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

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: