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On 1 October commissioning of the health visiting service transferred from NHS England to local authorities. This change enables local areas to consider how health visitors can work closely with wider public health services to tackle health inequalities and promote the best outcomes for children. New commissioning arrangements support the development of more integrated ways of working in child health, to improve access and experience for all families and provide most effective services when families need extra help. 

The health visitor 4-5-6 model describes the transformed service: the four levels of services, five vital universal reviews and six high impact areas that clearly identify the main areas where health visitors make the biggest impact to child health outcomes.

The six high-impact areas are:

1. Transition to parenthood and the early weeks

The antenatal period is vital to prepare for parenthood, and providing support in the very early days and weeks of life is the time to promote positive attachment behaviour. Health visitors see all families from 28 weeks of gestation, mostly in their homes, to listen, teach and advise on the needs of a newborn and assess and support parenting skills. Attachment training and a renewed understanding of infant brain development has fuelled a shift in early intervention practice, and has made this contact important.

2. Perinatal mental health

Health visitors work very closely with mothers in the prevention, screening and detection of postnatal depression. Health visitors support women and refer on if needed. They work closely with the multidisciplinary team and use high-level communication skills to provide individualised interventions, for example, listening visits.1 Enhanced training means health visitors are more adept at detecting, preventing and intervening early if a mother feels low or anxious. Greater understanding of the skilled interventions delivered by health visitors in the postnatal period also promote infant mental health outcomes.

3. Breastfeeding

Health visiting teams work with families to lead interventions that promote breast feeding. Giving women the information to make an informed choice and continuing to teach and advise how to initiate and sustain breastfeeding is vital to address low breastfeeding levels and variation.

4. Healthy weight and healthy nutrition

Health visiting teams are in a unique position to be able to intervene early to encourage weaning and healthy food choices. Health behaviours are formed in these early days and there is a strong connection to parental food choices. Health visitors use approaches like HENRY (Health, Exercise and Nutrition for the Really Young) to educate and inform parents on this.

5. Managing minor illness and reducing accidents

Health visitors are often the first port of call for a worried parent, and the professional group that parents turn to for advice and reassurance when their child is ill. Education and support to manage the ill child and advice on when to seek further help, including access to hospitals, is an area where health visitors are developing practice in response to health needs.

6. Health, wellbeing and development of the child

Research informs us that intervening at two years of age is crucial to bridging the gap in current health inequality and for ensuring children are school ready at the age of four. We also know that missing this opportunity can cost us far more socially and economically to repair later. This knowledge is crucial to ensure all children develop positive health outcomes and get the best start in life. An example includes health visitors and staff at a children's centre working together to tackle school readiness through a joined-up pathway of referral and intervention after the two year review.

Being a universal service, health visiting is accessible and available to children and families. As leaders of the healthy child programme and providers of personalised care to local families the profession makes a significant contribution to the life chances of children, now and into the future.


1. Segre L, Stasik S, O'Hara M. Listening Visits: An Evaluation of the Effectiveness and Acceptability of a Home-based Depression Treatment. Psychotherapy Research 2010;20(6):712-721.