The Health Visitor Improvement Plan 2011-2015
The Health Visitor Improvement Plan 2011-2015 outlines plans to develop and expand the Health Visiting Service in England. It is proposed that Health Visitors (HVs) will provide four different levels (tiers) of service based on assessment of the needs of the child and family:
- Community Services (available to all families)
- Universal Services (provided for all families with children aged 0-5),
- Universal Plus Services (offered to families with children aged 0-5 with specific issues)
- Universal Partnership Plus Services (offered to families with children aged 0-5 with complex needs)
Support may be provided direct by the HV (e.g. breastfeeding guidance), in partnership with community services (e.g. parenting advice) or via referral to specialist services (e.g. mental health) and in a range of community settings e.g. Children’s Centres, GP Practices and homes.
In order to deliver these objectives it is proposed that the number of Health Visitors in England should be increased by over 50%, from 8000 in 2010 to over 12000 by 2015.1
This policy reflects a cross-government commitment to focus on developing & improving services for young children. These have been recognised as providing the best opportunity to improve health and social development throughout life and reduce or prevent social inequalities and inequalities in health.2
The development of the Health Visiting Service has been identified as a key component of this policy based on the rationale:
HVs are trained health professionals capable of:
Ø Delivering health services for all families with children.
Ø Identifying families in need of extra support at the earliest opportunity.
Their role enables them to:
Ø Provide a link between families and other health and social services.
Ø Take a lead role in the development and delivery of a co-ordinated package of care tailored to individual family needs.
Evidence of Potential Benefits
The evidence of the effectiveness of early intervention on improving health and social inequalities outcomes throughout life is well established.3,4 There is also clear evidence that using a tiered model of service provision, i.e. one that includes services available to all and for those with more complex needs, can lead to better engagement with families who are most in need of assistance.5,6,7
Recent reviews indicate that the delivery of support within a home environment remains an important element of the HV service. However most of this research was conducted outside the UK where different systems and processes may influence outcomes.5, 6, 8, 9, 10, 11
There is some evidence that health-led services can achieve better outcomes than services lead by non-health professionals, particularly when supporting families with complex issues.4, 9, 12
There is a broad consensus that Health Visitors should continue to lead the delivery of the Healthy Child Programme, a programme of public health services for all children aged 0-5.13, 14 At the same time recent reviews have highlighted that a current lack of capacity in HV services is restricting their ability to deliver this service and fulfil their wider role in promoting public health.8, 13, 15, 16
Evidence of Potential Risks
The principles of health economics suggest that any investment decisions should be based on a comparison of the cost-effectiveness of alternative options and consideration of the opportunity costs (the potential benefits which could have been achieved through investment in other services).17
Unfortunately there is a lack of evidence considering the cost-effectiveness of Health Visitors.3, 5, 6, 10 This makes it difficult to determine whether increasing the number of Health Visitors offers the best value for money in comparison to other methods of providing early intervention for health improvement.
In addition, given the financial constraints on public sector spending, it is unlikely that the investment required to expand the HV service on the scale proposed will be possible without diverting resources from other services. HVs have warned that too much emphasis on the provision of services for those with specific/ complex needs will leave insufficient resources for the delivery of universal services available to all.8, 13
Health & Well-Being Implications
Improving the health and well-being of young children and their families is a complex task requiring interventions from a broad range of services. This policy takes a narrow approach, concentrating investment in expanding professional capacity in a service which can only provide part of the solution.
Given the lack of evidence of the cost-effectiveness of Health Visitors and the current economic climate this is a high risk strategy which, if unsuccessful, could result in worsening health and well-being if resources are diverted from other important services.
Author: Helen M Buttivant MScPH, Public Health Specialty Registrar, Wessex Deanery
UK area affected: England only
Further Information:
Department of Health. Service Vision for Health Visiting in England. Department of Health, London 2010
(available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124204, accessed 10/03/11)
Department of Health, Unite, Community Practitioners’ and Health Visitors’ Association. Getting it right for children and families: Maximising the contribution of the health visiting team. Department of Health, London 2009.
Department of Health. Transforming community services: Ambition, action, achievement – Transforming Services for Children, Young People and their Families. Department of Health, London 2009. (available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124198.pdf accessed 10/03/11).
Department of Health. Facing the Future: A review of the role of health visitors. Department of Health, London 2007.(available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_075642).
[1] Department of Health. Health Visitor Implementation Plan 2011-2015: A call to action. Department of Health, London 2011
(Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124202, accessed 10/03/11)
[2] Allen G. Early Intervention: The Next Steps. Cabinet Office, London 2011
[3] Marmot M. Fair society, healthy lives: the Marmot review; strategic review of health inequalities in England post-2010. The Marmot Review
[4] Irwin L, Siddiqi A, Hertzman C (2007) Early child development: a powerful equalizer. Final Report for the World Health Organization’s Commission on the Social Determinants of Health. World Health Organisation, Geneva 2007
[5] Department of Health, Unite, Community Practitioners’ and Health Visitors’ Association. Getting it right for children and families: Maximising the contribution of the health visiting team. Department of Health, London 2009
[6] Barlow J, Schrader McMillan A, Kirkpatrick S et al. Health-led parenting interventions in pregnancy and the early years. DCSF Research report, DCSF-RW070, London. 2008
[7] Bull J, McCormick G, Swann C, Mulvihill C. Ante- and post-natal home-visiting programmes: a review of reviews. Health Development Agency, London 2004
[8] Department of Health. Transforming community services: Ambition, action, achievement – Transforming Services for Children, Young People and their Families. Department of Health, London 2009. (available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124198.pdf accessed 10/03/11).
[9] UK Public Health Association. Response to ‘Facing the Future: a review of the role of health visiting’. UKPHA, London 2007 (available from: http://www.ukpha.org.uk, accessed 10/03/11)
[10] Hall D and Elliman D. Health for All Children (revised 4th edition). Oxford University Press, Oxford 2006
[11] Kendrick D, Elkan R, Hewitt M, Dewey M, Blair M, Robinson J, Williams D, Brummell K. Does home visiting improve parenting and the quality of the home environment? A systematic review and meta-analysis. Archives of Disease in Childhood 2000; 82:443-451
[12] Center on the Developing Child. A Science-Based Framework for Early Childhood Policy: Using Evidence to Improve Outcomes in Learning, Behavior, and Health for Vulnerable Children. Cambridge, MA: Center on the Developing Child, Harvard University, Massachusetts 2007 (available at http://developingchild.harvard.edu/library/reports_and_working_papers/policy_framework/, accessed 10/03/11)
[13] Department of Health, Department for Children, Schools and Families. Healthy Child Programme: Pregnancy and the first five years of life. Department of Health, London 2009.
(available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118525.pdf, accessed 10/03/11)
[14] UK Public Health Association. Health Visiting Matters: Re-establishing Health Visiting. UKPHA, London 2009
[15] Lord Laming. Safeguarding children in England: a progress report. The Stationery Office, London 2009
[16] Cowley S, Caan, W, Dowling S, Weir, H. What do health visitors do? A national survey of activities and service organisation., Public Health 2007; 121: (11) 869-879
[17] Wonderling D, Gruen R, Black N. Introduction to Health Economics. Open University Press, Maidenhead 2005.
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