The future of health visiting

Public health investment continues to shrink in real terms. Rekha Vijayshankar believes this only makes health visitors and their timely interventions more important than ever.

In the autumn budget, the chancellor pledged an extra £6.3bn to the NHS in England. Substantial as it might seem, this amount does not include funding for public health, or medical education and training. 

In 2013-14, the government transferred the responsibility for funding most public health services from the NHS to local authorities. With the government continuing its austerity, in 2015-16 there was a £200m in-year cut to public health spending by local authorities in England. Worryingly, on a like-for-like basis, spending on public health will actually fall by 5.2%, from £2.6bn in 2013-14 to £2.5bn in 2017-18, with the overall funding gap for local authorities estimated to be in the region of £5.8bn by 2019-20 (Local Government Association, 2017; The King’s Fund, 2017).

Concomitantly, the number of health visitors has fallen by more than 1000 in England since the Health Visitor Implementation Plan ended in 2016, and in 2016-17 there was a 22% reduction in planned health visitor training commissions from the previous year (RCN, 2017). This means fewer nurses are taking up the specialist community public health nursing (SCPHN) qualification, and the impact of the proposed changes on training for public health nursing remains to be seen.

Maternal and children’s mental health

These trends are concerning, particularly as the school-age population rises and the need increases to support mothers and families, and help children and young people develop and achieve the best possible outcomes. 

Healthy, happy children are the bedrock of a robust and healthy society. For parents on low incomes working two or three jobs to make ends meet, early years community services are often their only support. Supporting investment in early years is one of the key ways to address health and social inequalities by ensuring that every child gets the best possible start in life. 

The state of maternal and children’s mental health is hard to ignore. Suicide is the leading cause of maternal death during pregnancy and up to a year after birth (MBRRACE-UK, 2017). Perinatal mental health problems are believed to cost the NHS £1.2bn a year (Bauer et al, 2014), and the impact on mothers and children can last for decades. 

Between 10% and 20% of women will suffer from perinatal mental illness, including depression and post-traumatic stress disorder. Most of these women will be looking for help from their health visitor, GP or midwife. In 2015, £365m was pledged to be spent over five years on specialist maternal mental health services in England. But it is estimated the NHS would need to spend £337m a year to bring maternal mental healthcare up to the standard recommended by NICE (Bauer et al, 2014).

As a nation, we spend less than 1% of the NHS budget on children’s mental health. According to NHS England, even with the extra £1.4bn that was committed in 2015, only one in three young people with diagnosable mental health problems will get the help they need (NHS England, 2017).

Local authority commissioning is looking at setting up complex 0 to 19 professional services in the absence of government funding, but lacks the money to pay for dedicated, well-educated professional SCPHNs. As a result, 0 to 19 service managers are being forced to look at how their service is being ‘paid for and counted’, rather than focus on the holistic, comprehensive and complex relationship-building and looking for health needs through a nurturing relationship-building that health visitors are trained to do. 

This scenario is further complicated as some services move to providers outside the NHS. Given that 0 to 19 services are driven by key performance indicators, trusts are beginning to introduce skill-mix teams – ostensibly to improve efficiency – and a complex picture of workforce changes is emerging. Tracking workforce developments and workforce planning will potentially be increasingly difficult for commissioners and 0 to 19 managers alike, given the gaps in data and the difficulties of tracking future workforce developments. 

The importance of delivering key 0 to 19 public health services is directly linked to the future of our children, families, society and way of life. There is a clear and consistent link between poverty and lack of access in younger years and poor health outcomes in older years (Royal College of Paediatrics and Child Health (RCPCH), 2017a).

The government approach to cut public health funding is economically unviable, with the cost of late interventions spiralling to £17bn in 2015-16 (Early Intervention Foundation, 2016).

We require committed action from the government as well as innovative and creative ways of service delivery by the 0 to 19 service and its commissioners.

What can the government do?

First, a clear vision from the government about the way forward for 0 to 19 services in the next five to 10 years is required: these services are largely preventative in nature and require complex, time-intensive relationship-building. Thus, in 2016, Unite-CPHVA, among other organisations, called for the reintroduction of the minimum dataset for health visitors by the Department of Health.

Second, a commitment is needed to invest in early years service provision to help families on low incomes and facing vulnerabilities such as domestic violence and unemployment. 

The Wave Trust (2013) report on the economics of early years found that returns on investment in well-designed early years interventions significantly exceeded their costs. The benefits outweighed the costs over a range of 75% to more than 1000%. 

Returns are not merely financial, but bring health improvements for the whole population, including lower infant mortality at birth and reduced heart, liver and lung disease in middle age (Wave Trust, 2013). There is certainly room for improvement: the UK ranks 15 out of 19 western European nations in terms of infant mortality (RCPCH, 2017a).

Third, a review should be set up on the way public health spending is currently funded. We await the evidence that abolishing ring-fenced public health spending and replacing it with local authorities’ retention of business rates to pay for the services has been effective. And I believe that the government’s social justice agenda should include a review of the impact of public health funding cuts on the delivery of the Healthy Child Programme. 

The devolution of healthcare to reflect local health needs and priorities – the sustainability and transformation plans – has, according to the RCPCH (2017b), not prioritised infants’ and young people’s health. Its report states that there is ‘wholly inadequate appreciation that the health and wellbeing needs of infants, children and young people are crucial to securing long-term population health and reducing the national burden of healthcare provision.’

What can other stakeholders do?

All stakeholders in public health – Unite-CPHVA, Health Education England, Public Health England (PHE), individual trusts and the NMC – urgently need to work together in the context of training and for future policy development. Teaching institutions and NHS trust employers can help by introducing placements in health visiting and school nursing to reinforce and re-affirm multidisciplinary working. 

A review of government spending on services like Sure Start and children’s outreach teams should take place. These are at the heart of families and health-visiting support. Some of the biggest falls in local authority spending have been directed at Sure Start children’s centres, which have seen budgets reduced by almost half (48%) in real terms in the past five years (Action for Children, 2016). 

What can health visitors do?

The six high-impact areas for health visiting as outlined by the 4-5-6 model are highly valued and form the basis of the PHE routine monitoring of the health and wellbeing outcome indicators relating to the 0 to five years population.

The value of health visiting in these areas is evidenced by an estimated £11m of savings through infection control, reducing complications arising from obesity and addressing problems facing those at the bottom of the socioeconomic scale (RCN, 2017). Intensive health-visiting programmes for vulnerable families can reduce their likelihood of using other social care services by the age of 12 – and, for the most high-risk families, by the age of four (Olds et al, 2010).

Extending the role of maternal mental health provision through additional training and specialist posts for health visitors willing to undertake the additional training will render universal health-visiting contacts more robust.

The loss of a health-visiting service means the loss of a critical gateway through which a range of other interventions pass, leaving long-term social and personal impacts. Safeguarding is a prime example: health visitors are the only service to visit every single family, making them one of the best mechanisms for identifying children at risk.

Improving healthy life chances helps build a fairer society and addresses rising demands on the NHS. There is a need to invest in skilled specialist practitioners, reduce the need for intensive interventions later in life and provide increased opportunity for everyone to reach their full potential. 

Rekha Vijayshankar is a health visitor based in Redhill.

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Bauer A, Parsonage M, Knapp M, Iemmi V, Adelaja B. (2014) The costs of perinatal mental health problems. See: http://everyonesbusiness.org.uk/wp-content/uploads/2014/10/Embargoed-20th-Oct-Final-Economic-Report-costs-of-perinatal-mental-health-problems.pdf (accessed 13 February 2018).

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Royal College of Paediatrics and Child Health. (2017a) State of child health. See: www.rcpch.ac.uk/state-of-child-health (accessed 13 February 2018).

Royal College of Paediatrics and Child Health. (2017b) State of child health short report: sustainability & transformation partnerships. See: www.rcpch.ac.uk/state-of-child-health/stp (accessed 13 February 2018).

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