In 2011, the Coalition pledged to increase health visitor numbers by 4200 by April 2015. The Health visitor implementation plan 2011-2015 was put in place to help the government achieve this target by expanding and strengthening the health visiting workforce. As the April deadline approaches, what effect has the plan had on the health visiting workforce?
Between 2004 and 2010, the number of health visitors decreased from 10,137 to 8017.1 There are now more than 11,000 health visitors in England, according to figures from the DH, and more are due to complete their training in the next month.
Increasing the number of health visitors was the priority, but there were also a number of targets highlighted to refresh the health visitor service and create a more universal service for all families. This reflected a wider emphasis on prevention for improving public health and an understanding that what happens in the first two years of life determines future physical and mental health.
The plan was a 'call to action' and mandated the high impact areas in which health visitors could make the greatest difference.
'The expansion of the health visitor workforce has been one of the most rapid and successful in NHS history,' says health minister Dan Poulter.
'Investment by government has reversed the historic decline in the number of health visitors with latest figures showing that there are 3218 more health visitors than in 2010, and we are rapidly closing in on our target of 4200 extra health visitors with 1036 due to complete training in March 2015.
'There have also been big improvements in access and user-experience. We have revitalised the service from one that varies around the country to one where every parent has access to a consistent service.'
Improving child health
The plan intended to grow the workforce, mobilise professionals and align delivery systems, focusing on measures to improve the services that health visitors deliver. It stressed the need for closer working between health visitors, GPs, practice nurses, midwives, specialist services and other early years teams.
The revitalised health visiting service brings together existing practice and newly mandated areas under the name of the Four Five Six model. This articulates what all health visitors need to deliver and the areas over which they should be in contact with parents.
The implementation plan outlined the need for a revised commissioning specification, which includes applying the Healthy Child Programme, and ensuring that health visitors work across all health and early years services, including general practice and Sure Start children's centres.
In October 2015, the commissioning of health visiting services will move to local authorities, bringing them in line with nursery nurses and social workers who work together to deliver care for children in the early years.
Madeleine Murphy, editor of the Journal of Health Visiting, says: 'There is some apprehension regarding the move of service commissioning to local authorities, but many health visitors see this as a great opportunity to work more closely with other agencies to achieve the best outcomes for their communities.'
Sharin Baldwin, health visiting clinical academic and innovations lead, at London North West Healthcare NHS Trust, says: 'The mandated health checks and the high impact areas have really focused our work so it means that along with moving over to the local authority there is a sense of clarity around where we need to focus.'
Chief executive of the Institute of Health Visiting (iHV) Cheryll Adams says health visiting had reached a 'sad place' in 2010. 'If a health visitor was busy and the family looked like they didn't have any issues, then the health visitor often didn't have time to go back to them and would instead focus on those families that obviously weren't OK.'
Sabrina Fuller, head of health improvement at NHS England, says that since the plan has been put in place the number of antenatal visits has increased from 32,541 in 2013/14 to 45,232 in 2014/15. The percentage of new birth visits undertaken within 14 days in England has increased from 74% in the second quarter of 2013/14 to 79% in the second quarter of 2014/15. The percentage of children receiving the 12-month development review by the time they turn 15 months has increased from 64% to 77% and the percentage of children receiving a two- to two-and-a-half year review increased from 63% to 68%.2
Ms Adams says that health visiting, as a profession, is very difficult to research. 'You cannot assess what would happen to child health outcomes if there weren't any health visitors, as you can't take the service away.
'However, the health visiting workforce had virtually disappeared before the plan was put in place and it had an impact on things like [the number of] children starting school in nappies and with speech problems.'
Keep up the good work
The deadline for increasing the numbers of health visitors is approaching, which means that government funding will end. However, the iHV, which was set up in 2012 as a direct response to the plan, will continue to build on the plan's vision on a national level. Ms Adams says the organisation will carry out research into the impact of health visitors, provide resources and CPD opportunities, and support the workforce.
The iHV also appointed 150 fellows across the country. These are health visitors who have shown examples of good practice in their local area. Part of their role is to lead new health visitors and contribute to developing health visiting.
Locally, health visitors are taking the plan into their own hands to improve the service in their communities. London North West Healthcare NHS Trust was given funding to set up a super training hub to recruit, retain and educate health visitors.
'Caseload sizes are still quite high as we haven't fully recruited to our numbers. But we are confidently recruiting and we are definitely much better off than we were a few years ago,' says Ms Baldwin.
Beverley Bailey, a health visitor from Gloucester Care Services NHS Trust, says she has seen the positive effects of the plan. 'There has been a reduction in caseloads and three newly qualified students in our team alone. There is a new energy and commitment to developing our service using innovative ideas. We are also able to re-establish and develop links with partner services and attend relevant training as it arises.'
Ms Murphy says: 'Health visitor numbers are up, but many areas still face a shortage of resources and huge, demanding caseloads — so there is a lot of work still to be done. It's essential that we don't lose momentum, and the ongoing education and training of health visitors doesn't suffer once the implementation plan has run its course.'
Four of the main political parties (Conservatives, Labour, Lib Dems and Green) signed up to the 1001 Critical Days: The Importance of the Conception to Age Two Period manifesto, produced by the Wave Trust and the NSPCC in June 2014.3 The manifesto acknowledges the importance of the time between conception and age two in defining future physical and mental health.
'It costs more to invest later on in life than in early intervention and the majority of the political parties seem to understand this,' says Ms Adams.
It is not only England that has recognised the valuable contribution of health visitors in child heath services. In Scotland, in June 2014, the government announced that funding would be allocated to recruit 500 more health visitors across the country, to meet new legislation which specified that every child should have a 'named person' to oversee their care.4 Health visitors will be heavily involved in ensuring this target is met.
The plan and call to action appears to have succeeded. Government officials are optimistic that the target will be met and organisations such as the iHV will continue to support the professional development of health visitors.
So will any other group of public health nurses benefit from an expansion and strengthening of the workforce, as health visiting has? A DH spokesperson said there are currently no plans to focus on any other sections of the public health nursing workforce. If the health visitor implementation plan is anything to go by, investment in primary care nurses would produce results that outweigh the costs.
1.The Health visitor implementation plan 2011-2015. Department of Health. https://www.gov.uk/government/uploads. February 2011.
2. How the service has been transformed: the numbers by Sabrina Fuller. https://vivbennett.blog.gov.uk. March 2015.
3.1001 Critical Days: The Importance of the Conception to Age Two Period http://www.wavetrust.org. June 2014.
4. Investment in health visitors in Scotland. http://www.independentnurse.co.uk/news/investment-.... June 2014.