Over 1200 English health visitors reported in the 2018 Institute of Health Visiting (iHV) annual survey that for many their caseloads are increasing, that they are experiencing high levels of stress, and they worry about not being able to deliver the services they should to all children with needs, especially the most vulnerable. This follows a significant reduction in local authority public health funding since 2015.

The Institute’s 2018 survey shows that 44% of health visitors reported working with caseloads of more than 400 children, up from 28% in 2015 when commissioning of their service transferred to local authorities. The Institute recommends a maximum of one health visitor to 250 children to deliver a safe service.

Higher caseloads have led to 42% of health visitors reporting the quality of their service as being inadequate or poor with increased stress levels (72%) in the practitioners and concerns about child safety with a shocking 43% reporting that they are so stretched they fear a tragedy at some point (when a child in need isn’t recognised until it’s too late).

Dr Cheryll Adams CBE, Executive Director iHV, said:

“Cuts to public health budgets by the Treasury have led to a loss of around a quarter of the total health visiting workforce over the past three years (NHS Digital), but these losses aren’t consistent across the country with losses being greater in some areas and smaller in others.”

The losses come against a backdrop of increasing need, especially related to poverty. 69% of health visitors told the Institute they had seen an increase in the use of food banks over the past 2 years.  Health visitors also report working with many more families facing multiple adversities, including parental substance misuse, domestic abuse and mental illness. In the words of one health visitor:

“….. complexity of families and increase in poverty has increased need, especially around mental health”

The survey responses also indicate that health visitors’ capacity to deliver all of the five mandated universal health and development reviews from the Healthy Child Programme (HCP) in England, the minimum service that every family is entitled to, has been seriously reduced.

Many reviews are delegated to non-registered practitioners without health training, and some are not carried out at all, with reports of around 65% families not having an appointment with a trained health visitor after their child’s 6-8 week contact, and even less, 79%, after the first year of life.

Dr Adams continued:

“This is hugely worrying as many of the issues that health visitors are trained to assess during these contacts with families are hidden and are easily missed by less qualified practitioners.  This means that these issues may be much harder and more costly to address by the time that they become conspicuous.

“The Children’s Commissioner for England has recently discussed the need to be concerned about so called ‘missing babies’ (A Crying Shame, Oct 2018) who are very vulnerable but not recognised as children in need and only found if you look for them.

“Another negative impact of the fall in health visitors has been on breastfeeding rates, for example a reported fall from 70% to 46% at 6 weeks in one London Borough after the funding for their breastfeeding team was cut. We know that breastfeeding protects against many illnesses, so this will ultimately result in increased costs to the NHS.”

There are just five mandated universal contacts prescribed for all families in England, in stark contrast to the health visiting services delivered across the other parts of the UK. Nine core universal contacts are being delivered to Welsh families, families in Northern Ireland receive seven with a planned increase to nine, and Scottish families receive eleven.  These are all health visitor contacts, not delegated to more junior staff.

Dr Adams commented:

“It is about much more than the number of contacts, it’s the quality of those contacts that matters – having enough time to listen to family concerns and to act on them.  It is clear there is now a significant postcode lottery of health visiting services across England with some parents still receiving a good service (for example, Blackpool has invested into eight contacts) on a sliding scale to many parents receiving very poor services depending on where they live.  This is an unacceptable situation for English children as it has implications for their wellbeing across the life course.”

The Institute is calling for reinvestment into public health services, a new joint integrated commissioning framework between local authorities and the NHS for universal children’s health services, a refreshed and re-launched Healthy Child Programme and enough health visitors to be able to address the unique needs of every child and family.

President of the Royal College of Paediatrics and Child Health, Professor Russell Viner, said:

“Health visitors play a vital role in public health and prevention. They provide crucial health advice to parents, identify and put interventions in place for children with health, educational and potential safeguarding needs, and help to prevent accidents, injuries and more serious problems later in life.”

Dr Adams concluded:

“Another round of public health budget cuts are due in 2019/20. Unless these are stopped now, we will see a further reduction in health visitors and more negative outcomes for children and families, and in turn, for society as a whole.”


  • More than 1 in 3 health visitors worry that they are so stretched that there may be a tragedy in their area at some point
  • More than 1 in 5 health visitors are working with caseloads of over 500 children

Results from the Institute of Health Visiting (iHV) annual survey 2017 show the worrying impact of a reduction in health visiting services on babies and families since responsibility for the service in England moved from the NHS to cash-strapped local authorities in October 2015.

This year’s iHV survey of over 1400 health visitors shows major concerns around safeguarding and protecting children at risk, with a third of health visitors in England feeling that they are so stretched that there may be a tragedy in their area at some point – this is up from 25% in 2015 and strongly suggests a very unsafe situation for both children and health visitors who must manage that risk and worry, and know they may be blamed if a child is injured.

The survey also disturbingly showed that more than 1 in 5 (21%) health visitors in 2017 are working with caseloads of over 500 children – which is in stark contrast to the 1 in 8 (12%) reported in the iHV survey in 2015 when the funding transferred from NHS to local government, and when a recommended ‘minimum floor’ was set of three whole time equivalent health visitors to cover 1000 children. The Institute recommends an average of one health visitor to 250 children to deliver comprehensive health improvement.

42% of those surveyed reported they can only offer continuity of care to vulnerable children and those subject to child protection processes (26% in 2015). This is worrying when it’s the ability of health visitors to build a trusting relationship with families over time that gives those families the confidence to disclose sensitive areas where they need help promptly.

Dr Cheryll Adams CBE, executive director of the Institute of Health Visiting, commented:

“Health visitors are advanced specialist practitioners, previously nurses or midwives, who are very skilled at working with families to support them through stressful times.

“We are being told that many families see a health visitor only until their child is 8 weeks old, with less skilled staff carrying out all their later developmental reviews.  Health visitors’ time is being targeted to picking up work once done by social workers in some areas of the country, meaning that these health visitors are not able to deliver their primary preventative role – the only professionals previously able to offer this as a universal service.

“Without a universal preventative service many children and families in need will be missed until their problems become serious, which goes completely against the role and responsibilities of a trained health visitor and where they can have their greatest impact.  Our worry is that the number of children needing care proceedings will increase, even more children will need mental health services, postnatal depression will go undiagnosed, there will be greater demand on GPs and hospital services and more children will enter school less well prepared in terms of their social, emotional and communication skills. Cutting the public health workforce is a false economy.”

Dr Adams continued:

“There is a significant research base that demonstrates the importance of investment in the early years to reduce later costs by up to eight or nine times including the cost of social care, the NHS and criminal justice services*. As a nation, we cannot afford to not invest in our children – they are our future.   There is already a large group of children and families who are affected by the recent reductions to public health budgets, and without new investment this number seems set to increase.”

* See the work of Nobel Prize winning economist James Heckman: https://heckmanequation.org/resource/the-heckman-curve/ and Masters et al (2017), Return on investment of public health interventions: a systematic review http://jech.bmj.com/content/71/8/827

The Institute of Health Visiting’s State of Health Visiting Survey 2016 shows the drastic impact the cuts to the local authority public health budgets are already having on the universal public health services delivered by health visitors. In response, the Institute is calling upon the government to reinvest in public health to protect and support mothers and babies by stopping cuts to the health visiting service by cash-strapped local authorities.

According to the State of Health Visiting survey 2016, 85% of health visitors (HVs) of the 1224 surveyed say their workload has increased over the past two years – with 40% of the increase in workload due to a reduction in the number of health visitors, this is despite the huge investment which went into the service between 2012-15.  16% of HVs reported they now have caseloads of between 500 and 1000 children – the optimum average caseload for safe and effective practice is 250.  Most worryingly, this is at a time when 80% of the respondents also report seeing an increase in domestic violence and abuse and perinatal depression in the families they visit.

The cuts have impacted on the delivery of the universal service, with only 70% of all families receiving the mandated health visitor reviews at 6-8 weeks, one year and 2-2.5 year, and only 30% of all families receiving the antenatal visit.  Through these stretched resources, only 5% of HVs are able to offer consistent continuity of care to all families and 72% worry about providing inadequate safeguarding and child protection support.

Official figures show that at least 988 full time posts (NHS Digital, 2016) have been lost between Sept 2015 and August 2016, with 56% of local authorities planning further cuts next year (Evidence to Health Select Committee, 2016).

Dr Cheryll Adams CBE, executive director of the Institute of Health Visiting, said:

“Our annual survey of the state of health visiting shows a radical downgrading of this public health asset, which serves the most formative period of children’s lives.  Health visitors should provide a universal service to every family in the country with a child under the age of five. This survey hence exposes the risks to all children and families from a decommissioning of health visitor posts, which it seems is just about to accelerate. The impact will not only be felt by children and families, there will be a knock-on effect on the NHS and other local authority services such as safeguarding services.  We can expect increased use of secondary health and local authority children’s services in the short, medium and longer term as many health and social concerns won’t be identified early enough. The cuts will also increase health inequalities as needy families will be missed until their problems are obvious.”