; 2017) between 2015 and 2018.

In Scotland, however, there has been governmental investment to meet the pledge to increase the number of health visitors by 500 (Scottish Government, 2018).

As Community Practitioner reported in February this year (Scott, 2019), Northern Ireland, Scotland and Wales all had some issues with workforce capacity, and of course there’s still deadlock in the government in Northern Ireland.

On a more positive note, Annie Hair, senior nurse and chair of the CPHVA occupational and professional committee, says that in Glasgow, where she works, from September all HV posts will be fully staffed with lower caseloads designed to reflect the level of need in a community.

There has also been a significant investment that has created four new school nursing posts, with at least four more training posts planned this year.  

‘The number of HVs has increased dramatically and we are in a positive place at the moment, but this needs to be sustained,’ she says.


You are urged to keep your paperwork up to date, and raise concerns swiftly and repeatedly with managers 

A fine line

Another issue that can complicate matters for HVs and other CPs is when clients reject services that are offered.

If a family or other client comes below a threshold where services would automatically get involved but a professional feels they need that support, the parent can choose to reject it.

‘If there is a concern about child neglect that doesn’t meet the threshold for non-consent, a parent can say no to involving any other supportive service, such as social work,’ says Annette Holliday, health visiting team leader at Glasgow City Health and Social Care Partnership.

‘The HV is still holding the concern but has not got anywhere to go unless the situation gets worse and meets the level where you don’t need consent. There is nothing to do but keep working with parents to manage the risk and maintain the relationship. Continue to risk-assess and analyse the situation so that the reasons for your decisions can be identified and recorded.’

But these situations have an impact on the professional involved. ‘Ultimately it often makes you very worried,’ says Annette.

Your action steps

When you’re unsure about what steps to take next, you are first urged to keep your paperwork up to date. You should then raise concerns swiftly and repeatedly with managers. As John explains: ‘While paperwork can be one of the first things to slip when people are overworked, it is essential it is completed.

‘Staff should also escalate concerns through their risk register systems, so that managers can be held to account. This should include issues caused by a lack of support from other services and the problems this causes for clients.’

Practitioners should also approach Unite-CPHVA representatives for advice early on to avoid later problems, advises John.

For clients stuck on waiting lists, professionals should give advice to help them while they wait. Janet Taylor, chair of the CPHVA executive, says giving practical pointers such as behaviour management or speech development to families waiting for referral can make a vital difference.

‘The reality is that parents may be waiting for an assessment to find out if their child has autism or ADHD, but it is really important that an HV gives the family coping strategies for before and after the assessment,’ she says.

It is also essential that you know well the area you work in. Signposting an isolated new mother to a local mother and baby group can be as important as a referral, says Janet.

‘CPs are the glue in the system, and we refer people to other services as we should, but we can also give parents tools to empower them in the meantime,’ Janet adds.

When you don’t know where to turn… A summary of action points

  • Keep good records and escalate concerns to managers as they arise
  • Continue to risk-assess clients and discuss the outcome with managers
  • Contact Unite-CPHVA representatives for support and advice. Seeking early support can avoid more serious problems
  • Give families on waiting lists coping tips and strategies, such as behaviour management advice, for the issues they face
  • Get to know communities well and tap into local support such as parenting groups.



BBC. (2019) Mental health: funding blamed for six-fold rise CAMHS waiting list. See: bbc.co.uk/news/uk-northern-ireland-48702233 (accessed 29 July 2019).

I CAN. (2019) A Little Less Conversation... A Little More Action Required for Children and Young People with Speech and Language Communication Needs. See: https://www.ican.org.uk/news/a-little-less-conversation-a-little-more-action-required-for-children-and-young-people-with-speech-and-language-communication-needs/ (accessed 2 August 2019).

ISD Scotland. (2019) CAMHs Waiting Times - Number of patients waiting during the month by Health Board, Jan 2018 - Mar 2019. See: https://www.isdscotland.org/Health-Topics/Mental-Health/Publications/2019-06-04/2019-06-04-CAMHS-Waiting-Times-Tables.xlsx (accessed 21 August).

NHS Digital. (2019) NHS Hospital & Community Health Service (HCHS) monthly workforce statistics. See: https://files.digital.nhs.uk/70/0A4E65/NHS%20Workforce%20Statistics%2C%20May%202019%20Staff%20Group%2C%20Care%20Setting%20and%20Level.xlsx (accessed 28 August 2019).

NHS Providers. (2019) Mental health services – The demand challenge. See: nhsproviders.org/mental-health-services-addressing-the-care-deficit/the-demand-challenge (accessed 29 July 2019).

Northern Ireland HSC. (2018) Northern Ireland Health and Social Care Workforce Census March 2018. See: health-ni.gov.uk/publications/northern-ireland-health-and-social-care-workforce-census-march-2018 (accessed 29 July 2019).

Northern Ireland HSC. (2017) Northern Ireland Health and Social Care (HSC) workforce census March 2005 to March 2017. See: health-ni.gov.uk/publications/northern-ireland-health-and-social-care-hsc-workforce-census-march-2005-march-2017 (accessed 29 July 2019).

PHE. (2019). Health Visitor Service Delivery Metrics (Experimental Statistics), Quarter 4 2018/19 Statistical Commentary (July 2019). See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/818444/2018-19_Q4_-_FINAL_Health_Visitor_Statistical_Commentary.pdf (accessed 29 July 2019). 

PHE. (2018)  Health Visitor Service Delivery Metrics 2017/18 Annual Data Statistical Commentary (October 2018 release). See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/750446/2017_2018_Annual_Health_Visitor_Statistical_Commentary.pdf (accessed 29 July 2019). 

QNI. (2019) Outstanding models of district nursing. See: qni.org.uk/explore-qni/policy-campaigns/outstanding-models-of-district-nursing/ (accessed 29 July 2019).

Scott A. (2019) Shining a light. See: https://www.communitypractitioner.co.uk/node/1099 (accessed 29 July 2019).

Scottish Government. (2018) National health and social care plan: part 3. See: gov.scot/publications/national-health-social-care-workforce-plan-part-3-improving-workforce/pages/10/ (accessed 29 July 2019).

Smyth L. (2019) Misery of Northern Ireland children waiting four years for hospital appointment. See: https://www.belfasttelegraph.co.uk/news/northern-ireland/misery-of-northern-ireland-children-waiting-four-years-for-hospital-appointment-37854635.html (accessed 2 August 2019).

Welsh Government. (2019) Nursing, midwifery and health visiting staff, by grade and area of work. See: https://statswales.gov.wales/Catalogue/Health-and-Social-Care/NHS-Staff/Non-Medical-Staff/nursingmidwiferyandhealthvisitingstaff-by-grade-areaofwork-year (accessed 29 July 2019).

YoungMinds. (2018) A new era for young people’s mental health. See: youngminds.org.uk/media/2620/a-new-era-for-young-peoples-mental-health.pdf (accessed 29 July 2019).


Image credit| iStock


Subscription Content

Click To Return To Homepage

Only current Unite/CPHVA members or Community Practitioner subscribers can access the Community Practitioner journals archive. Please provide your name and membership/subscriber number below to verify access:

Membership number

If you are not already a member of CPHVA and wish to join please click here to JOIN TODAY

Membership of Unite gives you:

  • legal and industrial support on all workplace issues 
  • professional guidance on clinical and professional issues 
  • online information, training and support 
  • advice and support for all health professionals and health support workers
  • access to our membership communities 
  • CPHVA contribution rate is the Unite contribution rate plus £1.25 per month 

Join here https://www.unitetheunion.org/join-unite/

If you are not a member of Unite/CPHVA but would like to purchase an annual print or digital access subscription, please click here