5th July 2023
To celebrate the 75th birthday of the NHS (#NHS75), we are delighted to share this Voices blog by Professor Dame Sarah Cowley as she recounts her nursing and health visitor life.
Professor Dame Sarah Cowley
What an honour to have been chosen by Nursing Times as one of 75 nurses and midwives who have had an ‘especially significant impact on the NHS’! I was born in the same year as the NHS – when Britain was a very different place to the country we live in now, in 2023. As a small child, I was, of course, unaware of the massive post-war building programme. I knew only that, at the age of five, I was to move with my family into a council house with real indoor plumbing: a bath big enough to swim in, that didn’t hang behind the door for the rest of the week! Likewise, I was unaware of the huge, unwieldy infrastructure that had developed through the war years, that was now being reimagined, merged and moulded into the promised welfare state.
One part of those changes involved understanding how the long-established profession of health visiting would fit with that emerging scene. There was a shortage of health visitors then, as now, with concerns about recruitment. The 1956 Jameson Report led to the formation of the Council for the Education and Training of Health Visitors (CETHV), which was to take over the register previously held by the Royal Sanitary Institute (now the Royal Society for Public Health) and extend the training from nine months to one year (51 weeks). This ‘new breed of health visitor’ preparation began in 1965 and was to last for another thirty years.
Apart from regulating health visitors, the CETHV maintained a watching brief on how many were employed: the numbers across Great Britain rose from 6403 full time equivalents (FTE) in 1967 to 10,248 a decade later; 8477 were employed in England in 1977. Health visitors had been employed by local authorities since the early years of the twentieth century, and this did not change immediately when the new NHS was formed. Instead, they continued to be employed by the ‘public health authorities’, which were part of local government rather than the NHS; they eventually merged in 1974. Since 2015, the situation has changed again, with the public health grant for commissioning health visitors (amongst others) being held in local government in England, even though the majority of health visitors are employed within NHS Trusts. The workforce has fallen back towards those 1967 levels too, with only 5677 FTE health visitors employed in the NHS in England, in March 2023, and perhaps another thousand employed by independent healthcare providers (998 FTEs in September 2022).
Professor Dame Sarah Cowley as a cadet nurse
I became a cadet nurse in 1964 when I was just 16 years old, before completing my nurse training then working in acute general nursing. I moved into health visiting in 1980, at which time health visitors were regarded as autonomous professionals; we were attached to GP surgeries, but also covered a geographical patch and worked in teams across the area. We were encouraged to use our own professional knowledge, covering all ages, whilst prioritising infants and children under five-years-old. We had staff nurses as part of the team, who helped with visiting most of the older people on the caseload, and school nurses who worked fairly autonomously, unless there was a child protection concern: their training at the time was still only four-months long. The term ‘skill mix’ hadn’t yet been invented – but teamwork and collaboration with professional colleagues certainly had.
Of course, it was not all perfect – there was very little evidence for the effectiveness of our work and such professional freedom also allowed wide inconsistencies in practice, although discussions in regular staff meetings helped iron out concerns as they arose. One of the first things that attracted me to health visiting, was the ‘can-do’ attitude of most of my colleagues. If something was needed, we worked out how to deal with it. It meant we were always busy because there were always health needs but, in my experience, far more of the work was genuinely preventive then, instead of having to wait until problems were established and intractible.
Sadly, by the end of the 1980s, that positive can-do attitude was being seen as a negative: staff were encouraged to give things up, not take them on, and searching for health needs was discouraged as the workforce began to reduce in line with the cost-cutting agenda. And as the NHS internal market developed after 1989, health visitors found their long-term, preventive and health-creating agenda was a poor fit for the countable ‘episodes of care’ and ‘measurable outcomes’ required by commissioners and funders. The work needed to be systematised and explained better, we were told. And why couldn’t health visitors be more biddable, like their nursing cousins? That need to explain health visiting is what drew me into research, and I was fortunate to obtain funding for my PhD, which I completed in 1991.
Those were very early days for research in health visiting and I was fortunate to join King’s College London, first as a health visitor tutor student, then as a member of staff in 1992. I became a professor five years later and worked at King’s until I retired in 2012. Those 20 years were a period of turmoil for the health visiting workforce, which has hardly abated since. Yet, over those same decades, the amount of evidence pointing to the need for a preventive focus on the first 2000 days (conception to age five) has grown exponentially. As health visitors, we all understood Tudor Hart’s ‘inverse care law’ which states that people with the greatest need are provided with the least health support, particularly where market forces are involved. Similarly, it seems, the greater the evidence for preventive health care in the early years, the lower the amount of funding provided for it: an ‘inverse evidence law’, perhaps.
We have so much more evidence now, than in the last century. The seminal Black Report in 1980 foreshadowed an exponential increase in evidence about the social determinants on health. Every day, health visitors see the impact of these inequities, as families strive to cope with poverty, poor housing and multiple other challenges. The 2022 annual Institute of Health Visiting survey of health visitors reported “escalating levels of population need, widening health inequalities with an increase in vulnerability and safeguarding risks.”
Scientific interest in how infants’ brains develop grew dramatically once it was possible to take MRI images of them. But it is not just neurodevelopment, we have clearer evidence than ever about the importance of early nutrition, of genomics, and so much more: those early days can establish the infant’s future health, education and life chances. When I was a student health visitor, ‘Born to Fail’ by Wedge and Prosser was a set text – I recognised myself on almost every page! But now we know, for sure, that no infant needs to be defined by the circumstances into which they were born, if early preventive actions are taken.
Also, we have evidence about how to work successfully alongside parents living in difficult situations, now. We know so much more about how to enable relationships that nurture the future wellbeing and resilience of their infants and protect their future health. There is a mass of evidence about specific interventions that health visitors can use, included in ‘Health for all Children,’ NICE guidelines, and the recently published schedule of interventions for the Healthy Child Programme. As well, we are far clearer now, than when I first started my research some 35 years ago, about how health visitors work and the specific skills and knowledge that they bring to the table. They work in partnership and through relationships, using a distinctive ‘orientation to practice’ based in positive health creation, being person- and family-centred, with their practice rooted in the local social situation for their caseload and the families they serve.
Throughout the 75 years of the NHS, and certainly since I joined the profession in 1980, it feels as if health visitors have been somewhat on the edge of the ‘main business’ of its hospitals which care for the acutely sick or people with long-standing disabilities and need for immediate help. At present, with the reduced workforce and an NHS that, itself, often feels under siege, it would be understandable for health visitors to seek safety in mainstream or defensive positions. Yet there is much to be positive about now, as well.
First, there are pledges to increase the staff numbers, starting with another 17% by 2028, in the new NHS Workforce Plan. Should a different government be elected within the next year or so, the Labour Party has pledged an additional 5000 health visitors. Either way, an increase in the number of health visitors is on the way.
Second, the NMC published a new set of standards of proficiency for health visitor training last year. They are still under the umbrella of ‘specialist community public health nursing,’ but they have a far closer fit to the current extensive role and knowledge base needed for the job than the standards they replaced. And, of course, the Institute of Health Visiting has an extensive range of short courses, modules and learning opportunities for qualified health visitors, as well as rapid ‘go to’ top tips for parents and key good practice points to help maintain effectiveness in practice.
Finally, last year, an alliance of over 200 organisations joined together to explain ‘why health visitors matter’. This booklet supported a call to government to maintain a fully staffed health visiting service, free at the point of delivery, proportionately universal in its coverage, and encompassing the range of health needs faced by parents, their infants and children. This substantial endorsement shows that, even though the present may seem tricky, the future looks good for health visiting, along with the families and communities they serve, just as much as it does for the NHS.
