Today, Rt Hon Andrea Leadsom MP announced the Public Health Grant allocations to local authorities in England for 2024/25. The public health grant provides the financial envelope for a wide range of services including health visiting. The scale of the funding is therefore an important measure of the Government’s priorities and their commitment to improving the nation’s health through prevention and early intervention.

Whilst there has been some additional discretionary funding for some policy areas (smoke-stop services, drug and alcohol addiction treatment, and the Start for Life Vision), no additional funding for health visiting services was forthcoming. The local government allocations for public health in 2024/25 represent a below inflation uplift of only 2.1% on 2023/24 (or a further cut to the grant in real terms). Overall, cuts to the public health grant since 2015 have amounted to more than £850 million. As a result, health visiting services have been scaled back and the health visitor workforce has been cut by more than 40% since 2015. Ultimately, families face the brunt of this, with many families missing out on the vital support that they need during the crucial earliest years of a child’s life.

Commenting on the announcement, Alison Morton, iHV CEO, said:

“Set against a backdrop of increased inflation, and increased pay, today’s public health grant settlement is a huge disappointment. It is nowhere near enough to deliver the Government’s own blueprint for health visiting and represents another cut to funding and a blow to services.

“Today’s announcement must also be viewed in the context of growing pressures on services, as more families are struggling with poverty and vulnerability that increase the demand for health visiting support. Cutting vital health visiting services is a false economy as we know that early intervention can make such a difference to a child’s outcomes and is much cheaper in the long run. We need to act now to turn policy rhetoric on prevention into action – today’s announcement sadly represents another wasted opportunity to turn this situation around.”

More and more reports highlight the dire state of child health and development across our nation that cannot be ignored – immunisation rates are falling, A&E attendance rates for children are increasing, more children are falling behind with their development, babies and children are being harmed by conditions that are entirely preventable, and health inequalities are widening. Health visitors see the realities of family life first-hand and the imperative to act was set out in our recent “State of Health Visiting” survey report published last month.

The iHV is not alone in its concerns about the lack of attention being given to babies and children in the UK. Just today, the hard-hitting report from the Academy of Medical Sciences has been covered in the news, highlighting a growing crisis across the early-years – with wide ranging evidence of declining health that takes root from preconception through pregnancy to the first five years of life.

PHE’s Oral Health Survey of 5 year old children 2017 shows tooth decay in 5 year olds continues to decline in England, with current levels at 23.3% – down from 30.9% in 2008. However, clear inequalities in oral health remain, with children in deprived areas more likely to be affected.

Public Health England has published, for the first time, these 2 reports presenting information on the oral health of children at local authority level:

  • ‘Local authority area variation in the oral health of 5-year-olds‘ identifies the 30 local authority areas with higher levels of tooth decay and the trends in decay over the past 9 years
  • ‘Oral health improvement programmes commissioned by local authorities’ shows which oral health improvement programmes local authorities are currently commissioning

Both reports should be read in conjunction with the official statistics publication National Dental Epidemiology Programme for England: oral health survey of 5-year-old children 2017.

  • 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: and Masters et al (2017), Return on investment of public health interventions: a systematic review

iHV is a signatory to a letter, lead by the Royal College for Paediatric and Child Health (RCPCH), which was sent to the Health Service Journal (HSJ) in response to an article written last week about how public health cuts are damaging to child health.

The HSJ investigation revealed that services aimed at children and young people are bearing the brunt of cuts to public health spending by local authorities.

Overall, their analysis identified planned spending reductions worth £50.5m in 2016-17, across 77 local authorities which provided information. Of the £50.5m cuts in 2016-17, the biggest single area was a £7m reduction to services directly aimed at improving the health of children and young people, such as health visiting, school nursing and childhood obesity programmes. These represented 14% of the total.

The letter signed by 12 leading specialists, warned that any spending cuts imposed by local authorities could have a “significant impact on the future health of children”. Scaling back spending on health visitors, child obesity programmes and school nurses will have a detrimental effect on the future health of children and young people in the UK it said.

A copy of an article in relation to this can be found on the HSJ and you can see a copy of the letter in full on the RCPCH’s website.

The letter is also shared below:

Dear Sir,

At a time where child wellbeing in the UK ranks a poor 16th out of 29 income rich countries, putting us below Slovenia and the Czech Republic, children are becoming overweight or obese earlier and breastfeeding rates are deemed the worst in the world, it is highly concerning to learn that of the £50.5m spending reductions planned for 2016-17 by local authorities, the biggest single area affected was services directly aimed at improving the health of children and young people (‘Children’s services hardest hit by public health cuts,’ 4 July 2016). Cuts are also affecting services for pregnant women such as smoking cessation and this could have a significant impact on the future health of children.

If we are to improve outcomes for children and young people in the UK, then it is vital that services provided by local authorities such as health visiting, school nurses and weight management programmes are protected. Without them, obesity rates will rise and the associated health costs will spiral, breastfeeding rates will fail to get better and thousands of babies each year will miss out on the many benefits it provides. In addition, obesity prevention, school nurses and health visitors are all important in the prevention and early detection of mental health problems, so these services are vital for maintaining both the physical and mental health of our children. We call on Government to invest in child health now because by doing so, it will protect the future health of the nation.

Professor Russell Viner, Officer for Health Promotion, Royal College of Paediatrics and Child Health (RCPCH)
Shirley Cramer, CEO, The Royal Society for Public Health (RSPH)
Professor John Middleton, President of the Faculty of Public Health
Sarah Carpenter, head of Health, Community Practitioners’ & Health Visitors’ Association
Sarah Carpenter, head of Health, Unite
Dr Ingrid Wolfe, Chair, British Association for Child & Adolescent Public Health
Janet Davies, Chief Executive & General Secretary at the Royal College of Nursing
Dr David Richmond, President, Royal College of Obstetricians and Gynaecologists (RCOG)
Dr Cheryll Adams, CBE, Executive Director, Institute of Health Visiting
Cathy Warwick, CEO, Royal College of Midwives
Jane Barlow, President, Association of Infant Mental Health
Stephen Dalton, Chief Executive, NHS Confederation
Bernadka Dubicka, Vice-chair, faculty of child and adolescent psychiatry, Royal College of Psychiatrist, Honorary reader, University of Manchester; Consultant psychiatrist, Lancashire Care Foundation Trust
Prof Karen Middleton, chief executive of the Chartered Society of Physiotherapy