Targeted but Tired: How Specialist Perinatal Health Visitors Are Carrying a System Without Capacity

23rd January 2026

We are delighted to share this Voices blog by Sarah Kargbo. Sarah is a Specialist Perinatal and Infant Mental Health Health Visitor based in London, with professional experience across maternal mental health, sexual and reproductive health, safeguarding, and work with vulnerable families. Her work focuses on how workforce capacity, population complexity and structural inequality shape maternal and infant wellbeing. She is committed to strengthening early intervention through equitable, evidence-informed public health practice.

Specialist Perinatal Health Visitors (SPHVs) play a critical role in identifying perinatal mental health needs, supporting early intervention, and contributing to safeguarding across the early years system¹. Increasingly, however, the effectiveness of specialist practice depends on the stability of the universal health visiting workforce. Across London, vacancies, recruitment delays, financial constraints and rising complexity are reshaping the context in which specialist roles operate. This article draws on London-wide patterns to explore how workforce pressures, population diversity and system variability affect specialist practice, and why protecting the SPHV role is integral to improving outcomes for women and infants.

This article is offered as a way of putting words to experiences that are often felt but not always easily articulated in everyday practice. By creating a shared language around continuity, capacity and complexity, it aims to validate frontline experience and support ongoing advocacy for systems that allow health visitors to work as effectively and relationally as they are trained to do.

While this article is intentionally London-centric, reflecting the data and practice context on which it is based, the experiences described are widely echoed by colleagues across the UK and reflect national pressures within the health visiting workforce.

Universal capacity: the foundation of specialist practice

Effective perinatal mental health support begins with a well-resourced universal service. Universal health visitors provide continuity, relational assessment and mandated contacts that act as a gateway to early intervention pathways³. Yet across London, the universal workforce continues to operate under sustained pressure.

In many boroughs, caseloads exceed recommended levels, compounded by recruitment freezes and difficulties filling vacant posts. Reduced staffing capacity limits continuity and weakens the early identification of emerging need.

When universal services experience reduced capacity:

• early signs of poor maternal mental health may go unnoticed
• domestic abuse or safeguarding concerns may remain undisclosed
• bonding difficulties and infant cues may be missed
• engagement may be inconsistent due to lack of continuity
• referral thresholds shift from preventative to reactive.

The result is a growing mismatch between what specialist services are designed to deliver and what they are increasingly required to hold. Vacancies do not simply create workforce gaps; they generate clinical risk, inequity and moral injury for practitioners.

When continuity is lost: reflections from practice

Following my recent presentation to the iHV Specialist Health Visitors in Perinatal and Infant Mental Health Special Interest Group, practitioners across services reflected on how closely these themes resonated with their own local experiences. Many described parallel conversations already taking place within safeguarding supervision and team spaces, particularly around the impact of reduced continuity on early identification and relational work.

A consistent theme was the sense of being on the back foot, intervening once difficulties had already escalated rather than being able to notice and respond early.

The expanding role of Specialist Perinatal Health Visitors

SPHVs were designed to enhance universal provision, not to compensate for workforce shortfalls. Their expertise lies in targeted perinatal mental health assessment, risk formulation, parent-infant relationship support, and specialist safeguarding input². However, as universal capacity diminishes, referral patterns have shifted.

Across London, SPHVs report increasing numbers of late referrals and higher acuity presentations, with complexity often reflecting cumulative social adversity rather than primary mental health need. This widening scope places SPHVs at the point of crisis response more frequently than intended. Time that should be protected for relational, specialist intervention is increasingly redirected towards holding risk, managing escalation, and providing consultation to overstretched colleagues.

Practitioner voices: what the workforce is saying

“It was really validating to hear this articulated. It put into words what we are experiencing locally and helped us realise it is not just us.”

“We were discussing in safeguarding supervision how lack of continuity means we miss early signs. By the time concerns are picked up, families are already more complex.”

“Because of vacancies and frozen posts, we are often just managing to complete mandated contacts. That loss of continuity is felt by staff and families alike.”

“As specialists, more is being pushed towards us because we can offer some continuity, but that often means needs are identified later than they should be.”

“Every day feels like a battle of advocating for continuity. We are intervening, but it is already later than it could have been.”

These reflections reinforce a shared concern that erosion of the universal offer undermines the preventative function of health visiting and places disproportionate pressure on specialist roles.

Variability, inequality and the need for standardisation

London is characterised by marked intra-urban inequality, with wide variation in deprivation, housing stability, population mobility and linguistic diversity. These structural factors shape both the prevalence and presentation of perinatal mental health need.

However, population need should not result in variable access to care. Differences in mandated contact coverage, referral pathways and specialist capacity risk creating postcode-based inequities.

A London-wide standardised baseline, covering mandated contacts, referral criteria, safeguarding processes and minimum specialist capacity, would help mitigate variation and strengthen equity across the system.

Workforce pressures as a safeguarding concern

Perinatal mental health, domestic abuse, trauma and infant safety frequently intersect. When universal oversight is reduced, early indicators of risk may remain hidden.

As a result, SPHVs increasingly encounter families at points of heightened acuity. Safeguarding work becomes more urgent and complex, requiring significant time and emotional labour. Workforce shortages therefore carry safeguarding implications for both infants and parents.

Conclusion

Specialist Perinatal Health Visitors bring depth, expertise and relational skill to some of the most complex areas of early years practice. However, ongoing vacancies and recruitment freezes have destabilised universal provision, reshaping both the volume and nature of referrals into specialist pathways.

Protecting the integrity of the SPHV role requires renewed investment in universal capacity alongside system-level alignment and standardisation. Without this, specialist services risk being stretched beyond their remit, and families risk receiving support too late.

Key messages

• Universal health visiting capacity is essential for early identification of perinatal mental health need.
• Staffing shortages have significantly reduced continuity across many London boroughs.
• Reduced universal visibility leads to later and more complex referrals to specialist services.
• SPHVs were designed to enhance, not replace, universal provision.
• Postcode variation risks widening perinatal mental health inequalities.
• Workforce pressures carry safeguarding implications for mothers and infants.

Sarah Kargbo, Specialist Perinatal and Infant Mental Health Health Visitor

References

1. Health Education England. Specialist Health Visitors in Perinatal & Infant Mental Health. What they do and why they matter. 2016. Available from: https://bit.ly/3n4Jsvg [Accessed 19th January 2026]
2. Homonchuk O, Barlow J. Specialist Health Visitors in Perinatal and Infant Mental Health. Department of Social Policy and Intervention, University of Oxford. 2022. Available from: https://bit.ly/40EFqHN [Accessed 19th January 2026]
3. Morton A, The role of the health visitor: where are we now?, Paediatrics and Child Health, https://doi.org/10.1016/j.paed.2024.04.006