Health visitors’ fear for children’s wellbeing due to relentless service cuts

Public health budget cuts have left health visiting services unable to offer the minimum level of support in many areas

Many health visitors across England have been robbed of their ability to protect vulnerable families by devastating cuts to public health budgets. That is the headline finding of an annual survey of health visitors in England, published today by the Institute of Health Visiting (iHV), alongside calls to ring-fence new funding for the profession.

Released just days after the Duchess of Cambridge highlighted the importance of a secure childhood for future health and wellbeing, the iHV State of Health Visiting survey indicates that those professionals best placed to help children get the best possible start in life lack the resources to do so.

Official figures indicate that around one in five health visitors were lost between 2015 and 2019 – the full-time equivalent of 18% of the workforce. This is due to public health budget cuts and the failure to protect health visitors’ preventative role by many cash-strapped local authorities, after health visiting commissioning moved from the NHS to local authorities in 2015.

The consequences can be devastating, with 48% of health visitors saying they feel so stretched that they fear a tragedy where they work.

As one health visitor told the iHV: ‘Larger caseloads and fewer staff mean families are not getting a tailor-made service to meet their needs. Vulnerable children are slipping through the net.’

Almost a third of health visitors report they are now responsible for between 500 and over 1000 children. Meanwhile, the iHV considers the optimal maximum to be 250 children in order for health visitors’ work to be fully effective, less in areas of high vulnerability. Consequently, 58% of health visitors are working long hours and feeling ‘worried’, ‘tense’ and ‘anxious’.

One health visitor said: ‘I have taught myself to become numb to what is happening within health visiting – as a coping mechanism.’

The iHV is calling for urgent action to address this crisis – before more damage is done.

Dr Cheryll Adams CBE, Executive Director of iHV, said:

“It is absolutely unacceptable that many families are struggling through the significant demands of early childhood without the vital support that they need and are entitled to through the government’s flagship Healthy Child Programme. Indeed, the government’s pledge to give every child the best start in life has been left in tatters after year-on-year cuts to the public health grant, which have dismantled the health visiting services designed to support them in many areas.”

The Institute is calling for:

New ring-fenced cross-government funding for early intervention and the health visiting profession.
Statutory protection for the health visitor role in leading the delivery of the Healthy Child Programme and for health visiting to be returned to statutory regulation.
Workforce modelling and a new workforce strategy for health visiting.
A new focus on improving the quality of services which health visitors can offer families, regardless of where they live.

Dr Adams continued:

“Our survey indicates that health visitors have seen rising demand for support from families, almost certainly related to austerity. Meanwhile, they themselves have battled with ever increasing caseloads, due to the fall in health visitor numbers. It was particularly disturbing that one in four health visitors told us that they are seeking professional help from a GP or elsewhere, due to the demands of their job.”

“Health visitors worry about children being at risk and there is no doubt that their stress levels directly related to them feeling unable to deliver the quality of service that they know they can – and should be able to – offer, as well as the fear of children’s needs being missed. Our children are our future. They deserve much better than this.”

The headline findings of the iHV State of Health Visiting survey are:

Only 21% of health visitors rated the quality of care that they can now offer families as ‘good’ or ‘excellent’.
48% of health visitors said they feel so stretched that they fear a tragedy where they work. This is up from 23% in 2015, which even then suggested a profession under pressure.
29% of health visitors are now responsible for between 500 and more than 1000 children.
While in 2015, 65% of health visitors were able to offer continuity of carer to all, or most, families, by 2019 that number had fallen to just 35%. Continuity of carer has been shown to be greatly valued by parents and health visitors, as it allows them to build a trusting relationship and gives parents confidence to ask for help.
58% of health visitors reported that they are working longer hours and are feeling worried, tense and anxious.
36% of health visitors said they would leave health visiting if they could.
Despite being mandatory, only 34% of health visitors reported that they were able to offer an antenatal contact to families.
81% of health visitors reported that they are not conducting 12-month reviews of children and 90% were not completing the 2 to 2.5-year review. This directly contradicts government’s call to reduce the language gap. These essential checks are most frequently delegated to more junior members of staff. This means that many families will not see a health visitor after their infant is 6-8 weeks old – especially with the closure of many child health clinics alongside the cuts to health visiting numbers.

Download State of Health Visiting in England: Results from a survey of 1040 practising health visitors

Find out more about Our Vision for Health Visiting

What do parents want from a health visiting service?

Continuity of health visitor – someone who knows them as an individual and who they can trust
Equity of access to support – receiving all mandated contacts and extra help when needed, regardless of where they live

Health visitors remain the most trusted source of information and support for new parents. Yet, a survey of 1000 parents by the Institute of Health Visiting (iHV) and Channel Mum has found that parents are experiencing very different levels of support depending on where they live, rather than their level of need.

Whilst many families continue to receive a high quality of support, the survey equally found that some parents felt let down by the service which did not have the capacity to offer them enough support when they needed it most and didn’t understand the needs of their family.

The survey found that the main drivers for dissatisfaction were lack of continuity of health visitor, the appointments feeling rushed and too little time spent on emotional transition to parenthood.

The survey report ‘What do parents want from a health visiting service?‘ is a new report that seeks to understand what parents want and what a good service should look like – the results of a survey of 1000 mothers of children aged 0-23 months completed by Channel Mum in April 2019 on behalf of iHV.

Alison Morton, Director of Policy and Quality at the Institute of Health Visiting, commented:

“Understanding what is important to parents should form the starting place for any policy for health visiting. Parents’ insight, experiences and suggestions are an invaluable resource to help us shape our services around the type of support that families require.

“Parents in this survey have clearly described the vital support that they received from their health visitor. Mothers described their experiences of early parenthood as a time of enormous adjustment and uncertainty, and they valued being treated as an individual, with easy access to personalised support when they needed it, rather than a ‘one-size fits all’ approach.

“We can’t ignore the facts, however, that some parents are not receiving the support that they need or that health visitors want to provide.

“There are many reasons for this. The challenges facing health visiting have been described as a ‘perfect storm’ driven by significant cuts to public health budgets, reductions in health visiting numbers, unmanageable caseloads and some poor commissioning decisions that have affected the quality of support. For the past five years the Institute of Health Visiting, alongside other professional bodies, has been warning government that cuts have consequences.”

Siobhan Freegard, founder of Channel Mum, said:

“We are acutely aware of the importance of mothers bonding with their babies and giving continuity of care – and this survey shows mothers want to bond with their health visitors and have continuity of care too.

“Often, health visitors are ‘mothering mothers’ and so it’s vital new mums feel safe, secure and able to talk openly and honestly, and for this, they prefer to have contact with the same person where possible.

“This type of care is costly and needs greater investment in health visitor numbers, but ultimately, it’s a cost saver. Early intervention can spot issues and support families to flourish and grow.”

We are privileged to live in a time when we have more evidence than any other generation before us on the importance of the first years of life as a foundation for future health and wellbeing. We need to use this opportunity to make a difference to the lives of infants, children and their families – investment during the first 1001 critical days is a smart investment and saves money in the long run.

Ms Morton concluded:

“By listening to the stories of those who have experienced health visiting services as they really are, we can strengthen a learning culture which will be integral to quality improvement and help inform the refresh of the health visiting model and the Healthy Child Programme.

“I would like to thank all the parents who generously shared their time and experiences with us and Channel Mum for carrying out the survey. Parents are the true experts on what a good health visiting service needs to look like.”

Download 'What do parents want from a health visiting service?' survey report

Additional survey information:

The Institute of Health Visiting has incorporated the findings from this survey in the development of our recently issued ‘Health Visiting in England: A Vision for the Future’ – our evidence-based blueprint to improve outcomes for children and families and reduce inequalities through strengthened health visiting services. It was published to support Public Health England’s refresh of both the 4-5-6 health visiting model for England and the Healthy Child Programme during 2020.
The key findings of the Channel Mum survey are:
- Continuity – Parents want continuity of health visitor so that they can build a positive, trusting relationship with them and feel that their needs are understood – this was found to be the most important factor in parents’ satisfaction with the health visiting service.

Mothers’ comments:

“My health visitor knows me and addressed my emotional needs when no one else understood. She supported me, gave me advice and pointed me in the right direction, boosting my confidence as a first-time parent. I felt completely comfortable knowing she had my interests and my baby’s interest as a priority”.

“Keeping to one health visitor – in the past 2 years I’ve had 5 different health visitors”.

- Unwarranted variation in services – The survey has highlighted a mixed picture of health visiting nationally – many mothers valued the service that they had received, however some reported a poor experience:
  - The quality of the service that families receive is based on where they live, rather than their level of need with a wide variation in the type of support available.
  - Every child in England should be offered five mandated health reviews in the first years of life. Yet based on PHE data, in the last year around ¾ million children did not receive one of the five mandated reviews. And our own iHV survey of health visitors in November 2019 found that in England only 10% of 2-2½ year reviews were completed by a health visitor, with some areas completing these reviews by a postal questionnaire rather than a face to face contact.
  - Health visitor workload and caseload size will directly influence how much time a family will have with a health visitor. The iHV annual survey 2019 highlighted that in England almost 29% of health visitors are responsible for 500 – 1000 children (the optimum recommended number is 250), with only 25% being responsible for 300 or less children.

Mothers’ comments:

“More standardised care [is needed] – A friend lives 1.5 miles from me and had a baby within 2 weeks of me yet had a very differentexperience of health visitors. She had a home visit prior to birth and was given useful advice. I didn’t receive this”.

“Be consistent – If I have a friend who has a child the same age as mine (a week apart) and she has had a health visitor appointment as routine, then so should I”.

Go to Health Visiting in England: A Vision for the Future (full report and executive summary available)

Follow and support #FutureofHV on social media.

Your views needed on role of Health Visitor and Infant Mental Health

The iHV is delighted to support Infant Mental Health (IMH) Awareness Week 2019 (10 – 14 June).

As part of the Week, the Institute will be publishing a report on the role of the Health Visitor and IMH.

We need your help! It would be fantastic if you would join forces with us on this report by completing this short survey.

We anticipate that the survey will allow us to better:

Understand the current context of health visiting practice in supporting good IMH
Influence strategic direction to support good IMH

The survey questions have been created based on the:

We are sending this request out to as many health visitors as possible to get as large as response as we can to support this report. We would like as many as possible to complete the survey – we would really appreciate it if you could complete the survey, share it and encourage other health visitors to complete it too!

The survey will close on 5 June – please create some time now so that your voice can be heard!

Go to Health Visiting and Infant Mental Health Survey

Public Health Skills and Knowledge Framework Evaluation

Have you used or looked at the Public Health Skills and Knowledge Framework (PHSKF)?

If so, please could you complete this short online evaluation that is being conducted for Public Health England on behalf of the four UK nations of England, Scotland, Wales and Northern Ireland?

The aim is to evaluate Public Health England’s redesigned 2016 PHSKF to determine its impact on the public health workforce and their employers, and its utility.

The survey should take no more than about ten minutes to complete.

The deadline for submission of survey is 8 March 2019.

Go to Public Health Skills and Knowledge Framework Evaluation survey

Share your experiences of working with multiple birth families

The Elizabeth Bryan Multiple Births Centre (EBMBC) is a collaboration between Birmingham City University (BCU) and the Multiple Births Foundation. One of the aims of the EBMBC is to establish an evidence base on supporting multiple birth families – the term ‘multiple birth families’ is used to refer to families with twins, triplets and higher order multiples.

As part of this work, we are inviting you to participate in a survey of health visitors working in the United Kingdom. This study is a collaboration between the EBMBC and the Institute of Health Visiting (iHV).

The survey will investigate health visitors’ experiences of supporting multiple birth families.

We would like find out about any education and professional development that you have received and your experiences supporting multiple birth families.

This will provide evidence of health visitor experiences, perceptions and education and professional development needs regarding multiple birth families.

Download Participant Information Leaflet

Go to Supporting multiple birth families survey

Nursing Now Global Survey: Gender and Nursing

Nursing Now, in collaboration with the World Health Organization and International Council of Nurses, aims to raise the status and profile of nursing

Nursing Now has teamed up with Intrahealth International and Johnson & Johnson to conduct a survey of nurses worldwide to look at how gender is related to:

Perceptions of nurses, and of nurses in leadership positions
Nurses’ experience with discrimination and harassment
Challenges and barriers nurses face in moving into positions of leadership

Nursing Now welcomes and encourages all currently certified or formerly certified nurses, including nurse-midwives, to participate in this survey.

Your answers will be confidential and your contribution will be incredibly valuable to their campaign to raise the status and profile of nursing and strengthen nursing leadership.

Go to Nursing Now: Gender Assessment of Nursing Leadership Global Survey

If you have any questions about the survey, please contact Samantha Rick, advocacy and policy officer for IntraHealth, at [email protected].

Your views are needed to help shape SLC training for health visitors

As part of the government’s commitment to reducing the word gap, the Department for Education (DfE) and Public Health England (PHE) are leading a joint programme of work as part of the Social Mobility Action Plan (SMAP). One element of this is that the Institute of Health Visiting has been commissioned by PHE to develop training for health visitors to:

promote a strengths-based approach to supporting parents and carers of pre-school children with their child’s speech, language and communication development;
to support early identification and appropriate signposting to speech language and communication services.

We need to establish a baseline in relation to health visitors’ current knowledge of speech, language and communication. This will help us to shape the planned training and the development of resources which we will be rolling out in 2019.

Your participation in this survey is entirely voluntary and this short survey will take no more than 10 minutes of your time.

Go to Speech, Language and Communication Survey

“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

Last chance to have your say – Health Visiting Oral Health and Sugar survey

We have to close our Health Visiting Survey on Oral Health and Sugar very soon – so this is a final call for anyone still wishing to share their views.

We would love to have the insights of health visitors and health visiting team members on what is confusing and what is helpful in addressing sugar consumption with families. The survey totals 13 short questions and should take an average of just 6 minutes to complete.

Please tell us about some of the challenges regarding sugar consumption / oral health and give us some messages to take with us. Complete our survey now to share your views.

Go to Health Visiting Oral Health and Sugar survey

If you have already completed it – thank you!

What is your knowledge of retinoblastoma?

National Eye Health Week (24-30 September 2018) is a key point in the year for the Childhood Eye Cancer Trust (CHECT), a charity supporting the families of babies and children affected by a rare form of eye cancer called retinoblastoma, to raise awareness of their work with healthcare professionals, especially health visitors and GPs.

Retinoblastoma – image courtesy of CHECT

Over half of babies affected by retinoblastoma (childhood eye cancer) currently experience delays in their diagnosis – and CHECT wants to reduce this. Because retinoblastoma is a cancer which primarily affects babies and pre-school children, health visitors have a key role to play in identifying and referring potential concerns.

Further to our work last year with CHECT to develop a GPP on retinoblastoma, please take the the time to test your knowledge of retinoblastoma (childhood eye cancer) with a short questionnaire from CHECT:

Go to CHECT survey on retinoblastoma