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What lies ahead? The future of practice after Covid

11 January 2021

Regardless of how much we dare to hope the beginning of the end of the pandemic is in sight, its ripple effects on the UK’s health and their implications for CPs are just starting. Journalist Anna Scott asks if Covid-19 has changed the professions’ methods forever.

Covid-19’s indirect impacts on children, families and the community healthcare professions are becoming clearer with each passing month.

In September 2020, for instance, research revealed that a significant number of potty-trained children had lapsed back into nappies, particularly those whose parents couldn’t work flexibly during the first lockdown (Ofsted, 2020).

Concern is also increasing about children who were out of sight during the school closures, with a decline in the number of referrals to social care teams prompting fears that neglect, exploitation and abuse are going undetected (Ofsted, 2020). A survey of health visitors in summer 2020 found that 96% were worried about children at risk of domestic violence, while 92% were concerned about deteriorating mental health among parents (UCL, 2020).

Indeed, there has been a dramatic rise in parental loneliness: 63% of parents polled in October 2020 said that they were feeling lonely, compared with 38% before the pandemic (Royal Foundation of the Duke and Duchess of Cambridge, 2020 – see page 8).

‘As we start seeing the longer-term effects of poverty, loneliness, missed schooling and long-term ill health on those who were already at risk before the pandemic, the importance of community health professionals will become even more apparent,’ says Dr Geraldine Walters, executive director of professional practice at the NMC. ‘Specialist community and public health nurses have a key role in supporting the most vulnerable people and maintaining safety, health and wellbeing among those who might otherwise be at risk.’

With these emerging trends adding to 2020’s disruptive effect on the professions’ working methods, what might ‘standard’ practice look like moving forwards?

Longer-term considerations

The pandemic has already changed how community practitioners (CPs) operate, introducing many to practices such as social distancing, homeworking and virtual consultations for the first time. But a CP’s work will need to evolve further as the broader ramifications of the crisis play out over the longer term, according to Professor Viv Bennett, director of nursing at Public Health England (PHE).

‘Children have lost learning, for instance, so health visitors are having to consider how they can be part of supporting them to mitigate the effects,’ she says. ‘That will go on for a much longer time than the pandemic, so we’ve been doing a lot of work on training for HVs in speech, language and communication. We have now published a new measure enabling HVs to assess and identify early any need in children aged two to two and a quarter, with further training being rolled out in January.’

There will also be a refinement to their roles when it comes to supporting expectant and new mothers from ethnic minorities who live in multigenerational low-income households in densely populated areas.

Viv explains that, although HVs already prioritise the needs of these particularly vulnerable individuals and their families, ‘we’ve learnt that continuity of care is one thing that makes a really big difference to pregnant BAME women. This has mostly been seen as a midwifery undertaking, but what we’re talking about now is achieving a very smooth handover and ensuring continuity of care into the health visiting side.’

She also predicts that school nurses (SNs) will need to play a ‘critical part’ in supporting children presenting with anxiety, depression, eating disorders and other mental health conditions ‘in what’s going to be a different way of living for quite some time’.

‘This [vaccine]provision will mean seven days a week in assembly halls – we won’t be able to do it in GP surgeries’ 

Community immunity

The government’s planned large-scale vaccination programme will be a ‘game-changer’ for the acute Covid-19 response, according to Viv. The logistics of its delivery were yet to be confirmed at the time of interview, but the skills of CPs are sure to be in demand, she predicts. ‘We’ve already seen some super practice from SNs who ran an outdoor immunisation clinic for the human papillomavirus vaccine in the summer to ensure that vaccination rates for young people didn’t fall during the school closures.’

Janet Taylor, nurse manager, children’s services, at Belfast’s South Eastern Health and Social Care Trust, agrees that the Covid-19 vaccinations are likely to present a significant diversion from the day job in the short to medium term. ‘This will be everybody’s responsibility. It’s going to be all hands on deck,’ says Janet, who is also chair of the CPHVA UK Executive.

Her trust has already offered staff additional hours of work on the vaccination programme. ‘We’ve started compiling lists of volunteers,’ she says. ‘This provision will take place seven days a week in assembly halls – we won’t be able to do it in GP surgeries.’

Given that the redeployment of many CPs to other frontline services during the first lockdown caused problems for several teams that were seriously depleted as a result, could all this extra work have a detrimental effect on community health provision?

Gavin Fergie, lead professional officer for Scotland and Wales at Unite, says that there needs to be a recognition that CP services have ‘already been compromised by the demands of Covid-19. We shall see whether locally managed vaccination programmes can function using dedicated workforces without detracting from other essential services.’

Viv notes that CP teams managed to ‘sustain their services in some shape or form all the way through the first surge’ of the pandemic, despite losing staff through redeployment. But she stresses that the early lessons arising from that policy have not been forgotten, noting that some HVs and SNs were ‘very upset to be redeployed away from their families. Going into the second set of lockdowns, the chief nursing officer for England, the Local Government Association and I were absolutely clear that they should not be redeployed again.’

In August 2020, the chief nursing officer for Wales, Professor Jean White, instructed health visiting and school nursing services to deliver the Healthy Child Wales Programme (HCWP) in full. This is ‘exactly what is happening, but in different, more creative ways’, reports Amanda Holland, lecturer and manager of the specialist community public health nursing (SCPHN) programme at Cardiff University.

Amanda, who is also chair of CPHVA Wales, observes that there may well soon be ‘calls for volunteers to vaccinate – and I know HVs who would support that effort while also managing their caseloads’.

She continues: ‘SCPHN practice has evolved in Wales much the same way as it has elsewhere in the UK. It’s continuing to do so on a daily basis. One HV recently told me that the core HCWP is being delivered as normal and teams are as committed as ever to the principles of health visiting. They are identifying and addressing even more inequalities resulting from Covid-19, while health boards are continuing to recruit and support student visitors.’

Staffing levels

Sinead Toner is a HV from County Antrim and chair of CPHVA Northern Ireland. She reports that staffing levels have been adequate in her region during the Covid crisis, despite all the pressure on resources. She is part of a team that has ‘continued its home visits throughout the pandemic’. Janet adds: ‘Certainly in Northern Ireland, we have increased our intake of health visiting students, but we want to recruit more SNs.’

In Scotland, Gavin notes that ‘team shortages that existed before March’ in certain areas have contributed to a ‘multifaceted’ situation.

In England, by contrast, there have been staff shortages across the board. ‘There are certainly not enough HVs here and we’re very concerned about the need for long-term investment in school nursing in particular,’ Janet says.

Understaffing has long been a problem – research indicates that 34,100 HVs and nurses left the NHS in England between 2012 and 2018 – that ultimately requires a financial solution (The King’s Fund, 2019). But changes in practice that CPs adopted as a result of the need for social distancing have mitigated the problem to some extent.

Home office politics

Whether these new methods, including working from home, flexible hours and virtual appointments, become permanent remains to be seen. The eventual outcome is likely to vary from region to region.

In Wales, Amanda says: ‘The Covid-19 restrictions meant that some areas developed policies to support their workforce with agile working. The HVs I’ve spoken with are in favour of this, but they value the times when they are in the office with colleagues. In some areas, there are limits on the number of people who can attend certain offices at the same time. This means that they have to work more flexibly to use those spaces on a rota basis, for example.’

Amanda notes that not all areas are yet in a position to allow staff to work from home. ‘The use of electronic records in SCPHN practice is still to be rolled out across Wales. Many health boards here still rely on paper, which makes homeworking inappropriate where confidentiality may be at risk,’ she says.

Despite the limitations of their communal workspace, CPs in Northern Ireland have made very little use of their own homes as offices. One of the factors behind this is a lack of adequate IT, but there has been resistance to working from home for other reasons. For instance, the practice ‘changes the team dynamic because you don’t get to see your team’, according to Janet, who adds: ‘The other thing that would have to be put in place is an effective policy for working from home, covering aspects such as confidentiality and the safekeeping of records, that gives staff formal guidelines.’

Sinead says: ‘I don't think we will ever be working from home in Northern Ireland. I think we’ll go back to how things were before the pandemic.’


Distanced learning

Clients are typically ‘very accommodating’ to students who accompany HVs on home visits, despite the complexities presented by the need for social distancing, according to Sinead Toner.

‘Initially, people were scared of Covid-19, but I think they are delighted to see us,’ she says, noting that HVs don’t car-share with students.

Typically, student HVs and SNs will use their own vehicles, says Janet Taylor, who adds: ‘There are risk assessments in place and CPs have to be clear with their clients about student visits. Nine times out of 10 there is no issue – people are wearing the right PPE and doing the right things to control infection.’

Amanda Holland agrees. ‘Our students are involved in all aspects of health visiting practice while following the Covid-19 safety measures,’ she reports. ‘They are using their own cars for home visits and wearing full PPE as expected.’


A mixed model?

What is likely to prove a more lasting change in CP practice is the use of digital technology to support virtual working and engagement with families. A survey of HVs about their practices during the first lockdown in England found that 45% of respondents had used videoconferencing to deliver antenatal contact (UCL, 2020).

‘The provision of support for breastfeeding via Zoom calls has been working very well,’ Janet reports. ‘It won’t be for everyone, obviously, but it does offer a choice. Some mums have said to me: “I wouldn’t go to a breastfeeding group, but I’m really happy to come to a Zoom call because I’m more relaxed sitting at home and getting the guidance I need.”’

Bearing out Janet’s caveat, a survey of new mothers during the first lockdown found that that while some respondents valued digital health appointments postnatally, others found it a negative experience (Best Beginnings et al, 2020). One told researchers: ‘I missed out on breastfeeding workshops, so this has been a huge struggle.’

The use of videoconferencing may be a relatively new innovation, but practitioners have long used text messages to confirm appointments and chatted with clients between appointments on their mobile phones.

‘SNs were working with young people virtually – using the ChatHealth confidential messaging service, for instance – for quite a while before Covid-19 arrived,’ Viv says. ‘They have been able to build on that during the pandemic.’

Amanda acknowledges that practitioners will engage with families on the phone or via apps, using these methods to gather most of their information before making decisions about home visits. But she stresses that home visits are too valuable to be replaced by virtual interactions.

‘The evidence is very clear that home visiting is key to searching for health needs and developing trusting therapeutic relationships with individuals and families,’ Amanda says. ‘We know how safeguarding issues have risen in number during the pandemic. The HV’s invaluable role in prevention is crucial in protecting children from harm.’

Janet agrees, adding: ‘I think the gold standard will always be face-to-face engagement with clients. We’ll take technology that has made for a better experience, but there will always be times when people need to be sitting in a room with their HV.’

 

Changes for the better?

Many changes to CP practice were forced by the pandemic, but several of these have had a positive impact – and not just on infection control.

‘The current climate seems to have brought teams closer together – people care more for each other,’ Amanda says. ‘HVs tell me that they feel their managers are more aware of their workloads and more concerned for their wellbeing.

We have also seen how practitioners have embraced learning new methods and technologies.’

CPs have demonstrated great adaptability under challenging conditions, according to Gavin, who says: ‘Much to their credit, they are tackling situations even when they’re unable to carry out supportive home visits, working out what the new normal is for social support, and addressing many more questions daily.’

The pandemic has also served to expedite infrastructure improvements that might ordinarily have taken years to reach fruition. For instance, NHS Digital built a system to identify vulnerable patients in need of shielding from scratch in record time, according to its CEO, Sarah Wilkinson. This was mainly because the demand for it was clear and urgent, fewer parties than normal were involved in the project and there was a strong appetite to take the risk when it was set against the huge threat posed by Covid-19 (NHS Digital, 2020b).

Indeed, the NHS has discovered things about its own systems that it could not have learnt in normal times, including ‘the choices that frontline professionals make if you give them greater freedom’, according to Matt Hancock, secretary of state for health and social care (Department of Health and Social Care, 2020).

‘The care delivered by HV and SN teams has been an essential part of the nation’s response to the pandemic’

A ‘new normal’?

The profession remains on a steep learning curve, so it’s hard for anyone to predict which of the new practices it’s been forced to adopt will endure after the pandemic.

‘“New normal” is a relative term,’ says Viv. ‘There is general agreement in the NHS that widespread tests and vaccinations are the two big focuses. We have no real sense yet of how long it will take for both to kick in. But there will be an impact on early years, right across the country.’

What is certain, though, is that CPs will play a crucial role in society’s recovery from Covid-19. As Viv says: ‘The care delivered by HV and SN teams and their community nurse colleagues has been an essential part of the nation’s response to the pandemic. They will continue to support vulnerable individuals and families, especially in deprived communities, who are experiencing indirect impacts and hidden harms.’


Resources


References:

Best Beginnings, Home-Start UK and the Parent-Infant Foundation. (2020) Babies in lockdown: listening to parents to build back better. See: https://babiesinlockdown.files.wordpress.com/2020/08/babies-in-lockdown-main-report-final-version-1.pdf (accessed 8 December 2020).

Department of Health and Social Care. (2020) The future of healthcare: speech to the Royal College of Physicians. See: gov.uk/government/speeches/the-future-of-healthcare (accessed 2 December 2020).

King’s Fund. (2019) Closing the gap: key areas for action on the health and care workforce. See: kingsfund.org.uk/sites/default/files/2019-03/closing-the-gap-health-care-workforce-full-report.pdf (accessed 2 December 2020).

NHS Digital (2020a) NHS Hospital & Community Health Service (HCHS) monthly workforce statistics. See: https://files.digital.nhs.uk/12/E31CA4/NHS%20Workforce%20Statistics%2C%20August%202020%20Staff%20Group%2C%20Care%20Setting%20and%20Level.xlsx (accessed 15 December 2020)

NHS Digital. (2020b) The next generation of NHS innovation – embracing the digital revolution: keynote by NHS Digital’s CEO, Sarah Wilkinson. See: digital.nhs.uk/news-and-events/news/sarah-wilkinson-keynote-ppp (accessed 2 December 2020).

Ofsted. (2020) Covid-19 series: briefing on early years, October 2020. See: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/933836/COVID-19_series_briefing_on_early_years_October_2020.pdf (accessed 2 December 2020).

Royal Foundation of The Duke and Duchess of Cambridge. (2020) State of the nation: understanding public attitudes to the early years. See: mk0royalfoundatcnhl0.kinstacdn.com/wp-content/uploads/2020/11/Ipsos-MORI-SON_report_FINAL_V2.4.pdf (accessed 27 November 2020).

UCL. (2020) The impacts of Covid-19 on health visiting in England. See: dropbox.com/s/ib1c25imf5318ob/Conti_Dow_The%20impacts%20of%20COVID-19%20on%20Health%20Visiting%20in%20the%20UK-POSTED.pdf?dl=0 (accessed 27 November 2020).

This piece was written for the journal in late November/early December 2020.

 

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