The Institute of Health Visiting and SAPHNA (School And Public Health Nurses Association) have written an open letter to Neil O’Brien MP, Parliamentary Under Secretary of State (Minister for Primary Care and Public Health) in advance of next week’s Spring Budget.
The Spring Budget 2023 will be presented by the Chancellor of the Exchequer, Jeremy Hunt, to Parliament on Wednesday 15 March 2023.
Yesterday’s budget provides some welcome investment in the NHS, social care and education. However, a quick search for the terms ‘children’, ‘babies’, ‘prevention’ or ‘early intervention’ will leave you disappointed. We know that the country faces a tight fiscal settlement – money is tight. But are we spending our money on what matters?
The autumn budget misses the mark and is focused on firefighting. The settlement is presented as sound economics in the ‘here and now’. However, our children will not thank us for failing to grasp the evidence on prevention and early intervention. We have more evidence than any other generation that the foundations for future health and wellbeing are laid in the earliest years of life. It therefore follows that ‘smart economics’ will ensure that spending on babies, children and young people is front-loaded in any fiscal settlement and seen as the smart investment that it is, rather than a cost.
Failing to invest in the public health budget at a time when inequalities are widening, preventable deaths in children are increasing, and 1 in 3 vulnerable children are not known to services, is short sighted and will end up costing much more in the long run. Public health has been at the bottom of the list for investment for too long and this is undermining the Government’s ambition to improve the nation’s health and reduce the long-term burden on the NHS and adult social care.
Health visitors and school nurses working in local government play a pivotal role in ensuring all children get the best possible start in life and can thrive throughout their school years. Their work includes both prevention and direct support for babies, children, young people and families for a range of health needs, and often during times of great distress.
Failing to invest in these services will lead to significant pressures and reductions in capacity across the country. Where services are reduced or cut, this will have a real impact on families, babies and children, and many will be left without the support they need.
The public health grant has already been cut by 24% on a real terms per person basis since 2015/16. There is nothing left to cut. Health visitor and school nurse numbers are continuing to decline without additional investment, whilst pressure grows for both professions as demand continues to soar.
Further investment is urgently needed to enable councils to develop strong and innovative health visiting and school nursing teams in their local areas. Increased funding in this area will protect and support parents, babies and children so they can achieve the best possible outcomes.
NHS funding – The government is providing additional funding of £3.3 billion in each of the next 2 years to support the NHS in England in response to the significant financial pressures it faces, and enabling rapid action to improve emergency, elective and primary care performance. There is no mention of public health.
NHS workforce plan – The government is publishing a comprehensive NHS workforce plan, including independently verified workforce forecasts, next year. This will include measures to make the best use of training to get doctors, nurses and allied health professionals into the workforce, increase workforce productivity and retention. At face value, this offers nothing for staff working in public health – we are awaiting confirmation.
Maternity services – The government is bolstering maternity services by meeting recommendations supported by the Ockenden Review for 2,000 more midwives. This is welcome news for maternity services but fails to tackle the national shortage of more than 5,000 health visitors who have a significant role to play in improving pregnancy outcomes and supporting safer postnatal care.
Children’s Social Care – £1.3 billion in 2023-24 and £1.9 billion in 2024-25 will be distributed to local authorities through the Social Care Grant for adult and children’s social care. This much needed investment is welcomed, but any efforts to improve outcomes for our most vulnerable children, and reduce the risks of harm, will also require a strengthened ‘upstream’ approach through preventative public health and early intervention services.
Schools – The government has committed to, “redouble its commitment to support schools, enabling school leaders to continue investing in the areas that positively impact educational attainment”. The core schools’ budget in England will receive an additional £2.3 billion of funding in 2023-24 and £2.3 billion in 2024-25.
From a school nursing perspective, whilst investment in schools is welcomed, the link between attainment and good health cannot be ignored. Without a parallel investment into school nursing to improve the worsening outcomes for so many school-aged children, this is somewhat futile.
Similarly, for health visiting, it is also disappointing to see that there is no similar commitment to the first five years of a child’s life, despite compelling evidence that the early years are vital for social mobility as this is where gaps in outcomes first begin to take hold.
Alison Morton Sharon White
Executive Director CEO
Institute of Health Visiting School and Public Health Nurses Association
Yesterday’s Budget and Spending Review was launched with the title ‘A stronger economy for the British people’ – it sets out the Government’s priorities and vision of a Global Britain.
The evidence is clear that, if we want a ‘Global Britain’, we need to invest in our human future and build an infrastructure of support for babies, children and families to improve outcomes, reduce inequalities, and build happy, healthy and prosperous adults.
However, we currently have some of the worst child health outcomes in Western Europe, with widening inequalities and spiralling costs of child protection and late intervention. Put bluntly, as a country we are spending more than £16 billion pounds on costly late interventions, or ‘getting it wrong’, every year (and this is estimated to be only a fraction of the true costs). We need to do better.
In the run up to the Spending Review, more than 700 leading children’s organisations came together with ‘one voice’ and called on the Government to do things differently with investment in a public health approach. A national campaign to ‘turn off the taps, rather than mop the floor’ highlighted the importance of tackling the root causes of poor child health outcomes with prevention and early intervention which have been shown to make the biggest difference and make sound economic sense. This included a united call for 3,000 additional health visitors in the next three years.
The Treasury has listened, and we thank them for this. The funding announced yesterday is a welcome step in the right direction and will undoubtedly make a difference to many families. This autumn budget represents a significant turning point with a statement from the Chancellor that he had acknowledged the important work led by Dame Andrea Leadsom MP in her ‘Early Years Healthy Development Review’,
“For too long, far too long, the location of your birth has determined too much of your future… the awesome power of opportunity shouldn’t be available only to a wealthy few… but be the birth right of every child in an independent and prosperous United Kingdom. The evidence is compelling that the first 1,001 days of a child’s life are the most important”.
We would like to personally thank Dame Andrea Leadsom MP for her tireless work, over many years, making the case for babies and their families in the House.
Yesterday’s budget included a £500 million investment package over the next three years to support families and transform ‘Start for Life’ and family help services in half of the council areas across England. This will fund a network of Family Hubs, Start for Life services, perinatal mental health support, breastfeeding services and parenting programmes. It will also expand the Supporting Families programme, providing up to 300,000 families with high quality, multidisciplinary support.
The iHV welcomes all of these initiatives – in particular, we have worked with Leadsom in her campaign for well-resourced Family Hubs and additional funding to improve perinatal mental health support – these all represent an important step in the right direction.
It’s difficult to see from yesterday’s Spending Review how the Government will deliver on their pledge to ‘rebuild health visiting’ or how Family Hubs can be successful without a highly skilled workforce. We need a skilled workforce to welcome and work with families who attend the Hubs, but most importantly, if we are really serious about reducing inequalities, to reach out to the multitude of families who will not attend. The evidence is clear that the families who need the most support are the least likely to easily engage with services – they need a skilled health visiting workforce to ‘reach out’ to them.
Yesterday was not ‘our day’ – there was no workforce plan to deliver the additional 3,000 health visitors needed over the next three years to address the national shortfall of 5,000 health visitors, or ensure that the health visiting workforce is strengthened to address current and future ‘health’ priorities. The Healthy Child Programme is a ‘health’ policy and much of the work requires a highly skilled ‘health’ workforce – it is therefore essential that we have a workforce plan which delivers a ‘health’ workforce – it is ‘safety critical’, not just a ‘nice to have’.
The only mention of health visiting was a pledge that, “Trials of innovative workforce models for health visitors will also be funded in a smaller number of council areas to test approaches to improve the support available to new parents” – the pre-budget announcement indicated that this would be £10 million.
Whether this is good news or not, will really depend on the detail of this proposal. As part of our Spending Review submission, we proposed the establishment of ‘ICS academies for child and family health’ within selected early adopter sites, to bring partners together to collectively plan, test and refine health and care services to meet the needs of babies, children, families and communities. Working in more integrated ways represents a significant shift in health policy, it will therefore be important to have systems in place to support and evaluate the implementation of ICSs and inform wider system learning. It is unclear whether this is what is being proposed.
Given that the Best Start in Life budget delivery metrics all relate to ‘education’, our longstanding concerns are that ‘health’ is not a priority in the Early Start vision and, as such, the important ‘health’ function of health visitors will continue to be overlooked. Others have expressed concerns that the “innovative workforce models” described are actually a dilution of the health visiting workforce to increase the proportion of lower-skilled staff.
We recognise that the Government faces a tight fiscal settlement, having already invested significant sums of money into almost every part of society. In terms of Government priorities:
You decide – have we got our priorities right with only £500 million for babies and young children, who represent our ‘human potential’? Against a backdrop of piecemeal child health policies and years of disinvestment, with £1 billion stripped from the public health grant, the sector is united that this does not go far enough.
But for now, there are still opportunities for health visitors to maximise – keep close to the iHV as there is work to be done and plans are already emerging for next steps.
We look to the future when one day we can shift from a budget titled ‘A stronger economy for the British people’ to one which prioritises people through ‘Stronger people for the British economy’.
Joint letters from the Institute of Health Visiting (iHV) and the School and Public Health Nurses Association (SAPHNA) warn national and local leaders that the proposed cuts to health visiting and school nursing services in Hampshire will put children at risk of harm.
Despite rising levels of safeguarding concerns nationally which saw 285 children killed or seriously harmed in the first 6 months of lockdown in England, Hampshire County Council has forged ahead with their plans to cut their health visiting and school nursing services intended to support families and safeguard children.
Concerns have been raised that the proposals described as “Serving Hampshire, balancing the budget” bear no resemblance to the national Healthy Child Programme which sets out a programme of support for all babies, children, and their families. Within the proposed plans to reduce the 0-19 Public Health Nursing Service budget by £2.09 million per year are significant elements that will undermine delivery of the Healthy Child Programme, drastically cut the support available to families, and strip out the mechanism to identify vulnerable children:
The whole health and social care system is interconnected and changes like these cannot be made in isolation without consideration of the wider system impact; making radical cuts like these will cause harm to children and will create a ripple effect across other services like GPs, secondary care, and children’s social care that are already stretched and need to be accounted for.
The iHV and SAPHNA believe there are several sets of grounds which, singly and severally, mean the County Council and national government ought to review these plans, to ensure that they are not in breach of their statutory safeguarding responsibilities nor undermine the delivery of the Healthy Child Programme which has been mandated by government.
Post-covid, it is even more important that families with babies and children are supported, with rising levels of children living with vulnerability and risk. England already has a significant problem, with 1/3 of all vulnerable children recognised as ‘invisible’ [1] within the system and therefore not receiving the support that they need. Our children are also the unhappiest across Europe. This proposed model would place them at even greater risk
These cuts are the predicted consequences of insufficient funding and inadequate system levers, alongside a lack of prioritisation of prevention and early intervention at all levels. An urgent national review is needed to acknowledge the root cause of these cuts, and their significant wider system impacts, with a clear plan to tackle them once and for all.
Sharon White, CEO SAPHNA, said:
“We have seen a number of recent and significant cuts to health visiting and school nursing services with more planned; this must stop. We are fully versed in the Governments budget cuts, reduced public health grant and cash-strapped councils with our services clearly seen as ‘easy pickings’ in trying to rectify; this false economy as only serves to kick the can down the road, resulting in increased costs to services to say nothing of the long-term impacts on children’s and families’ lives.
We have more than enough evidence to demonstrate that our public health practice can and does make a vital difference. Hampshire’s proposals are radical, dangerous and a disservice to its population. We cannot and must not accept this.”
Alison Morton, Executive Director at the Institute of Health Visiting, said:
“We should all be worried about what’s happening in Hampshire. The proposed changes in Hampshire represent an important national test case, rather than an isolated outlier that only needs to be addressed locally. The national Government’s response is that it’s down to local authorities to decide how they manage their budgets. Conversely, the local authorities’ perspective is that the cuts are due to a lack of government funding. Both are true – and the time has come to move beyond this stalemate and find a sustainable solution that puts babies, children, and their families first. Unless resolved, families ultimately bear the brunt of these cuts.”
The council is seeking residents’ and stakeholders’ views on their proposals through an open consultation process. We urge as many people as possible to “have your say” by responding to this consultation. The consultation Information Pack provides further detail about Public Health services in Hampshire, the four areas under consideration and the options for change – available here.
The iHV response: Since the consultation was launched, the iHV has been working constructively and in collaboration with the School and Public Health Nurses Association, the unions, and colleagues in Hampshire County Council to find a resolution that meets the needs of babies, children, and their families. At the end of last week, the iHV and SAPHNA sent a joint letter to both Hampshire County Council and Public Health England outlining their concerns.
Serious Incident Notifications: The total number of serious incident notifications for children during the first half of 2020-21 increased by 27% (n=285) on the same period in 2019-20 – of these, 35.8% relate to under 1s who remain at the highest risk of homicide than any other age group[2].
[1] https://www.childrenscommissioner.gov.uk/report/childhood-vulnerability-in-england-2019/
2 BETA: .GOV.UK (2021) Part 1 (April to September) 2020-21. Serious incident notifications https://explore-education-statistics.service.gov.uk/find-statistics/serious-incident-notifications
New government funding of £210 million for NHS nurses to improve their training and skills should be expanded to cover public health workers, such as health visitors and school nurses, councils say.
Institute of Health Visiting. Library Photography. Picture: Cleverbox / www.matthewwalkerphotography.com
Offering greater training and upskilling opportunities would also encourage more people into nursing and to stay in the profession for longer, at a time when the sector is experiencing severe problems in recruitment and retention.
The Institute of Health Visiting (iHV) calls for Government to reverse the cuts to public health budgets and reinvest in health visiting services to protect and support the health and development of babies, children and families, and, in the medium and longer term, for all in our society.
In a letter to the Chancellor, the Institute details how the year-on-year reductions in the public health budgets is leading to far-reaching declines in health inequalities across England – impacting the long-term health outcomes for our children, as well as society.
A policy change in 2015 moved the commissioning of health visiting services to local government, coinciding with a 6.2% reduction of the public health budget during that financial year and further annual cost savings of 3.9% each year until 2020.
Dr Cheryll Adams CBE, executive director iHV, said:
“We know so much today with respect to what can influence children’s outcomes across their life course and in turn benefit the whole country. The impact of the public health budget cuts on babies and children is very worrying and upsetting. It is alarming that, in the two years since the commissioning change, the number of health visitors seems to have reduced by around 18%*, and could rapidly be approaching an all-time low.”
Health visitors play a vital role in supporting babies, children and families in the early years of life. There is a strong research base that demonstrates that a significant part of an individual’s ‘blue print’ for their future mental wellbeing is laid down in the first two years of life. This is a critical window for supporting parents to help their children build solid social and emotional wellbeing. Health visiting services are effective at identifying and reducing the impact of health inequalities, so reducing the burden of care both in the short and longer term.
Dr Adams continued:
“As a nation, we cannot afford not to invest in our children as they are our future, yet recently their needs seem to have become invisible against the many competing demands being made on Government and the NHS. The work of the health visitor often goes unseen, until you take it away. Government may soon have to face the effects of some of the lowest ratios of health visitors to children experienced by this country in living memory.
“It’s time to act, to help ensure the best health outcomes for all UK children today, and in the future. We need urgent action from the Government to increase their investment in public health prevention and early intervention to ensure that health visitors can continue to give every child the opportunity to have the best start in life.”
*NHS Digital
Institute of Health Visiting | c/o Royal Society for Public Health, John Snow House, 59 Mansell Street, London E1 8AN
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