The big story: slipping through the net

07 December 2018

With the number of health visitors falling and those that remain carrying ever greater caseloads, there is a real risk of missing contact with vulnerable children. But what can be done to mitigate that risk?

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It is hard to overstate the scale of the challenge facing health-visiting services across the UK. In Northern Ireland, health visitor vacancies led to a backlog of almost 700 children awaiting visits in one trust alone earlier this year (Connolly, 2018). In Scotland, the NHS saw health visitor vacancies rise by almost 50% (McArdle, 2018).

In England, there has been a staggering 24% drop in the number of health visitors employed in the NHS, from the October 2015 peak of 10,309 full-time equivalents following the national health visitor implementation plan, to just 7852 in July 2018 (NHS Digital, 2018).

The latest figures show that while almost 88% of new birth visits took place within 14 days, and 84.3% of six- to eight-week checks were done on time in England in 2017-18, one in four children hadn’t had their 12-month review by the time they turned one, and almost one in five had not had it by 15 months. A quarter of two- to two-and-a-half-year checks were not performed by the time the child was two-and-a-half (Public Health England, 2018).

These figures don’t even tell the whole story. Unite lead professional officer Dave Munday has sought to address the information gap.

His research, featured in the November edition of Community Practitioner, found that only 10 of the 136 organisations for which he gathered statistics have average caseloads below the 250 maximum that the CPHVA insist should be in place, and 15 have average caseloads of at least double that.


Breaking point

Unite national officer for health Colenzo Jarrett-Thorpe says: ‘The system is being stretched beyond utility and health visitors are at breaking point.

‘More situations are going to happen where there just won’t be the resources to make mandated visits. Where health visitors and other health professionals are increasingly stretched, they can only offer the bare minimum service and on occasions not even that.

‘When you have caseloads double what they should be, there are bound to be mistakes and vulnerable children and families being put at risk. That’s the result – the most vulnerable children and families will suffer.’

Without adequate time, health visitors’ ability to do their job is doubtless impacted, says Colenzo. ‘For community practitioners, their whole modus operandi is around building relationships with people – there is no quick fix for that.’ He adds: ‘There is lots of anxiety among health visitors who feel their service is being undermined, and what they contribute to the lives of children and families is being impaired by increasing stress and strain on the system and on them.’

In recent months, a serious case review of the care of a four-week-old boy who was admitted to hospital in Coventry with head injuries came to light.

While the review concluded his injuries could not have been ‘predicted or prevented’ by agencies, it identified ‘missed opportunities’, including two appointments with health visitors that could not go ahead because no one was home, and ‘a failure to undertake the primary visit in his home’ (Coventry Safeguarding Children Board, 2016).

The review also said there were no records showing the minimal requirement to inform the baby’s GP about the lack of a health visit within 14 days of the birth.

Cases like this are a health visitor’s worst fear – but, with services stretched wafer-thin, they are all too real a possibility.


What can HV's Do? 

  • When seeing a family antenatally, ask simple questions to find out if you should expect the family to be home or staying elsewhere after the birth of their baby.
  • If you can’t get access to a family, follow your unseen child policy, and escalate as guided.
  • Relationship building is crucial; use your skills to pick up verbal and non-verbal cues.
  • Work smart. Use other services appropriately.
  • When you have concerns, raise them and keep raising them – and ensure it is minuted or noted – for example in an email or at a management meeting.
  • Go beyond incident reporting – highlight systemic issues too. Raise concerns where you don’t have the resources you need, or you’re unable to follow a protocol – and again make sure it is recorded.
  • Involve your union – they will raise concerns on your behalf, and lobby for change at a governmental level.
  • Lobby your MP – add your voice to those fighting to reverse the savage cuts to public health budgets.


Less visible families

Unite regional officer Su Lowe says ‘savage’ budget cuts mean fewer universal services are being commissioned, and core contacts are happening in baby clinics instead of at home, all of which means ‘families are less visible’.

‘Services are being reduced to just the mandated contacts,’ she says. ‘The baby clinics, the baby groups, the breastfeeding groups are being cut. Health visitors have told me that because they aren’t identifying need and following things up as they did before, they are having less contact with the very families they want to see more of.’

She adds: ‘Health visiting creates work – it doesn’t create problems – but what it does is uncover need.

‘The fewer home visits, the less you see the home, the more likely things will be missed. Sometimes, if we don’t walk through that door, no one else does. Children don’t go to nursery until two, they don’t have to be in school until they’re four – a child can be kept isolated from their community and the authorities.’

Obi Amadi, Unite lead professional officer, agrees that the lack of continuity that so many families are experiencing is a concern.

‘If you have seen that family antenatally, you can ask very simple questions. Where will you be living after delivery? Will you be coming home after you deliver? Is your mum coming to stay? That contact gives you so much information.

‘New birth visits can be quite difficult. If there’s no answer, and no concerns were highlighted before birth, you wouldn’t necessarily think anything sinister is going on – they might be staying with family. You need to follow your unseen child policy, and then be escalating as guided.’

Health visitors have a difficult path to tread between support and monitoring for red flags, adds Obi: ‘They are able to navigate that because they have the required skills and knowledge. They observe, they pick up the verbal and the non-verbal cues. That’s why the relationship-building is so important.

‘But they haven’t got the statutory right to enter – they are visitors in someone’s home and they conduct themselves accordingly.’

She also expresses concern that not only are contacts being missed, but in many cases they are not being carried out by health visitors, but by other members of mixed skills teams.

‘Despite the fact the Healthy Child Programme is supposed to be health visitor-led, the decision has been taken in some areas that visits should be delegated – so for example all one-year assessments are being done by community nursery nurses,’ adds Obi.

‘Health visitors are not leading it, they are not making the decisions – that in itself is a risk.’


Raising concerns

So what can health visitors do to mitigate some of the risk?

‘It’s very easy for their managers to say they need to prioritise,’ says Obi. ‘What health visitors really need to do is work smart. There are other services and they need to use those services appropriately.

‘But where they have concerns, they have to raise them and keep raising them. Where there is a near miss or an untoward incident, they need to use the system to record it. Conversations in the corridor are not enough. They need to keep raising the issues with their line manager – and it must be in a way that is minuted or noted – so sending an email or at a management meeting. Raise your concerns and ask for a response.’

Su agrees, adding that not only are overstretched services leaving children vulnerable – but health visitors too; the erosion of continuity and ‘quality home-visiting’ means they can find themselves having to ‘offer advice to families they know nothing about’.

‘That’s not a safe environment,’ she continues. ‘It is so important health visitors stand up and ask for help, and raise their concerns, not just incident reporting – the whole system is becoming the incident.

‘We need individual practitioners to write those emails to say “We haven’t got the resources”, “We aren’t able to follow this protocol”; it’s really important the concerns are being raised and being recorded, and if you feel vulnerable raising those concerns – we, as your union, will raise them on your behalf.’

A professional in crisis?

A wake-up call

The union is not just advocating at a local level. Unite has long campaigned against the cuts dished out to local authorities following the transfer of public health commissioning into their hands in 2015, and for an end to the ‘false economy’ of ‘marketisation of the NHS,’ adds Colenzo Jarrett-Thorpe.

Returning commissioning to the health service, reinvesting in services and bringing back the bursary for student nurses are vital steps the government must take, says Colenzo.

‘We urgently need a real investment in health visiting, school nursing and community nursing. The number of health visitors fell by 8% [in England] over the past year, and we think the number of school nurses fell by 25%. These figures are a wake-up call to those responsible for the welfare and safety of children, young people and their families.’

Picture credit | Shutterstock




Connolly, M-L. (2018) Health visitor shortage causing baby review backlog. BBC news website. See: (accessed 20 November 2018).

Coventry Safeguarding Children Board. (2016) Serious case review: baby F. See: (accessed 20 November 2018).

NHS Digital. (2018) NHS workforce statistics: July 2018. See: (accessed 20 November 2018).

Public Health England. (2018) Health visitor service delivery metrics: 2017/18 annual data statistical commentary. See: (accessed 20 November 2018).

McArdle H. Health visitor vacancies up 50 per cent in a year amid ageing workforce fears. See: (accessed 20 November 2018).