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A role in ascent? The future of health visiting

Cheryll Adams
D(Nurs) MSc BSc(Hons), RN RHV Dip Man
Independent Adviser, Nursing, Health Visiting and Community Health Policy and Practice
Honorary Senior Visiting Lecturer
City University

Why is this government so committed to health visitors? Perhaps it is because they fully understand that investing in the first few years of a child's life brings massive benefits, not only to that child in later life, but also for society and its fiscal spend ...

At the Community Practitioners' and Health Visitors' Annual Conference in October, health minister, Anne Milton announced that the government's plan to increase the number of health visitors by 4,200 by 2015 had survived the spending review.

This was greeted with delight by the profession. One health visitor with a case load of 700 children said, “If only I could split my caseload in half tomorrow I could achieve so much more”. Indeed, with the average recommended caseload being 250 children and over 40% of health visitors now responsible for over 500 children, the announcement is timely.

If we can create a nation of children with high self-esteem and low obesity, where cognitive and other learning challenges are identified early and addressed, who have sound psychosocial health, supportive parents who understand how to set boundaries, and good physical health, then our children will no longer be at the bottom of the UNICEF table of child wellbeing in the developed nations. We will start to address poverty and social exclusion and more children will meet educational goals.  

Traditionally, this work has been the ‘bread and butter' of the health visitor role; although in recent years, as caseloads have increased, health visitors have increasingly found themselves not working to promote health, but to contain health problems in our most vulnerable families. Others have been given responsibility for other parts of the health visitor role, either within the health visitor team, or in children's centres.
What has been lost is the critical holistic approach of the health visitor - their ability to assess the child in the context of the family and the local community, using their health background to make a psycho/social/physical assessment of need. For the most vulnerable families this process must take place in the home, and can be challenging work as effectiveness is based on the health visitor's ability to establish a therapeutic relationship of trust with the family. Many families don't have the confidence to attend children's centres, although for others they have proved an enormously helpful adjunct to the health visitor's work; a place where many services can be brought together efficiently.

However, the approach of other services is often to address a specific issue; for example, challenged parenting, rather than the cause - perhaps domestic violence, postnatal depression or financial concerns.  Much can be lost by not having the capacity to take a holistic approach.

However, no waving of a magic ‘ministerial wand' alone can increase health visitor numbers. There are many steps to be taken before we see the ongoing fall in numbers in the workforce reversed. The government has pledged ring-fenced monies, and this is a huge stride forwards. What is harder to manage is the age profile of the profession. Unless incentives are found to encourage them to stay in the workforce, then many health visitors will retire in the next five years. This will take brave steps, such as looking at the pay banding system, as health visitors were one of the losers when Agenda for Change came in. This would not be an easy step at a time of austerity, but the case can be made when the responsibilities are re-examined and the economic benefits health visitors can bring understood. Many employers in London have done upgraded these professionals.

Health visitors are nurses or midwives first; often have much experience in their previous role before applying to undertake the health visitor training, and many now opt to take this at master's level. Access to training depends on the individual's academic ability, and on their personal attributes - attributes that must allow them to be able to work autonomously in any home or community.

We can expect to see a growth in ‘return to practice' courses for health visitors, these must be accessible across the country. However, we also need easier access routes into health visiting. The development of a pre-registration public health nurse programme would be timely, as would innovative three-year courses for life science graduates. These must allow for the necessary background in nursing knowledge and skills, but with a greater focus on public health and the education and skills necessary for becoming a health visitor. Health visiting must be available as a primary, as well as secondary, career choice. It is an interesting and optimistic time for the profession, and this, in turn, should make it attractive. Ever considered a career change?