‘Time to make the most of health visitors'

Health visitors could play a crucial role in addressing the challenges of the cost of living crisis, but only if they are properly funded to do so, says Institute of Health Visiting chief executive officer Alison Morton.

The role of the health visitor is unique, says Institute of Health Visiting chief executive officer Alison Morton. “There is no other service which sees every family before the age of five. That puts them in a position to make a difference to people’s lives.

“But we have seen the number of health visitors fall by 40 per cent since 2015 – you cannot take that many out of the system without having a detrimental impact.”  

She says this has been exacerbated by what happened because of COVID-19. “During the pandemic we saw staff re-deployed and services scaled back – and we are still living with the legacy of that. Services have not been fully-restored. In many areas some of the five mandated visits are being done remotely on the phone or on video or sometimes just through a letter.   

“You cannot properly assess a young child like that and it means we are missing opportunities to spot things early and prevent problems developing. Babies cannot ask for help. What health visitors are really good at is picking up on those clues – whether it is abuse or neglect, substance misuse by parents, mental health problems or development delay. But if they are not seeing families in-person it is so difficult.  

“Even something like childhood vaccinations suffers. We have seen immunisation rates drop. Health visitors don’t do the vaccinations – practice nurses do. But those mandated meetings were an opportunity to discuss all sorts of things, including vaccination and checking whether they were up to date.  

“It is a missed opportunity. There are invisible vulnerable children out there who are being failed and it is widening health inequalities. We saw during the pandemic greater problems developing – children falling behind developmentally and now that is compounded by the cost of living crisis.”  

‘We see the stress poverty is causing’

She points to a survey of health visitors that was published by the iHV in January. It found 91 per cent reporting an increase in poverty affecting families alongside rises in perinatal mental illness, domestic abuse and delays in speech and language development.

Ms Morton said these findings were extremely concerning. “Health visitors are witnessing the impacts of stress associated with poverty. Despite these challenges, health visitors are working extremely hard and finding innovative ways to support thousands and thousands of families every week across the UK – a lot of their work doesn’t get the attention it deserves as it is hidden behind front doors.

“But the main problem is that there aren’t enough health visitors to meet the scale of need. 

Health visitor services are so stretched they are finding their workloads consumed by safeguarding – they have time for little else. 

“There is such a high threshold for social workers to take on cases that health visitors have little option. But this should not be the case. Health visitors should be working much further upstream, helping stop problems developing in the first place or getting worse. Instead, they are fire-fighting. 

“At their best health visitors don’t just identify those in need, they also provide direct support to families. Take perinatal mental health, for example, only those with the most serious mental health problems will qualify for specialist help – the majority are managed by GPs and health visitors in the community. Health visitors can provide direct help, either one-on-one or in group settings with the right resourcing. 

“We have seen other service innovations too. Some areas have introduced very effective health visiting intensive home visiting programmes which offer extra targeted support for the most vulnerable families and there has been some really proactive work on key health priorities like oral health that have shown tangible reductions in tooth decay.

“The problem is that we have not been able to scale up these because of what has happened to funding and workforce numbers.” 

Time to re-think approach to funding? 

As a result of the cuts, Ms Morton has been left wondering whether there should be a different approach going forward. She describes herself as a “supporter” of the reforms originally. 

“There was a degree of apprehension about public health moving into local government. The service was so ensconced in the NHS. They were employed by NHS trusts on the whole and working in GP surgeries. 

“But we recognised councils are close to their local communities and this opened up different sorts of opportunities to improve services for families. Health visitors now have a closer working relationship with other council services – education, social care and benefits. They are able to have input into strategic work of local government. 

“It has also opened up new career roles too. We have seen specialist health visitor roles created in areas such as asylum seekers, obesity, perinatal mental health and special education needs, while some health visitors have gone in to different areas such as safeguarding.

“But it has had some disadvantages too. The close working relationship with GPs has been weakened as most health visitors have moved out of GP practices and into community and family hubs. 

“Local government’s statutory responsibilities are also being prioritised.  These changes have impacted the ‘health’ functions of the health visitor – as services are scaled back there is less focus on supporting families to manage physical and mental health problems.

“This has inevitably driven pressures on A&E departments as more families are turning to them for support for conditions that would previously have been managed by a health visitor, for example, crying babies, feeding problems and minor illnesses.

“When adequately resourced the benefits of an effective health visiting service are seen across health, education and social care – but as the service is moved around you find this shift in emphasis depending on where the service sits. When it is in local government you find the pendulum swings more towards safeguarding and the other focuses of councils, while when it is in the NHS it swings more towards health. 

“It is impossible to judge the success of the move to council commissioning without looking at the wider context. The approach taken by central government has a huge effect on what councils can do - they create the environment in which the local government works and need to take responsibility for the current state of health visiting in England. The cuts to the public health budget have been incredibly damaging. 

“So I think we need to learn from the past and put an end to this constant pendulum swinging of priorities as the health visitor’s unique contributions to health, education and social care all matter. It needs a radical shift from siloed departmental thinking and perhaps we need to think about establishing a cross-government funding mechanism for health visiting to safeguard it against cuts – a pooled budget incorporating the government departments with responsibility for health, education, social care and local government.

“It’s all a matter of priorities - the government spent £3bn by taking 3p off a pint or lager. Just imagine what we could have achieved if it had taken just 2p off and invested the rest reinstating the £1bn cut from the public health grant and health visiting? It would have made a massive difference. We can do it – in fact we cannot afford not to.”