iHV launches ‘Health Visiting in England: A Vision for the Future’

The Institute of Health Visiting (iHV) is delighted to publish ‘Health Visiting in England: A Vision for the Future’, their evidence-based blueprint to rebuild health visiting services.

Developed in response to the government’s request for stakeholder engagement to inform their plans to refresh the health visiting model for England and the Healthy Child Programme, and taking into account the worrying loss of health visitors over the past 4 years, this publication sets out a new model of health visiting advising eight universal contacts and a particular focus on fifteen areas where health visiting can have a high impact on health outcomes.

Dr Cheryll Adams CBE, Executive Director of the Institute of Health Visiting, commented:

“Despite overall improvements in child health, England lags behind other countries on many key health outcomes: infant mortality reductions have stalled, our breastfeeding and obesity rates are amongst the worst in Europe, our immunisation rates are falling and health inequalities are seen across all indicators.

“The current status of health visiting is not serving families well, based as it is on universally delivered process outcomes which risk “ticking the box, but missing the point”. There remains a persistent gap between what the evidence tells us, and the profession aspires to achieve, and what is currently able to be funded and provided since the year on year cuts to public health budgets starting in 2015.

“Based on the evidence, we recommend that the universal offer in England includes three additional service “review points”, increasing the offer to eight contacts, with additional tailored support where needed, aligned primarily to fifteen High Impact Areas where health visitors can make the greatest difference to infant, children and family outcomes. But also recognising the value of health visiting in, for example, supporting the mother postnatally to manage on-going physical consequences of giving birth, supporting the family of a child who has a chronic and worrying health issue such as asthma, supporting families through a bereavement or working with a people within marginalised groups.”

Health Visiting in England: A Vision for the Future

The new iHV Vision for Health Visiting in England sets out an “upstream” public health response with action based on the principles of proportionate universalism. It seeks to address some of the limitations of the current 4-5-6 model, balancing the need for a population approach alongside a more personalised individual response.

In addition to renewed investment and revised workforce modelling, a plan for rebuilding the workforce will be needed to establish the workforce requirements to deliver a refreshed Healthy Child Programme and all levels of the health visiting service offer.

Dr Adams continued:

“National leadership by government is essential to set ambitious and binding national goals to reduce health inequalities for children in key public health priority areas.

“The health visiting service of the future needs to be built more closely around eight key elements to ensure the service is: evidence-driven, accessible, responsive, personalised, collaborative, fairer and effective. This will only be achieved with greater professional autonomy and a recognition of the importance of relationships at the heart of everything we do.

“We need action today, to support every child to have the best start in life and a ‘bright’ future.”

Download Health Visiting in England: A Vision for the Future

Follow and support #FutureofHV on social media.

Family homelessness crisis in England

The Institute of Health Visiting (iHV) comments on today’s publication of Bleak Houses: Tackling the crisis of family homelessness in England by the Children’s Commissioner.

iHV is saddened to learn that 124,000 children are now classed as homeless with some children needing to be housed in shipping containers. The councils blame this on a shortfall in their income of £159 million.

Dr Cheryll Adams CBE, Executive Director iHV, said:

“Whilst this sounds like a lot of money for the government to find, the actual costs of short, medium and longer term negative consequences for these children and their families on the fiscal purse will be very much more, including costs to the care, health, education, social security and criminal justice budgets.”

There are thousands of children in England who are living in homeless families, stuck in poor quality temporary accommodation, often with low prospects of finding something permanent. There are many others who are at risk of ending up homeless. This report shines a light on this homelessness crisis and shares the experiences of some of those children.

Go to Bleak Houses report

iHV supports launch of PIP UK’s Rare Jewels report

At the start of Infant Mental Health Awareness Week 2019, the iHV is delighted to support the launch of PIP UK’s report “Rare Jewels” on Specialised parent-infant relationship teams in the UK – published today, Monday 10 June 2019, at the APPG Conception to Age Two meeting in Parliament.

iHV Director, Dr Cheryll Adams, at launch of PIP UK’s Rare Jewels report at the APPG Conception to Age Two in Parliament

Alongside its focus on specialised teams, the report highlights the important role health visitors play in enabling good IMH:

“Health visitors play an important role in promoting parent-infant relationships as they have the opportunity to work with every family during this important period”.

“Nice Guidance for postnatal care states that assessment for emotional attachment should be carried out at each postnatal contact and home visits should be used as an opportunity to promote parent- or mother-to-baby emotional attachment”.

We are particularly pleased to see the value of specialist IMH health acknowledged. We look forward to strengthening this when we publish the findings from our own recent iHV survey into Infant Mental Health later this week.

The report, ‘Rare Jewels’, highlights the shocking lack of mental health provision for children aged 2 and under with data suggesting that 42% of Clinical Commissioning Group (CCG) areas in England CAMHS services will not accept referrals for children aged 2 and under.

The report makes several recommendations for local and national decision makers about how they could support the development of specialised provision. These include:

Collecting data disaggregated by age to ensure services are accessible to, and accessed by, children of all ages.
Ensuring there is clear accountability at a national and local level for commissioning mental health services to meet the needs of all children.
Creating a ringfenced transformation budget to support local investment in services for the first 1001 days of life.
Setting out clear implementation plans for how commitments to improve mental health provision will be realised for all children, including those 2 and under.

Governments across the UK have made commitments to increase early intervention, to improve children’s mental health and to close inequalities in outcomes.

The iHV supports this report’s call for them to provide focused and determined leadership and the investment required to translate their commitments into a reality to give every baby the best start in life.

Please do share the report with your networks and on any social media platforms using the hashtags #rarejewels #IMHAW19 #healthvisitors #infantmentalhealth. Please do also link to us using the handle @iHealthVisiting and @earlypotential

Go to PIP UK to download the Rare Jewels report

Government response to the ‘First 1000 days of life’ report

Today, the government has published the Command paper which sets out the government’s response to the Health and Social Care Select Committee report on ‘First 1000 days of life’, published by the House of Commons in February 2019.

The iHV supported the recommendations set out in the Health and Social Care Select Committee’s report ‘First 1000 days of life’, which makes a clear case for early intervention and a strengthened national strategy for the first years of life. The government’s response today and renewed commitment to ensure every child has the best start in life is welcomed – although today’s response is, in many ways, a holding response as we await the results of the Spending Review, the publication of the Prevention Green Paper and Inter-Ministerial group on early years (Leadsom Taskforce) which will hopefully fill the many gaps in detail.

Today’s response recycles a number of existing policy commitments to improve maternity services, support Troubled Families and address the inequalities in early language. In particular, we welcome the renewed commitment to the ambitions of the Maternity Transformation Programme “for maternity services across England to become safer, more personalised, kinder, professional and more family friendly; where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred on their individual needs and circumstances.” It also calls for all staff to be supported to deliver care which is women-centred, working in high performing teams, in organisations which are well led and in cultures which promote innovation, continuous learning, and breakdown organisational and professional boundaries. We would welcome a similar ambition for health visiting services.

We are concerned that there is a notable absence of new policies for children and families once discharged from maternity services and limited national levers to reverse the current unwarranted variation in the quality and quantity of support that families receive based on where they live, rather than their level of need.

Ultimately the success of any programme will rest on sufficient resources being allocated nationally through a cross-departmental plan, and the Spending Review funding settlement for local government will have an important impact on whether wider improvements in population health and prevention can be delivered. We will continue to advocate for a strengthened health visiting service as set out in our recent letter to the Treasury.

Go to Government response to the Health and Social Care Select Committee 'First 1000 days of life' report

Read iHV's response to Health and Social Care Select Committee’s report ‘First 1000 days of life’, February 2019

iHV supports RCN/QNI call for reinvestment into district nursing

The Institute of Health Visiting supports the RCN/QNI call for reinvestment into district nursing after a shocking loss of district nurses over the past 10 years.

A new report from the Royal College of Nursing (RCN) and Queen’s Nursing Institute (QNI) calls for urgent investment in District Nursing, as new figures show the number of District Nurses working in the NHS has dropped by almost 43 per cent in England alone in the last ten years. As a result, there are only some 4,000 District Nurses providing care for a population of around 55.8 million in England, a ratio of only one District Nurse for every 14,000 people. This compares with one GP for every 1,600 people.

The report, Outstanding Models of District Nursing, is published during the RCN’s annual Congress in Liverpool, where the 5,000 nursing staff attending include large numbers of District Nurses from around the UK.

Recent government strategy has called for more nursing care to be delivered in the community and in people’s homes in order to reduce patients’ lengths of stay in hospital and avoid unplanned admissions. The NHS Long Term Plan has identified the District Nursing service, which provides vital care for people in their own homes and in the community, as a key part of this strategy. However, government policies have not been followed by the investment needed to make the vision a reality, says the joint report.

Read full RCN news story

National Bereavement Care Pathway helps improve care received by parents

A project to improve the quality of care that bereaved families receive when their baby dies has been found to be making a big difference, and should be rolled out nationally, a new study has found.

To ensure bereaved parents and their families are supported in the best way possible, the National Bereavement Care Pathway (NBCP) was launched in 2017 and has been piloted in 32 NHS Trusts in England. The NBCP helps professionals to provide families with a greater consistency and quality of bereavement care after pregnancy or baby loss.

Independent research previously highlighted improvements made in the 11 Wave one sites when it reported its findings in October 2018. The final report relating to 21 Wave two sites published May 2019 analyses the experiences of bereavement care from parents and healthcare professionals.

The results have revealed high levels of satisfaction with the bereavement care they received when their baby died. Parents also said the hospital was a caring and supportive environment, they were treated with respect and many feel the decisions they made in the hospital were the right ones at the time.

Download NBCP Wave two report (May 2019)

Collaborators in the project, including the Institute of health Visiting, are calling on NHS Trusts to adopt the National Bereavement Care Pathway and adhere to nine specific bereavement care standards.

Since the Pathway was introduced, more health care professionals feel they now have consistent and clear guidelines which support them to provide good quality care for bereaved parents. The Pathway has improved the dialogue between hospital departments which has helped professionals to deliver care more consistently.

NHS Trusts are being encouraged to take up the NBCP as part of the collaboration’s roll out plans. A number have already taken part in local workshops to identify gaps in local practice and to develop plans to improve bereavement care, based on the 9 bereavement care standards promoted by the group.

Further information regarding these standards, how to register with the pathway and other details can be found at www.nbcpathway.org.uk

The National Bereavement Care Pathway is being led by: Sands (Stillbirth and neonatal death charity), Bliss, The Lullaby Trust, The Miscarriage Association, ARC (Antenatal Results & Choices), Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Nursing, Royal College of General Practitioners, Neonatal Nurses Association, Institute of Health Visiting, NHS England.

iHV welcomes Committee’s visionary report on the First 1000 Days of Life inquiry

The Institute of Health Visiting very much welcomes the Health & Social Care Committee’s visionary report on the First 1000 Days of life – which calls for cross-government action to improve support and services for children and families in England and to reduce health inequalities in childhood through a range of actions.

Dr Cheryll Adams CBE, Executive Director iHV, commented:

“We know every health visitor will join us in being delighted that the Health & Social Care Committee’s six principles reflect our own health visiting priorities for offering effective early years services for every infant and reducing health inequalities.

“We particularly support the H&S Committee’s call for the Government to produce a long-term cross-government strategy for the first 1000 days of life to give every child the best start in life supported by joint NHS/Local Authority joint commissioning. We believe the vision could realistically be enhanced by adding an objective of reducing the number of children requiring referral to mental health services, something not unrealistic if the recommendations are implemented, and this would quickly demonstrate an economic benefit to the NHS from doing so.

“We also warmly welcome the report’s call for the Healthy Child Programme (HCP) to be revised, strengthened and given more importance in policy. We are pleased that an extra mandated contact at 3-3½ years by a health visitor is recommended to extend the current reach of the HCP and we continue to recommend there should also be an extra contact (home visit) at 3-4 months, and for these mandated contacts be seen as the minimum and to all be done by a health visitor.

“The report helpfully endorses most families’ desire to have continuity of care with a named midwife and health visitor and we welcome the call for strengthened links between obstetricians, midwives, health visitors and primary care services – this is so fundamental alongside continuity of care. Health visitors, who are often trained to master’s level are well placed to build relationships with families and identify those at risk of poor outcomes who would benefit most from targeted interventions. We fully support the strengthening of early identification of families’ needs during pregnancy, with provision available at all levels (universal, targeted and specialist). Movement between levels of intervention needs to be fluid as needs may change over time; some families only require short-term additional support whilst others require much longer-term input involving a range of partners, as so importantly stated in the report.

“The Committee’s recommendation that the Government uses the forthcoming Spending Review to focus public health funding towards early intervention for children and families is essential. This will also reduce future expenditure in later life for children requiring high levels of support which is the unfortunate cost from not acting early.

“We look forward to seeing how this report is accepted by the Government and hope that its recommendations could receive early endorsement if the ‘Prevention’ green paper takes a pathway approach from pregnancy to old age. We further hope that, if it attracts additional validation by the Taskforce led by Andrea Leadsom MP, its recommendations and framework for action can quickly be implemented, offering an early years building block to the Government’s new prevention strategy and creating some parity in the quality of early years services for infants across the UK.”

Read H&S Committee news story on the publication of their report

Download H&S Committee Report on the First 1000 Days of Life inquiry

Find out more about iHV’s written and oral evidence to the inquiry

iHV's written submission to the First 1000 Days of Life inquiry

iHV's oral evidence to the First 1000 Days of Life inquiry

iHV welcomes EIF report on key competencies

iHV welcomes new Early Intervention Foundation (EIF) report – Key competencies in early cognitive development: Things, people, numbers and words.

Children’s early cognitive development should be prioritised as an essential necessity to help prepare them for school and address income-related learning gaps, or we risk disadvantaged children falling significantly behind from the very start of their education, according to a major new report from the EIF.

The report contends that the early development of core cognitive skills, including children’s language development and their understanding of objects, people and numbers, should receive the same level of investment and attention that we currently give to ensuring children are well fed, living in stable homes and have sufficient clothing.

Dr Cheryll Adams, Executive Director iHV, said:

“The Institute of Health Visiting very much welcomes the light that the Early Intervention Foundation has shown on the importance of investing in an infant’s early cognitive skills development, alongside trying to bring all children out of poverty. Their call for investment into more health visitors is particularly welcome.

“Health visitors, as highly trained, public health practitioners, can, not only identify children in need of additional support very early, perhaps even before birth, but start preventative and early intervention support when it will make the most difference, during the infant’s period of rapid development during its first 1001 days of life. We hope that the government will respond to this new evidence which supports so many other experts in recommending investing in health visitors to lead the delivery of the best evidence based outcomes for more vulnerable infants.”

Key findings in the report, Key competencies in early cognitive development: Things, people, numbers and words, include:

Early cognitive capabilities are highly associated with the quality of children’s early learning experiences and predictive of their later success at school and in the workforce
Income related learning gaps are already present at the age of four and increase as children grow older, although these gaps can be rectified when high quality support is provided early
Parents play a crucial role in their children’s early cognitive development – and support from health visitors, nursery educators and childcare can also make a positive difference. This is especially true for children growing up in disadvantaged circumstances

Download Early Intervention Foundation (EIF) report - Key competencies in early cognitive development: Things, people, numbers and words

“We are walking a very tight rope” Health visitors voice fear of another child tragedy “waiting to happen”

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.”

Download iHV State of Health Visiting Survey 2018 report

iHV evidence in call for national early intervention strategy to transform lives

Following the collation of evidence for their Evidence-based early-years intervention inquiry , the House of Commons Science and Technology Committee has published their report and is calling on the Government to draw up a new national strategy for early intervention approaches to address childhood adversity and trauma.

The Evidence-based early years intervention Report urges the Government to capitalise fully on the opportunity that early intervention provides to transform the lives of those who suffer adversity in childhood, while also saving long-term costs to Government.

Read iHV written evidence submission to the Early-years intervention and Adverse Childhood Experiences (ACEs) inquiry

This is a very important and hugely interesting report which includes the call for secure funding for early interventions and also cites the Institute in one of the recommendations:

Recommendation 9.

The Healthy Child Programme is the only mechanism in place through which all children in England should receive early years practitioner support before the age of five. Its coverage is therefore critical for identifying ACEs and other child development issues early. The Government should review the current provision of the
Healthy Child Programme across England and set out, as part of the new national strategy, a date for achieving complete coverage in the number of children who receive all five mandated health visits. Given existing workforce pressures, the Government must ensure that this required increase in coverage does not negatively impact the quality of health visits. It should consult the Institute of Health Visiting on how this can be managed, and be ready to recruit additional health visitors as required.
(Paragraph 54)

The Committee’s Report identifies examples of early intervention working well around the country, but also the challenges that local authorities and their partners currently face in delivering effective, evidence-based early intervention. It concludes that the overall provision of early intervention in England is fragmented, with varying levels of support, focus on evidence, and success.

The Committee calls for a new national strategy to be drawn up to ensure that the opportunity provided by early intervention—to transform lives and save long-term costs to Government—is seized fully, and by all local authorities in England.

Go to Full Evidence-based early years intervention Report

Read the report's conclusions and recommendations

Read the Committee's press release on the report's publication