Lord Darzi’s review on the state of the health service in England

Lord Darzi’s independent review on the state of health services in England has concluded that the service is in “serious trouble”, with long waiting lists, a deterioration in the nation’s underlying health, and problems for people accessing services. Focusing on children, the review highlights soaring demand for child health services, with too many babies, children and young people waiting years for treatment. Lord Darzi is clear that the solution is not to build more hospitals, but instead to follow the evidence and invest in better community care, stating that:

“When things go wrong the knee-jerk response from ministers has been to throw more money at hospitals where the pressure is most apparent as waiting areas fill up and ambulances queue outside.

“The result is that NHS has implemented the inverse of its stated strategy, with the system producing precisely the result that its current design drives. The problems are systemic. In the current paradigm, patients have a poorer experience, and everybody loses – patients, staff and taxpayers alike.”

The Institute of Health Visiting provided evidence and data for the review. And we are delighted to see Lord Darzi’s recognition of the challenges that services are facing, alongside acknowledgement of the crucial role that health visitors play in child health and development in the early years, stating:

“The Health and Social Care Act moved the commissioning of public health services to local authorities. As we have seen, the public health grant has fallen by more than 25 per cent in real terms. This has had a particular impact on Health Visiting, where numbers of health visitors have fallen … Given the extensive evidence base on the importance of the first 1,000 days of life; it is clear the NHS is missing an opportunity to intervene early.”

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

“The findings from the Darzi Review are shameful for a developed nation such as ours. Yet, they are not surprising given years of neglect of our healthcare services – they echo the issues that we have repeatedly raised over too many years. Childhood is short and the impacts of delays in care and treatment during these crucial developmental years are magnified and are unacceptable. Our babies, children, young people and families deserve so much better.

“Importantly, the report does not shy away from the stark realities – we can’t fix a problem until we are honest about it! We welcome the spotlight that this review has shone on the current state of services and are keen to work with the new government to push ahead with their plans to create the healthiest generation of children ever. This needs to include actions to fix the foundations of health by rebuilding health visiting services.”

This week, iHV also submitted evidence to the Spending review, setting out our call for investment in health visiting and case to rebuild services. It is precisely because the government faces a tight fiscal settlement that action needs to be taken to address the soaring costs of preventable problems which have their roots in early childhood. Failure to invest in prevention has been a costly mistake, with spending on late intervention spiralling out of control across health, education and social care.

The evidence is clear that investing in our nation’s children represents the smartest of all investments, with spending in the earliest years yielding the greatest return on investment across the life-course.

Read the Darzi Review here

Read iHV submission to the 2024 Spending Review here

NHS publishes Vaccination Strategy for all vaccination programmes

Today, NHS England has published the first national Vaccination Strategy, bringing together all vaccination programmes, to protect communities and save lives. The strategy outlines how getting vaccinations will be made easier than ever before, including through expansion of the NHS App, ‘one stop shops’ and community outreach.

Vaccinations provide one of the most effective public health interventions, preventing between 3.5 and 5 million deaths every year across the globe through childhood vaccinations alone. Whilst the UK has a comprehensive childhood immunisation programme, falling rates of vaccine uptake over the last decade are a source of considerable concern. Tackling this issue will require a whole system approach and health visitors have an important role to play.

At the end of October, the UK Health Security Agency (UKHSA) issued an urgent letter regarding preparedness for measles resurgence in England. Measles is a highly infectious disease which can only be controlled by vaccination. Through their universal work with all families, health visitors can support uptake of the MMR immunisation programme to meet the WHO target of 95% coverage with two doses of MMR vaccine by age 5 years. Achieving this target is essential to maintain measles elimination status for the UK and prevent measles outbreaks from occurring.

The new national Vaccination Strategy outlines three clear priority areas to reverse these downward trends in vaccine uptake and prevent deaths and hospitalisations from vaccine-preventable diseases. These include:

Improving access including an expansion of online services: Many more people will be able to book their vaccines online quickly and easily, including via the NHS App. Families will be able to view their full vaccination record with clear information and guidance on what vaccinations they should have to keep them well.
Vaccination delivery in convenient local places, with targeted outreach to support uptake in underserved populations: Bespoke outreach services should be tailored to communities that are un- or under-vaccinated, building trust and confidence.
A more joined-up prevention and vaccination offer: Vaccination services and activities should be holistic, offering multiple vaccinations for the whole family where appropriate.

The Strategy sets out its plans for improved integration with clinical pathways and greater joint working across all local service providers, including acute, community, mental health and local authorities. Systems should consider how they can:

Make vaccination the business of everyone working in patient-facing settings, through training and awareness campaigns. This includes using key contacts to talk to the person about relevant vaccinations, answer questions and, if they cannot deliver the vaccination there and then, signpost to the appropriate services.
Base vaccinators in healthcare settings accessed by people who may benefit most from vaccination. This may include emergency departments, outpatient departments, family hubs and community diagnostic centres. The report highlights that, “Family hubs may be especially beneficial for babies and children where parents may be less likely to access a standard offer.”
Train and deploy a wider set of professionals to deliver vaccinations. The reports states that, “Local authority services for 0–5 year-olds, for example, have unparalleled contact with underserved communities. Health visiting teams as well as school nursing teams have successfully delivered vaccinations in the past and continue to do so in parts of the country, making use of their extensive skills and relationships. Any such arrangements would need to be locally planned and take into account workforce capacity and funding requirements.”

Whilst the Vaccination Strategy does not set out all the specifics of implementation (and there will be a range of considerations that will need to be addressed), NHS England has indicated that they will continue their work with stakeholders (including the iHV) to develop their plans in order to deliver the proposals. With sufficient resource, there are significant opportunities to build on the work that has already started in Integrated Care Systems to provide more ‘joined-up’ vaccination programmes in the future, across the whole pathway including through integrated neighbourhood, place and system teams. We are particularly pleased to see the emphasis on reaching all parts of the community, with a specific focus on underserved and marginalised communities that will be needed to tackle widening health inequalities.

Professor Helen Bedford, Professor of Children’s Health, Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health and iHV Expert Adviser: Immunisations, commented:

The UK vaccination programme is among the most successful worldwide, yet there is room for improvement to ensure we offer maximum protection to the population against infectious disease. Each year for the past ten years, small declines in uptake of childhood vaccines, together with large disparities in uptake between geographical areas and social and economic groups, are a cause for concern. If fully implemented, the Vaccination Strategy will be vitally important to ensuring we improve our current position and placing us well to maintain the success of the programme into the future. Through their contacts with families, and the trusting relationships they build, health visitors play a key role in boosting vaccine confidence and in securing the success of the childhood vaccination programme.

Read NHS Vaccination Strategy

Read NHS Vaccination Strategy online

Read iHV Good Practice Points: Promoting the Uptake of Childhood Immunisations which contains advice on health visitors’ role supporting vaccination uptake as part of an integrated approach.

Health visitor workforce numbers in England reach an all-time low

New data on the health visiting workforce figures published yesterday show that health visiting (HV) numbers in England have reached an all-time low.

Raising concerns about the falling number of health visitors (HVs) in England has been challenging, as workforce data are not published in a single dataset. Since 2015, our members have been reporting a significant and ongoing reduction in HV workforce numbers and we have been calling for a workforce plan to address this – so far, this has fallen on deaf ears. Some policymakers have provided repeated reassurance that the situation is not as bad as the iHV has stated, as the NHS workforce data does not capture all the health visitors who work outside the NHS.

Yesterday’s publication of the most recent workforce numbers lays this bare. Health visitor numbers are falling in both NHS and non-NHS providers. There is now no doubt, if we want to retain an effective health visiting service in England, that we urgently need a HV workforce plan, and this cannot wait any longer. Despite health visitors’ best efforts, families are being left without the support that they need, and the consequences have been catastrophic for some families.

Georgina Mayes, iHV Policy and Quality Lead, says:

“Despite health visitors working tirelessly, supporting hundreds of thousands of babies, children, and families during the pandemic, we do not have enough health visitors to meet rising levels of need. As a result, too many families are missing out on essential health visitor reviews and the vital help that they need. Consequently, families are feeling alone and let down; health visitors are reporting work-related stress and burnout, all of which risks further HVs leaving the profession. Urgent action is required by national Government now to address the health visiting workforce shortages.”

How are health visiting workforce data reported?

Health visiting workforce numbers are published in two national datasets, one captures the number of practitioners working for NHS organisations and a separate dataset presents a smaller number of health visitors who work in non-NHS organisations. Whilst we have watched a month-on-month decline in the numbers of health visitors working in the NHS, the last Independent Healthcare workforce data was last published in February 2021 which has made it impossible to get a clear picture of current overall workforce numbers.

The newly published data now fully exposes a crisis in the HV workforce.

HV workforce numbers are currently published via two datasets:

The NHS workforce data (using data from May 2022) = 5979 FTE HVs employed by NHS organisations.
The Independent healthcare workforce statistics (using data from March 2022) = 1051 FTE HVs employed by non-NHS organisations.

The current total combined published HV workforce data (August 2022) = 7030 FTE.

The graph below visually shows the rapid decline in HV numbers. The HV workforce has decreased by over a third (37%) since 2015.

Contributing factors of the health visiting decline include:

The Public Health Grant falling from £4.2 bn in 2015–16 to £3.3 bn in 2021–22.^[1]
A reduction in HV training places since 2015, which has coincided with budget cuts.

HV numbers are now well below the figures which triggered the Government’s Call to Action and investment in 4,200 more HVs in 2011 (7849FTE).

When adequately resourced, health visitors provide a vital infrastructure of support to all families – preventing problems and identifying needs early to reduce the burden of costly late intervention. Health visitors lie at the heart of the Government’s ‘Start for Life Vision’, as one of six essential services – we are therefore calling on the new administration to take the health visiting workforce situation seriously and provide the much-needed investment and the workforce plan that will be required to deliver this vision.

This is needed now more than ever to address the health visiting workforce crisis and reverse the national decline in the profession.

[1] The Health Foundation 2021 ‘Public health grant allocations represent 24% (£1bn) real terms cut compared to 2015/16’ (16 March)
https://www.health.org.uk/news-and-comment/news/public-health-grant-allocations-represent-a-24-percent-1bn-cut

A recovery plan for health? or only for sickness and the NHS?

Waiting for policy announcements is a bit like waiting for buses. Yesterday saw the long-awaited announcement of the local authority public health grant settlements, and this was followed swiftly today with Sajid Javid’s announcement of the elective recovery plan for the NHS.

The announcements lay bare the glaringly different priorities afforded to ‘sickness treatment’ in the NHS and the poor relation of preventative public health and early intervention.

It has been estimated by the NHS that 10 million people did not seek treatment during the pandemic, and around 6 million people are waiting for elective treatment. To address this backlog, Sajid Javid says the government has already allocated an extra £2bn to tackle waiting lists this year, with another £8bn being spent over the next three years – alongside this, there is a further £6bn of spending announced for capital investment in the NHS.

In contrast, England’s public health grant allocation for 2022-23 saw a 2.81% rise to council’s public health budgets, which brings total funding to £3.42bn in 2022-23, up by £93m from 2021-2022. The Government had previously pledged to maintain public health funding in real terms in the autumn budget, however, when compared to the current rate of inflation of 5.4%, this settlement represents a cut in real terms.

Recently, Sir Michael Marmot said: “It shouldn’t be that we either invest in treatment services or improving public health, we need to do both if we want to create better societies for people.”

Alison Morton, Executive Director iHV, responded:

“Yesterday’s funding settlement for local authorities in England is not good news. With long-standing workforce shortages, rising levels of vulnerability and a backlog of babies, children and families missed in the pandemic, this is another blow for public health. Where is the public health recovery plan?

“Our role at the iHV and as health visitors is not to be party political but to stay true to the key principle of health visiting to ‘Influence policies affecting health’ – and it is in our view that the Government needs to reconsider its priorities for babies, children and families as a matter of urgency. Whilst we are all acutely aware of the costs that this country faces in the wake of the pandemic, to gain perspective we need to view these decisions in the light of other policy decisions. In the autumn Spending Review, the price of a pint of beer was cut by 3p – this came at a cost to the Treasury of £3bn.”

We have escalated our concerns in a recent letter to the Minister, Maggie Throup, and officials in the Office for Health Improvement and Disparities. Whilst we welcome their plans for a workforce roundtable in February and the commitment of £10m for workforce pilot schemes, action is urgently needed to address the much bigger problem posed by the ever-increasing health visitor workforce shortages now – this cannot wait for another 2 years for these pilots to report their findings. Babies, young children and their families are at risk because we know that we have a shortfall of about 5,000 health visitors and this is having a significant impact on the service and the level of support offered to them.

Further details on the Public Health grant settlement are available here

Read Alison Morton and Dr Cheryll Adams recent paper: Health visiting in England: The impact of the COVID-19 pandemic

RCNi Webinar: Genomics in Routine Care Part 3

Following the success of the first two webinars, watched live by over 1,000 attendees combined, the Genomics Education Programme, NHSE/I and the RCNi would like to invite you to join the third and final part of their free webinar series on 8 September.

This final webinar in the series will feature a range of speakers looking at how genomics is being applied to healthcare and opportunities available for learning, including a look at courses and resources designed to show health professionals how genomics is and will be used in specific areas of practice.

The webinar will be chaired by Professor Chris Morley, Chief Nurse for the North East and Yorkshire NHS Genomic Medicine Service Alliance, with opening remarks delivered by Professor Mark Radford, Chief Nurse for Health Education England.

For those health visitors who have an interest in genomics, Sally Shillaker will be speaking about genomics and the health visiting role during the webinar.

This webinar is CPD-certified and will allow you to gain two hours of participatory CPD towards your revalidation.

To find out more or to reserve your free space now, please visit the registration page.

Book your free place at Webinar 3 - Genomics: It’s my time to learn!

Queen awards George Cross to NHS

The Institute of Health Visiting wishes a very happy 73^rd birthday to our fabulous NHS. In recognition of the enormous contribution that the NHS has made to the health and wellbeing of the country, the Queen has awarded the George Cross to the NHS as the service marks its anniversary today.

In a personal message, the Queen said NHS staff across the UK had worked “with courage, compassion and dedication” for more than 70 years.

The Duke of Cambridge is hosting a Buckingham Palace tea later to thank NHS workers.

The awarding of the George Cross by the Queen is made on the advice of the George Cross Committee and the prime minister. This latest award is only the third time the George Cross has been given to a collective body, country or organisation, rather than an individual.

Accelerating the return to near-normal levels of non-Covid health services

On 31 July, plans for the next – third – phase of the NHS response to the COVID-19 pandemic, effective from 1 August 2020, were set out in a letter from the Chief Executive Sir Simon Stevens & Chief Operating Officer Amanda Pritchard; this includes providers of community services.

The Government has agreed that the NHS Emergency Preparedness, Resilience and Response (EPRR) incident level will move from Level 4 (national) to Level 3 (regional) with effect from 1 August. This approach matches the differential regional measures the Government is deploying and builds on the guidance set out in the COVID-19 restoration of community health services for children and young people: second phase of NHS response to “fully restore [the health visiting] service, with some prioritisation where indicated and as capacity dictates”.

The priorities for this phase are:

Accelerating the return to near-normal levels of non-Covid health services, making full use of the capacity available in the ‘window of opportunity’ between now and winter
Preparation for winter demand pressures, alongside continuing vigilance in the light of further probable Covid spikes locally and possibly nationally.
Doing the above in a way that takes account of lessons learned during the first Covid peak; locks in beneficial changes; and explicitly tackles fundamental challenges including: support for our staff, and action on inequalities and prevention.

Read the letter here

Newsflash – restoration of community health services for children and young people

Hot off the press is the updated Prioritisation of Community Health Services – “COVID-19 restoration of community health services for children and young people: second phase of NHS response“.

We are delighted to see greater prioritisation of the role of health visitors as an essential part of the country’s support structure for children and their parents during this public health pandemic. In particular we welcome:

The removal of the wording around redeployment of health visitors
The reinstatement of the health visitor 6-8 week review
The inclusion of additional safeguards to protect vulnerable children – “Face-to-face contacts should be prioritised for families who are not known to services to mitigate known limitations of virtual contacts and support effective assessment of needs/ risks”
Prioritisation of home visits where there is a child safeguarding concern.
Reinforcement of messages that “routine and selective immunisation programmes should be maintained. This includes the seasonal flu programme”.

Download COVID-19 restoration of community health services for children and young people: second phase of NHS response

This document supersedes the prioritisation guidance for community health services first published on 20 March and subsequently updated on 2 April.

To see all documents go to NHS COVID-19 prioritisation within community health services

Health visiting during COVID-19

We have received numerous enquiries from health visitors asking for greater clarity for the health visiting service during the COVID-19 pandemic. The Institute is doing all we can to expedite this information for the profession and have a dedicated COVID-19 section of our website which we are using to provide updates as and when they are received. However, at the moment the content still lacks this much needed detail for health visitors’ roles.

We have contacted Public Health England, the Local Government Association and the Association of Directors of Public Health to highlight the need for advice to manage the numerous queries that we are receiving from health visitors, including service leads around emergency planning and escalation for the health visiting service – things like, “should we carry on with universal contacts?” “Will I be redeployed? And if so, when?” “What about families who have safeguarding concerns or high levels of vulnerability?” “Am I in a priority key-worker group?” etc…

The latest update that we have received from Public Health England is that the NHS is leading on drafting guidance on community services including health visiting. PHE and local government have provided advice and we are awaiting publication. We will alert our members and followers when we receive advice that it has been published – hopefully very soon. As there is considerable pressure and pace within the healthcare system due to the pandemic, we suggest that you also keep a look out on the government COVID-19 update web pages and contact your local commissioner and Director of Public Health who will be coordinating the response to the NHS guidance in your area.

Our position at the iHV is that we need to support the government-led decisions (nationally and locally) rather than issuing our own guidance which may cause confusion and mixed messages at this time when clarity is needed.

We will continue to do all that we can to help.

A big thank you to everyone working in health visiting at this time. You are all doing an amazing job during the uncertainties of the COVID-19 situation – it is comforting to know that we have great teams of people who care so much about the communities they work in, and the health and wellbeing of families.

Institute of Health Visiting welcomes new NHS Long Term Plan

The Institute of Health Visiting very much welcomes the new NHS Long Term plan, in particular the new focus on investment into community and preventative services, and the commitment ‘….to consider whether there is a stronger role for the NHS in commissioning sexual health services, health visitors, and school nurses, and what best future commissioning arrangements might therefore be.’ (see NHS Long Term Plan page 33, 2.4).

Dr Cheryll Adams CBE, Executive Director iHV, said:

“This can’t happen soon enough as we continue to see fragmentation of health visiting services and a loss of very experienced health visitors across the country. This has been accompanied by an inevitable impact on the quality of services that the profession can now provide for babies and their families, our most vulnerable members of society. We know that this is leading to increased use of GP and A&E services, an increase in the number of children needing safeguarding protection, and that far too many children are starting school without adequate communication as well as other delays in their development. All these cause much greater expenditure for the state than the cost of providing a robust health visiting service and it is very encouraging to see prevention recognised in the ‘Plan’.

“We hope that this statement is the first step towards providing proper protection for primary preventative services, such as health visiting and school nursing, into the future and beyond. A cycle of investment and disinvestment, as has happened over at least the last 25 years, must now become a thing of the past so that England can be proud of the support it offers young families. Furthermore, society will feel the benefit of this with babies suffering less mental illness, less heart disease and less cancer in their later lives. These are all things that are impacted by what can happen to babies during pregnancy and the first months of life such as poor nutrition and being exposed to a poor emotional environment.

“We also hope that pledges for maternity services, such as continuity of care, will also be invested in for those receiving health visiting services. No one wants to discuss their problems with a stranger – trusted professionals in the community, such as health visitors, can literally change lives when their help is sought.

“In addition, we are delighted by the significant attention which the plan gives to addressing health inequalities. This is something which health visitors and the Institute see as key to creating healthy communities, so it’s very encouraging to see it so well articulated in the ‘Plan’.

“Whilst the commissioning of health visiting services is being re-examined as recommended by the Institute in its 10 year plan (September 2018), we call for the strengthening of training commissions in 2019 as a visual demonstration of the commitment to the professional contribution of health visitors as laid out in the ‘Plan’. This would start to rebuild the profession to a place where its impact can be felt once again.”

Go to NHS Long Term Plan