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Is a secondary pandemic on its way?

6th April 2020

Everyone in the NHS and country is working commendably hard and fast to come together to quell the COVID-19 pandemic and we have been moved by the number of health visitors who have offered to embrace nursing roles in hospitals, or the community. However, whilst there is undoubtedly a huge increase in capacity needed for the frontline NHS workforce, are we risking losing sight of the secondary impact of the pandemic on children and families?

Health visitor staff redeployments, if not very carefully risk assessed, may be leaving behind unseen vulnerable families without enough capacity left in the service to identify them. Evidence from China and Italy would confirm that this could be the case, with each country reporting increased levels of domestic abuse during the pandemic. Here too, there is already reported to be a 25% increase in the number of calls to domestic abuse helplines. If this is the case across the UK, it will be seriously impacting on the wellbeing of any children present in the homes affected.

It is not just the redeployments which is decreasing health visiting capacity to identify children at risk, there have also had to be changes to health visiting staffing practices to protect community staff from COVID-19 infection. As a result, national health visiting professional advice, developed by the Institute of Health Visiting in partnership with Public Health England, recommends that face-to-face contacts should only be completed where there is a compelling need, thereby reducing any risk of cross infection. Universal contacts have been reduced and prioritised, and traditional home visits are now much more likely to be carried out virtually and focused on families with known vulnerability.  However, there will still be a range of urgent situations that require a home visit, for example safeguarding concerns and failure to thrive. Where face-to-face visits are needed, it is not surprising that health visitors are frightened to do them if this is in the absence of personal protective equipment (PPE), which they tell us is the case in many areas.

The first years of life are our most important, laying down a blueprint for our future health and wellbeing.  However, for new parents the first few years of their parenting journey can be very challenging as they learn a totally new role, a role which can often be very unpredictable and one which may be made even harder if their child has particular health needs, or if they are living with challenged financial, social, emotional or housing circumstances.  Normally most new parents can expect to have at least some support from family and friends, and the Government provides an additional safety net in the form of the universal health visiting service. Local communities and charities offer a range of other support for those who most need it.  During this time of social distancing, all this support has now largely been lost at this vital time in the development of the UK’s young children and babies.

Christina Lamb wrote graphically in the Sunday Times this weekend about the implications of staying in over a long period for families with challenged circumstances. She described some families who are living in tower blocks with several children, and how much more difficult this was if one of these children had particular health needs. For the time being, there will be little emotional or practical support available to them and even accessing food is hard. At the iHV we are particularly concerned about the risk of increased incidence of domestic violence and abuse in some homes. Anecdotally, health visitors are telling us they are receiving more police reports of domestic violence.

We know that living in a home with domestic violence can have severe long-term consequences for children, putting them at increased risk of a lifelong trajectory of mental illness.  However, so too can living with a parent with perinatal mental illness which is known to affect around 25% of mothers at some time in the first year of their child’s life.  What will the levels be now?

One health visitor told us:

I had a mother suicidal ringing me this week and I was able to help her and immediately respond. What happens when the named HVs are no longer there and this is only going to get worse as time goes by with increased mental health issues and child vulnerability being out of sight and families at home all of the time.

The power of health visiting is that it reaches into every home with pre-school children, so it can provide timely support for parents and identify concerns for some children that would otherwise be hidden behind closed doors.  However, what are the risks and consequences if home visiting is limited by the availability of PPE and by health visiting capacity?  Health visiting contacts are already reduced by new national guidelines designed to maintain a skeleton service, but one that can respond to those children known to be vulnerable or with reported needs. But what of those suffering behind a closed door who are now invisible to any service, this could be tens of thousands of babies?

The redeployment of large numbers of health visitors, possibly as many as 50-70%, for as long as six months, into nursing or support roles for the NHS in some areas of England is happening at a time when health visiting services have already been severely constrained by recent workforce cuts in many areas of the country. These were described in our recent State of Health Visiting in England report. However, redeployment decisions do vary across the country so some populations of children stand to be much more disadvantaged than others, particularly in some areas of London.  Some organisations are strengthening their health visiting service with the appointment of many more health visitors and others are resisting calls to redeploy their health visitors as they understand that their skills have never been more needed than they are now.

We, and others, are beginning to dub the consequences of this ‘perfect storm’ for children, the “second pandemic”.  So far its symptoms remain largely hidden but health visitors are well aware that they won’t be hidden for long. We know, for example, that the incidence of homicide is highest in babies during the first year.

We urge all services being asked to redeploy their health visitors into nursing roles for the NHS to do a very, very careful risk assessment first and ensure that each and every family, that needs it, still has timely access to a health visitor for help and advice.  Also that they minimise the time any redeployment is for.

It is also imperative that health visitors have the recommended PPE for the essential home visits that they will need to continue to provide. Decisions on levels of PPE are set out in national guidance with the recommendation that individual risks need to be reviewed prior to the contact, and increased levels of PPE should be used “where staff consider there is a risk to themselves or the individuals they are caring for”. It may only be during these visits that the scale of challenge a family is facing will become visible.  We believe that with increased levels of stress in the home and unemployment levels rising, alongside all the other emotional and physical challenges that families are facing, there is now a very significant risk to babies who are too young to speak up for themselves, which the rising number of children contacting Childline have. We are not alone, many other charities working in this sector are also speaking out about the second pandemic.

We will be sharing some feedback from practice over the coming weeks, as it must be heard.  To conclude in the words of one health visitor:

The most vulnerable children, young people and families, many of who are no longer in work, nursery or school provision, have now suddenly become even more vulnerable and I am deeply concerned that Health Visiting is being considered as non essential.

I realise other services are struggling but I really worry about these vulnerable children, hidden away in dangerous homes, away from the professionals who safeguard them. I will support other services but are the families on my caseload now insignificant?

We urge the Government and HV employers to act now to do everything they can to quell the safeguarding storm for children and families that is so rapidly approaching and will already be affecting so many infants and children.

Dr Cheryll Adams CBE, Executive Director iHV