“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

New MBRRACE report published on maternal deaths and morbidity

The Institute joined colleagues from across perinatal services yesterday (Thursday 1 November) to learn lessons from the launch of the 2018 MBRRACE-UK report: Saving Lives, Improving Mothers’ care Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2014-16.

We commend the report as essential reading for all health visitors and will be prioritising translating the learning into our various training programmes and publications, so that all health visitors and colleagues working with families in the perinatal period, understand the risks and know what to do about them.

Key Points:

A total of 225 women died among 2,301,628 women giving birth, giving a rate of 9.78 deaths per 100,000 women giving birth – which is almost the same as what is was in 2010-2012 (10 women per 100,000 maternities)
Heart disease remains the leading cause of women dying up to 6 weeks after the end of pregnancy
Maternal suicide is the 3rd largest cause of direct maternal deaths during pregnancy and up to 42 days of the end of pregnancy, but it is the leading cause of direct deaths occurring within a year after the end of pregnancy
There are striking inequalities that require urgent attention: Black women are 5 times more likely and Asian women twice as likely to die as white women
Most women who died had multiple health problems and or other vulnerabilities

Key messages:

Healthcare professionals need to challenge assumptions, for example, that symptoms are related to normal pregnancy or the woman has too many complex needs to be helped
Continuity of care is essential for trusting therapeutic relationships between women and their healthcare professional to develop
There needs to be more emphasis on training for non-specialists involved in the care of women in the perinatal period
Women who experience pregnancy or postnatal loss or have a child removed into care need ongoing support – indeed care should increase rather than decrease

Go to MBRRACE report, lay summary and infographic

iHV supports call for more investment into Early Intervention

iHV supports the call by the Early Intervention Foundation for more investment into Early Intervention in England, following the publication of its report, Realising the potential of early intervention. This report sets out a bold plan of action to ensure effective early intervention is available to the children, young people and families who need it most.

Dr Cheryll Adams CBE, Executive Director iHV, said:

“The Institute of Health Visiting supports the call by EIF for more investment into Early Intervention in England. We would like to see this extended to research and investment into whole universal systems change, as well as individually focused approaches. For example, health visitors are alarmed by seeing current cuts to their services resulting in many more vulnerable children having their needs recognised late, and needing much more complex and expensive interventions, than if their families had received sufficient early support that health visitors could once offer.”

Go to EIF Report - Realising the potential of early intervention

iHV welcomes Children’s Commissioner’s report into childhood vulnerability

The Children’s Commissioner for England, Anne Longfield, has published a new report that brings together a range of information held by various government departments, agencies and others to reveal the scale of child vulnerability in England.

The report, “The Children’s Commissioner’s 2018 Report into Childhood Vulnerability”, estimates that 2.1 million of England’s 11.8 million children – one in six – are living in families with risks so serious that they need some level of help. The study also warns that for 1.6 million of those vulnerable children, the support is effectively ‘invisible’ – we don’t know if they are actually getting any coordinated help, despite the difficulties they are growing up with. Some of the risks these children face include parents with mental health problems or parents who are alcoholics or have substance abuse problems.

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

“The Institute of Health Visiting welcomes this very helpful report looking at the current status of services for our most vulnerable babies and children. It is very sad to see how the cuts to local authority children’s and public health funding have resulted in so many more children being put into expensive and life changing care proceedings.

“We welcome the Commissioner’s call for more investment into health visiting services for the most vulnerable babies, but this also needs to extend to the universal service for all families. We know that the majority of need isn’t conspicuous.

Dr Adams continued:

“Well trained and resourced health visiting services can not only prevent children ever needing referral to care services, but also ensure that all vulnerable babies are identified long before their difficulties become overt and needing referral for specialist help. Through their support to parents, health visitors can help to ensure all children have a more positive start in life with the service seeking to avoid children ever needing care proceedings.

“Investing early to save later needs to be a new direction for policy. It could have huge implications for the health and welfare of many vulnerable or potentially vulnerable children and families, whilst resulting in many savings to the exchequer.”

Read The Children’s Commissioner’s 2018 Report into Childhood Vulnerability

Read the full news story from the Children's Commissioner

Professional bodies and maternal mental health experts welcome report highlighting need for more maternal mental health experts

The Maternal Mental Health Alliance (MMHA), the Institute of Health Visiting (iHV), the Royal College of Obstetricians and Gynaecologists (RCOG), and the Royal College of Midwives (RCM) are delighted the NHS Benchmarking report on Universal Perinatal Mental Health Findings was published on Friday 14 September.

Prior to this study, information on service provision and staffing of universal perinatal mental health (PMH) services was not available at a national level. The study sought to gain an understanding of the extent of PMH provision in universal services across England, supplementing an annual audit of Specialist PMH services undertaken by the NHS Benchmarking Network for NHS England.

The data collected from providers suggested that:

Capacity in universal services is very limited and does not provide the necessary broad base from which the Specialist PMH services can operate effectively and efficiently as a secondary care tier.
The provision of specialist perinatal mental health care within universal services is highly variable across England, with some areas having no, or limited, provision (obstetric & midwifery providers 61%; health visiting providers 30%).

Specialist provision within universal services is necessary to coordinate, inform and support evidence based PMH care across the whole service, and therefore offers a clear reflection of the care women are able to access. The large gap in health visiting PMH capacity was particularly evident, with 70% of providers having no specialist provision within the service.

If we are to deliver on the ambition of the Five Year Forward View for Mental Health, attention must be paid to the full spectrum of need. This report is critical because it focuses on the universal element, where the vast majority of women need to receive their care. Most recognition of mental health problems and risks, most prevention and early intervention, can only be coordinated and provided within universal services. Universal services are therefore a crucial element of the PMH care pathway at every local level and have the potential to create great savings in relation to both human and economic costs in the short and long term.

Dr Cheryll Adams, Executive Director at the iHV, said:

“The Institute of Health Visiting warns that the real state of today’s health visiting support for mothers suffering with perinatal mental illness (PMI) may be significantly worse than that found by the NHS Benchmarking report based on data from 2016, as there have been further cuts to the workforce and the development of a significant postcode lottery of services up and down the country. Health visitors across the country nevertheless continue to strive to deliver an excellent service to children and families, and will do everything in their power to promote good family mental health.”

Alain Gregoire, Chair of the MMHA, said:

“There has been excellent progress in funding specialist perinatal service provision across England, but we know that specialist services alone are not enough. All women in pregnancy and postnatally should have equitable access to the support, prevention and treatment they need for their mental health as much as for their physical health. This report shows that investment is essential to ensure that there are sufficient, well-trained staff across universal services so that women get the care they should expect from the NHS, and our children can get the best start in life.”

Janet Fyle, Professional Policy Advisor at the Royal College of Midwives, said:

“Whilst there is progress in some areas, there is still a lot more to do. Our survey showed that we remain seriously short of specialist maternal mental health midwives and services to support women with mental health problems and needs in the community and in their homes. There is also a need to ensure that all midwives involved in the care of pregnant women receive adequate training, so that they can identify women with mental health problems and refer them appropriately for care and support as required.”

Dr Alison Wright, Consultant Obstetrician and Vice President of the Royal College of Obstetricians and Gynaecologists said:

“Despite maternal mental health being a key priority of the Government, this report shows the extreme pressure faced by obstetricians and psychiatrists, midwives and health visitors who provide perinatal mental healthcare. Healthcare professionals are usually the first point of contact that a woman reaches out to and we must ensure that all staff involved in the care of women during pregnancy and beyond, have the relevant education and training in perinatal mental health. Every maternity unit across the country should have in place a clearly defined care pathway for referring women to local specialised perinatal mental health services which all women can access when needed.”

Collectively, we will continue to push for equitable access to evidence based PMH care for women with mental health problems and their families through robust universal services alongside the development of specialist PMH services – women and their families need both. We support the call for all maternity and health visiting services (and GP services) to be sufficiently resourced, so that all professionals across universal services have sufficient capacity, competence and confidence to deliver top quality proactive mental health care to all families. Furthermore, we advocate that these healthcare professionals should be supported by having lead specialist professionals/Champions from within their respective professions in every organisation.

Download the NHS Benchmarking report on Universal Perinatal Mental Health Findings

Background Information to the report

In January 2017, the NHS Benchmarking Network was commissioned by Health Education England, funded by NHS England, and partnered with the iHV, RCOG and RCM to complete a stocktake of perinatal mental health (PMH) care within maternity and health visiting services. Data collection took place from February to May 2017 and referenced the year January to December 2016. Universal PMH services in this report included obstetrics, midwifery and health visiting.

There was a high response rate from organisations across England, with numbers of responses by service type as follows:

Obstetric services 141
Midwifery services 123
Health visiting services 88

In total, the following specialist practitioners were identified in the study:

Obstetric services = 40.8 WTE (1.3% of total obstetric capacity)
Midwifery services = 228 WTE (1.4% of total midwifery capacity)
Health Visiting services = 60.6 WTE (0.78% of total health visiting capacity)

Child health in England falling behind other European countries

A new report, published today by The Royal College of Paediatrics and Child Health (RCPCH) ,warns that child health in England is lagging behind other European countries, with child mortality potentially 140% higher than other comparable nations by 2030 and reported mental health problems set to increase by 60%.

The ‘Child health in 2030 in England: comparisons with other wealthy countries’ report compares England with European and other western countries known as the EU15+. With the combination of England’s current poor standing for key outcomes in line with the averages in the EU15+, and our slower rates of improvement for key outcomes, the report finds that child health outcomes in England will not only compare very poorly to similar countries in 2030, but that we will be falling even further behind. The marked health inequalities between the most and least deprived children in most key outcomes are also set to widen over the next decade – presenting real challenges for health services in ensuring and improving access to those who need them most.

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

“It feels very timely for the RCPCH to produce this report – ‘State of Child Health 2030’ to alert MPs and policy makers to the risks of not taking action now to strengthen all services for children. Health visitors are already very concerned by the impact of current issues for children such as increasing childhood poverty, mental illness and obesity set against a decommissioning of essential services such as health visiting and school nursing due to recent reductions in public health budgets.

“These challenges faced by children and families are not just worrying for their impact on the life course of those affected. We also now have good evidence that they will also be having significant impacts on the economy now and in the future. We recommend ministers heed the advice of Nobel prize winner James Heckman and invest into the very early years to reduce later fiscal expenditure. We believe that the benefits to the economy would quickly be felt by government.”

Amongst the report’s key findings are:

Mortality rates may be 140% higher for infants in England than in comparable wealthy nations by 2030
Reported mental health problems are set to increase by 60%, based on current trends
1 in 3 of the most deprived boys in England will be obese by 2030 without urgent implementation of the Childhood Obesity Plan and additional measures
A&E attendances for children may increase by 50% and outpatient attendances by 48%

In response, RCPCH is urging NHS England to develop and implement a Children and Young People’s Health Strategy as part of its long-term plan. They believe that a holistic CYP Health Strategy is essential to drive forward the ambitious actions, coordination and leadership needed to address the complex factors underpinning their findings. The long-term plan offers a critical opportunity to put children and young people at the heart of our health service, at every level, and the report demonstrates the risks of not taking action as soon as possible.

Download RCPCH State of Child Health short report: Child health in 2030 in England: comparisons with other wealthy countries

Download State of Child Health short report: Child health in 2030 in England - Recommendations

iHV publishes report from well-regarded breastfeeding conference

During #WorldBreastfeedingWeek, the iHV is delighted to publish a report from its well-regarded breastfeeding conference held in April with the World Breastfeeding Trends Initiative (WBTi) and Royal Society for Public Health (RSPH).

The Breastfeeding: A Public Health Priority report gives a conference summary and implications for Public Health.

Dr Cheryll Adams CBE, Executive Director iHV, said:

“This highly successful breastfeeding conference included, as speakers, some of the leading researchers in the field, as well as a range of successful local initiatives. We are delighted to be sharing a report from the day.”

Dr Cheryll Adams opening the breastfeeding conference

Go to members only Breastfeeding resources to download Breastfeeding conference report

Please note that these resources are available to iHV members only – if you’re not a member, please join us to get access to all of our resources.

The iHV is a self-funding charity – we can only be successful in our mission to strengthen health visiting practice if the health visiting profession and its supporters join us on our journey. We rely on our membership to develop new resources for our members.

Read the news story from the breastfeeding conference

iHV welcomes Mental Health Policy Commission: Investing in a Resilient Generation report

The root causes of mental health problems can often be traced to adversity in childhood or adolescence, but the effects can have a life-long impact on well-being and the ability to live a satisfying and productive life throughout adulthood.

iHV welcomes Mental Health Policy Commission: Investing in a Resilient Generation report which sets out the evidence base around the factors that can impact on young people’s mental health.

Dr Cheryll Adams CBE, Executive Director iHV commented:

“This is a very timely and helpful piece of work emphasising the huge benefits to NHS spending from investing in prevention of mental illness in the very early years, and in schools. We really hope that local authorities will take note of its recommendations and reconsider any more cuts planned to health visitor services. Savings can be made in different ways and this document makes clear that cutting preventative services creates a significant burden of expenditure that must be picked up later by public services.

“It is time to be brave and invest for tomorrow, not today, giving more children a bright future by supporting them as babies and infants when supportive interventions for families have the most powerful impact on their mental wellbeing. The toll of mental illness is now so significant and conspicuous that there is a civil and moral duty for all those with influence to reduce this by supporting investment into early preventative strategies as laid out in the recommendations of this report.”

Go to Mental Health Policy Commission: Investing in a Resilient Generation report

iHV welcomes Childhood obesity: a plan for action, chapter 2

Part 2 of the government’s plan for action to significantly reduce childhood obesity by supporting healthier choices was published this week.

This publication outlines the actions the government will take towards its goal of halving childhood obesity and reducing the gap in obesity between children from the most and least deprived areas by 2030. Building on the first chapter of the childhood obesity plan, the new measures include proposals to counter ‘pester power’ by preventing stores from displaying unhealthy food at checkouts or including it in buy-one-get-one-free deals.

Dr Cheryll Adams CBE, Executive Director iHV, commented:

“The Institute of Health Visiting welcomes the tightening of the update plan for Childhood Obesity. It is crucial that the preventative measures outlined are actioned with speed to ensure that all children in the UK are able to thrive and develop to their full potential.

“Tackling the wider factors that impact on obesity is crucial and we applaud the move to target advertising. The need to work across all sectors who provide “food away from home” is crucial and proposals to work with schools are well placed, we trust that these actions will also include early years providers – both state and private nursery provision, as the early years are crucial in the development of healthy weight in the later years.

“Whilst it is not explicitly stated there is a need to ensure that the revised actions have a focus on the early years (0-5 years) as we know from research that the influence of early nutrition and eating patterns is directly correlated with obesity in later years. To support this it will be crucial to consider the early year’s health and social care work force in the development of training proposed in this update.”

The government is calling on industry to recognise the harm that adverts for foods high in fat, sugar and salt can cause. It will consult on introducing new TV and online advertising restrictions to prevent children from being targeted by these unhealthy products, and to incentivise companies to reduce the sugar and calories in the products they sell.

The second chapter of the plan also promotes a new national ambition for every primary school to adopt a daily ‘active mile’ initiative, such as the Daily Mile.

Go to DHSC Guidance - Childhood obesity: a plan for action, chapter 2