NHS Greater Glasgow and Clyde
Health Visiting Review
Discussion Paper
August 2007
Foreword
In September 2006 we set out our intention to review health visiting services in the wider context of our commitment to improving services for children and their families.
This paper reports on the outcomes of that review
It sets out our conclusions on the future model of care and model of delivery for health visiting. The work of school nurses is closely linked to changes in health visiting and the implications for school nursing are there also considered where relevant.
The strong conclusion from the review was that we need a workforce which focuses on children aged 0-19 and their families, working in integrated children’s services teams.
One of the major challenges facing NHS Greater Glasgow and Clyde is the needs of vulnerable children and their families, and the intergenerational cycle of disadvantage. Early life and childhood is a particularly crucial period in the determination of future health for individuals. Effective services for children and young people are therefore an integral part of the route to improving health and tackling the widening health inequalities we see in our area.
The development and deployment of our skilled and experienced health visitor resource is the key to the contribution for the NHS to addressing those needs
There is no question about the value we place on health visitor skills and their central and unique role in the future delivery of children’s services. They are a skilled and experienced workforce who are highly valued and seen as an integral part of both the primary care team and wider children’s and family services. We are committed to supporting health visitors to make the best use of their skills.
We acknowledge that several of the conclusions in the review may be contentious. We are committed to discussing these further, and to taking the review forward in a way which maintains as much as possible of what works well at the moment while moving the service forward to meet future needs.
I would welcome your comments and ask that these be returned to me by the 28th September to:George Hunter c/o Anne Law at:
Anne Law
East CHCP
Templeton Business Centre
Building 1
62 Templeton Street
Glasgow
G40 1DA
George Hunter
Chair, Health Visiting Review Steering Group
1.The Review Process
1.1Background
In September 2006 NHS Greater Glasgow and Clyde signalled the intention to review health visiting as part of the wider context of improving and integrating services for children and young people. The review considered the development and deployment of health visiting staff as a key contributor in addressing the needs of vulnerable families and addressing wider inequalities.
At the beginning of the review process in September 2006 a discussion paper was issued to all stakeholders, including health visitors. This paper outlined an initial appraisal of current issues for the service including:
- There is no consistent definition of the role of a health visitor
- Management and supervision arrangements are limited and professional support is thinly spread
- Caseloads vary significantly in volume and intensity
- Priorities and focus are a mix of self-directed or linked to GP requirement rather than a consistent view of shared priorities
- At present there is limited sense of a joined up and cohesive children and families workforce with CH(C)Ps
- Infrastructure support in terms of administration, IT and support workers is not enabling the best use of health visitor skills
- There is no consensus on the right organisational model
- While health visitor skills and contributions are highly valued there is a limited appraisal of evidence and outcomes information to establish the right model and the right way to deliver it
The review was established to test this initial assessment and propose evidence based changes.
1.2The review process
East Renfrewshire CHCP was identified to lead the process and a steering group was established with wide representation from CH(C)Ps, health visitors, public health and children’s services.
Staff briefing sessions were arranged by heads of children’s service, integration managers and senior nurses in CHCPs.
To inform the review process a selective review of evidence was carried out by the Public Health Resource Unit. The evidence review was guided by questions posed by the steering group namely;
- What are we doing just now?
- What types of community child health service do we need for children in Greater Glasgow and Clyde
- What can we learn from other areas?
- What is the evidence of effectiveness in key practice areas?
Published and unpublished studies, policy documents and reports were reviewed. An audit carried out by the child protection unit and a staff survey was used to ascertain current patterns of practice.
The key milestones in the review were:
Sept- Dec 2006Initial Discussion Paper distributed to Key stakeholders
Dec 2006Improving children’s services event- responses to discussion considered.
Jan 2007Initial steering group meeting
Jan- June 2007Review of evidence underway. local consultation with staff via CHCP Hall4 implementation groups
The full evidence review can be found on –
All of the evidence gathered during the review process was considered by steering group members to inform their conclusions as set out in this paper.
1.3Scope
The review considered the role of health visitors across the whole of Greater Glasgow and Clyde.
Several issues raised in the review are also directly relevant to school nurses who since 2002 have undertaken the same training for entry onto the register, and have a key role in providing services for children and families. Issues and conclusions which are relevant to school nurses are explicitly noted.
2.Review Findings - Context
2.1Profile
The health of people in Greater Glasgow and Clyde is worse than most of the rest of the UK. One of the major challenges facing NHS GGC is the widening health inequalities in our population
People in Greater Glasgow and Clyde are more likely to live in deprivation than in any other part of Scotland. This particularly affects children who make up 37% of the population in our most deprived datazonesdata zones.
Although deprivation is a significant issue, not all children in deprived areas will face difficulties, and children in any part of Greater Glasgow and Clyde may face disadvantage and risk for other reasons. For example; disability, poverty, gender based violence, family breakdown and parental addiction. These issues can lead to higher mortality, mental health problems, lower breastfeeding rates and low educational attainment. Disadvantage in infancy, adolescence and early adulthood contributes to poor health in later adulthood.
There are significant numbers of children from ethnic minority backgrounds, travelling people, asylum seekers and economic migrants particularly within Glasgow city making a complex picture of need.
Children in the most disadvantaged circumstances are far less likely to take up routine health checks. The most vulnerable children have therefore been least likely to benefit from advice and support from health professionals providing universal services.
Research evidence shows that giving children a better start in life both improves opportunities for the child and contributes to reducing population health inequalities.
A step change in the approach to supporting children and families is required to address these major social and health issues. This involves understanding the many determinants which might impact on the health of families and children, and providing services which address these.
2.2Policy Context
The key messages from national policy were considered as part of the review.
Health for All Children (Hall 4) sets out a clear model of care based on each family’s circumstances and needs. It describes a core programme of contacts which every family can expect, with further support, guidance and help in addition to this for those who need it. The approach is represented in the diagram below:
Hall 4 is clear that while a universal programme of advice and information gives a unique opportunity or health improvement for the whole population, the most disadvantaged and needy groups often access these services less. Robust assessment and targeting of interventions at those most in need is therefore essential, as well as working with other agencies to provide effective services. This has implications for the way in which health visitors work and the balance between universal and more specialist and targeted services.
The implementation of Hall 4 in Greater Glasgow and Clyde has demonstrated the need for robust assessment and greater clarity and consistency about the thresholds used to assign the 3 health plan indicators.
Getting it right for Every Child promotes a unified approach to children’s services with a focus on outcomes for children, and clear duties for local co-operation and co-ordination between agencies. It promotes the use of a single integrated assessment tool, and a multi agency action plan where a child’s needs are complex or serious, with a lead professional to make sure this happens.
Facing the Future: A review of the role of Health Visitors (Department of Health, England) describes the focus of health visiting in England. They advocate early intervention, prevention and health promotion for young children and families, with a focus either on the universal child health promotion programme, or intensive programmes for the most vulnerable children and families. It emphasises the importance of health visitors being an integral part of joint children’s services teams, as well as the primary care team. Although this only applies to England, it provides a useful comparison.
The Scottish Executive review of community nursing is ongoing . We will continue to engage with this work. The model and requirements set out in this paper will inform our contribution to that review.
2.3Organisational context
There are a number of changes to the models of service delivery that will impact on the organisational context within which Health Visiting services are delivered:
CH(C)Ps
Community Health Partnerships are now in place across Greater Glasgow and Clyde and are responsible for planning and delivering community services to their populations. Key priorities for CH(C)Ps are to improve the access to services, to reduce inequalities and to ensure the effective integration of service provision. NHS GGC is committed to joint service development across all CH(C)Ps whether or not there are integrated organisational arrangements.
Integrated services
National policy, local experience and evidence from other areas particularly in the field of learning disability, addiction and mental health hashave demonstrated that the establishment of multi-agency teams of staff working to a defined geographical area significantly improveestablishment of multi-agency teams of staff working to a defined geographical area significantly improves outcomes for service users.
There are some local examples of services which have been developed to target particularly vulnerable children, for example the Parent and Child Together Teams in Glasgow which were developed from a national demonstration project which demonstrated the importance of multi agency working. The Inequalities Sensitive Practice Initiative is also exploring how services can take account of the whole range of factors which may impact on an individual’s health and wellbeing.
Resource allocation
In line with the NHSGGC’s corporate objective of tackling inequalities and focusing resources on the greatest need, a review of the resource allocation to CH(C)Ps is currently taking place, with a particular focus on children and families budgets. This is looking at how best to identify need, considering indicators such as age and deprivation, and to allocate resources to the areas of greatest need. The review of resource allocation will support the implementation of the health visiting review.
Primary Care
The future policy direction for primary care is also currently being reviewed in the light of changes to the GP contract, CH(C)P development, the focus on shifting the balance of care and the need to provide local services. Given the close relationship between health visitors and primary care teams, this provides an opportunity to review how primary care teams link to other community services to meet the needs of local populations.
2.4Evidence from other areas
The role of health visitors has been reviewed by a number of different areas across the UK. The evidence from changes in other areas was considered by the steering group. A summary of the papers sourced can be found on
The drivers for change and recommendations are fairly consistent across the country focusing mainly on the need to reduce inequalities through provision of integrated services. To support changes to health visiting and children’s services there has been a move to geographical based teams and redistribution of resources according to need. Staff development programmes, skill mix and the introduction of local leadership through team leaders have been used effectively to facilitate the process.
2.5Summary of key issues
The needs of children in Greater Glasgow and Clyde are significant and complex. This requires provision of universal services to provide initial assessment and support, with a more targeted approach for the most vulnerable children.
Effective services require robust and sensitive assessment and close working between different agencies and members of the wider children and families services team.
Thresholds for different levels of support need to be clear and consistent and be related to need rather than resources.
Health visitors should focus on those with greatest need. Their time and skills require to be released to enable this.
Flexibility in the management and organisation of services is essential to enable skills to be deployed most effectively.
The development of CH(C)Ps with a clear geographical focus provides an opportunity to develop organisational arrangements which meet these needs.
The protection of children is a key driver. Health visitors and school nurses have a central role in this. It requires a multi-agency approach with efficient communication and connections between services.
3.Review findings – the current picture
3.1Universal services
Health visitors provide services to children of families registered to the GP practice to which they are attached. They currently see all children born in the Greater Glasgow and Clyde area. Parents become engaged with health visitors around the 10th day after birth of a new child until school entry. Prior to that, parents engage with maternity services.
Health visitors provide the universal health improvement programme and support for parents as defined by Hall4 with families. They carry out single agency assessment for all new births and all those moving in to the area. This assessment is the platform from which families are assigned to additional or intensive care groups.
The need to see routinely all children and families within the universal programme beyond the assessment period takes up a large amount of health visitors’ time and can impact on their capacity to focus on other areas of practice
The antenatal period is a key time to form relationships with families, support and improve maternal and child health and assess future needs. Midwives currently carry out a public health assessment of all families which covers issues such as domestic violence, drug and alcohol abuse and mental health issues. There is currently no recognised common assessment and planning process that spans midwifery and health visiting. The assessments are also currently not sensitive enough to identify the full range of determinants which may cause risk or disadvantage, such as poverty and gender based violence.
Children are “handed over” to the school health service on school entry, although continuity of care and handover of key issues is not consistent. Contact with the service continues through school with the provision of health promotion and immunisation programmes. Programmes delivered by school nurses vary from CH(C)P to CH(C)P dependent on workload. Families with more than one child may have involvement from both school nurses and health visitors.
Key issues
Universal services are an important part of health visitors’ and school nurses’ role and provide a unique opportunity for advice, information and support to the whole population. However, there is a need to ensure that this does not take place to the detriment of more targeted support for those in greater need. Health visitors should therefore focus on assessment for all children and on supporting families in greatest need.
Robust and comprehensive assessment which is shared between relevant parties for all children and families is essential to ensure that risks are identified and appropriate services provided.
Health visitors need to work as part of a team with school nurses to provide continuity of support for families from birth to leaving school (0-19)