Health visiting: A career in crisis?

Lack of funding, dwindling numbers and heavy caseloads: the health visiting profession has suffered from all three in recent years.

Shockingly, around one in five health visitors now have a caseload of more than 1,000 families, five times the level recommended by health union Community Practitioners' and Health Visitors' Association (CPHVA).

Dr Cheryll Adams, lead professional officer of CPHVA, says: "The problem is that health visiting has been left up to local commissioners, which has produced a postcode lottery for services."

She says that too often primary care trusts fund the most cost-effective option, and not what is best for families. "Less skilled roles such as nursery nurses can work well alongside health visitors in a team," she says. "But in some areas these roles are being brought in as a cheap option to replace health visitors."

Both Labour and the Conservatives have made commitments to boost numbers and have acknowledged health visiting is crucial to improving child health. A House of Commons select committee report earlier this year also highlighted their effectiveness, saying health visitor-led programmes were most likely to succeed.

Here we ask what should be done to boost the role and status of health visiting.

THE MUM'S EXPERIENCE

Mother-of-two Ally Jones has been left disappointed by her experience with her local health visitor service.

Jones, from Somerset, says support from the service effectively stopped for both her sons, nine-month-old Ollie and three-year-old Freddie, after only one or two home visits.

"Follow-up phone calls and further visits would have been helpful," she says, but instead the main source of support she was offered were open sessions at the nearby health clinic.

"It was as if they took one look at us and decided we were middle class, could cope and didn't need any more help," she says.

"I could have asked them to come round more but I was left feeling that I wasn't a priority. The open sessions are not ideal either. They are very open and I don't want to discuss issues about my children in front of other people."

She also cites a lack of continuity of care, with the family's named health visitor often not available. "And when I do call the health visitors they rarely get back the same day," she adds.

She also says that health visiting is focused too much on new-born babies despite the service in theory providing support for children up to the age of five.

"At the weighing sessions for babies that the health visiting service runs there is nothing for older children to do - it's as if they are set up only for those without other children," she adds.

THE HEALTH VISITOR'S EXPERIENCE

"I work all hours God sends," says Jenny Beare, a health visitor in London and a union representative for CPHVA.

"I know of some health visitors in London who have a caseload of more than 800 families. We still try to provide a universal service but it is difficult to achieve."

Beare would welcome an increase in health visitor numbers so that she and her colleagues can attend more home visits and not rely on drop-in sessions in premises that "do not always offer privacy".

She also wants to see an end to the birth-to-five remit of health visitors.

"If I see a family and they have a problem with a child over five, I'll help them but it is not part of my role officially," she says

Instead she would like to see health visitors working as part of a wider team, including school nurses and youth services to focus on all children and young people from birth to 19. Better partnerships with social care, children's centres and other health workers are needed to achieve this, but she concedes partnership working is difficult.

Another reform she would like to see is the creation of a chief health visitor role in government. "There isn't anyone at the top to champion the profession," she says.

HEALTH VISITING IN NUMBERS

9,056 health visitors were working in the UK in 2007. This is a 13 per cent drop since 1998. Meanwhile, the number of live births has increased by eight per cent during this period.

20% of health visitors have caseloads of more than 1,000 families and 40 per cent have caseloads of more than 500 children.

253  Hew health visitors were registered in 2008. In 2004, 717 health visitors were registered

70% of health visitors believe they struggle to meet the needs of the most vulnerable children

46 is the average age of health visitors in the UK

Sources: Royal College of Nursing, CPHVA

THE LABOUR GOVERNMENT'S PLANS FOR HEALTH VISITORS

The Department of Health (DH) is confident that its Action on Health Visiting programme, which it launched with the union CPHVA in March, will help deliver the improvements health visitors have been calling for.

Led by Chief Nursing Officer Dame Christine Beasley, this will look at health visitors' role in child protection in the light of serious case reviews into child deaths that have criticised the under-funding of health visiting.

Boosting health visitor numbers, improvements to training and how the profession works with partners in social care will also be examined.

A DH spokeswoman says that firm plans will be unveiled at CPHVA's October conference. The spokeswoman says: "We are working closely with other key stakeholders to increase the number of health visitors by providing more training, support for people to return to practice, career routes to enable nurses to move into health visiting and more career development opportunities."

However, until October details about funding and new posts remain unknown. CPHVA wants to see targets imposed on children's trusts to reduce health visitor caseloads. Realistically, the union is expecting the October announcement to include guidance for trusts on the importance of investing in health visiting as well as clarity surrounding health visitors' role in children's centres.

Other government initiatives include a pledge in this year's child health strategy to give every children's centre in England a named health visitor.

But the DH spokeswoman indicates this is unlikely to lead to many new health visitor roles. "The named health visitor role in children's centres does not necessarily constitute a new post," she says.

THE CONSERVATIVES VOW TO TRANSFORM HEALTH VISITING

"Health visitors are at the heart of our public health agenda. What parents want is a universal health visiting service and currently they are not getting it," says Maria Miller, the Conservative Party's shadow families minister.

The party has pledged to fund an additional 4,200 health visitor roles and ensure families have at least six hours of home visits during the first two weeks after birth.

This is likely to be paid for through cuts to children's centres' outreach services, which Conservative leader David Cameron has described as "an army of untrained outreach workers."

But Miller adds that the party is still committed to children's centres as the focal point for delivering children's services, including health visiting.

Her party also wants better training for health visitors in child protection and relationship support as it believes health visitors play a key role in keeping families together.

"The view from health visitors that have contacted us is that they want more training, particularly in support on parenting issues and relationships," says Miller.

Miller says the extra health visitors it is calling for will go a long way to reducing caseloads and will be more effective than other measures such as tougher targets for trusts or appointing a chief health visitor in government. "This government has for too long used figureheads and targets and they do not work," she says.

She is equally dismissive of the Department of Health's Action on Health Visiting programme. "I'm not optimistic it will change anything. After all, this has been set up by a government that has overseen an erosion of the service over the last decade," she says.