On the face of it, putting the commissioning of health visiting services into the hands of local government, rather than the NHS, makes little material difference to the profession. Following the 1 October transfer, health visitors are employed by the same organisations as before, and some service continuity should be provided by the government’s decision to “mandate” local authorities to provide five core health visiting checks until April 2017 (see Box 1).
But make no mistake, the impact of the move will be felt by staff as local authorities seek to re-shape services – and look for savings. Hilary Earl, health visitor at County Durham and Darlington Foundation Trust, describes the change as “massive” and “one of the most significant” in her 19 years in the profession.
The government’s rationale for the transfer was that public health services for five to 19-year-olds already sit within local authorities, and that health visiting would benefit from closer integration with non-NHS services such as housing and early years education. According to NHS England, this will deliver “a more joined-up, cost-effective service built around the individual needs, paving the way to deliver across a wider range of public health issues”.
Rather than feeling like a sudden big bang, the shift in many areas has been a relatively gradual one as health visitors have broadened their focus in the run-up to 1 October.
Earl, who is also a practice teacher and a fellow of the Institute of Health Visiting, says staff in her area have seen the change as a chance to get involved, or lead projects such as one focusing on vulnerable families, and another one helping the Romany gypsy traveller community. Other pathways being developed with a range of services will look at teenage pregnancy, vulnerable mothers, and the inclusion of fathers. A home environment assessment tool is also being developed.
There are examples across the country of newly-transferred health visitors feeding more tangibly into local authorities’ wider public health messaging. In Hackney, east London, councillors are considering how to incorporate health visitors’ insights into its work on childhood obesity.
“A lot of thinking is going on about how we can do things differently,” says Jonathan McShane, Hackney Council’s cabinet member for health, social care and culture. He expands: “A lot of the focus [in the past] has been about making sure babies are feeding enough. How do we get more nuanced views about healthy weight, going forward?” People are “crying out” for ways to help children maintain a healthy weight as they get older, he adds.
In Gloucestershire, where services for young children were integrated under the former primary care trust, some health visitors work intensively, alongside non-health professionals, with young parents who have children under two to prevent child protection issues from arising further down the line. There is also a specialist health visiting team in the family drug and alcohol court.
Linda Uren, director of children’s services at Gloucestershire County Council says: “I think these are the sort of opportunities that local authorities will be wanting to build on. This is a skilled workforce and they’re quite unique in their skill set and knowledge and ability to engage with families.”
However, against this backdrop is the crucial issue of funding. Health visiting has been rolled into the public health fund from which councils have been told to cut £200 million and while the NHS is hardly immune from cuts, the fact that health visitors may be relatively unknown to local authorities puts them at greater risk after the transfer, argues Cheryll Adams, director of the Institute of Health Visiting. She explains: “[Health visiting is] a new world [for local authorities]. It’s easier to invest in something you understand.”
The five mandated visits (see Box 2) that must be made before a child is two and a half are “inadequate” in some cases, argues Adams, who worked as a health visitor for almost 20 years. “The danger is that they [local authorities] commission the minimum rather than the optimum,” she says. This is compounded by the fact that many of the local councillors “may not fully understand the role of the health visitor” or grasp the breadth of their work, she believes.
The Department of Health explains in a factsheet that it expects the five mandated reviews to be continued “with a view to securing continuous improvement in their uptake”. However, this expectation, and the delivery of the mandated reviews, is “as far as reasonably practicable… That is, there would not be an expectation that delivery of the reviews will suddenly be expected to be 100% after the point of transfer”.
Could momentum be lost? Overall, Adams feels the move “should” be positive. She says: “Health visiting doesn’t necessarily sit very comfortably within the NHS… local authorities understand public health and population health and early intervention, and stopping things getting out of hand.”
The big debate that local authorities will inevitably be having over the next few years, according to Uren, is whether to maintain health visiting as a universal service or to target funds towards the most vulnerable families. She says: “If the government is reducing the funding for the service – and they have explicitly told us that health visiting isn’t to be regarded as exempt from any reduction – then we will get a challenge from local authorities as to whether we’re being funded for the level of service we’re being told to deliver.”
Removing the universality of the service would be against the whole ethos of the transfer, says Virginia Pearson, director of public health at Devon County Council, who represented the Association of Directors of Public Health on the Department of Health’s programme board for the 0-5 transfer. She says: “The one thing the programme board really wanted to do was to make sure that the universal offer was enshrined as part of that transition process.” She adds: “It would be the wrong thing to do, to just cut health visitors, [and to be] sucked towards just providing a target service, because doing that we just end up creating further needs downstream.”
Any move to direct services solely at particular groups would raise the question of how to decide who to target. Earl points out that prioritising deprived families, for example, could potentially exclude mothers with postnatal depression, or households in which drug-taking occurs.
But cuts are already being made. Fiona Smith, professional lead for children and young people’s nursing at the Royal College of Nursing (RCN), says she is aware of services such as the Family Nurse Partnership – which transferred along with health visiting – being discontinued over the past couple of months and that this has increased health visitors’ workload.
The target to train 4,200 extra health visitors by 2015 has expired and councils will not be bound to any national requirements around workforce numbers. The publicity generated by the target – which was missed but only narrowly – may have led to a perception by local authorities that the staffing issues have been resolved, says Dave Munday, professional officer at union Unite. But he highlights that the improvements have been made from a very low basepoint. For example, although health visitor numbers have jumped by 500% over the past four years, the number of health visitors dropped by 14.2% between 2002 and 2012 – at the same time as the birthrate rocketed by 18%. A survey by the Community Practitioners’ and Health Visitors’ Association in August found 89% of the 750 participants reported their workloads had increased over the past year.
Training commissions are increasing by 14.6% in 2015-2016 compared to the previous year, and are then projected to stabilise in line with predicted demand, according to figures published by Health Education England. In certain parts of the country this may be sufficient to meet employer needs, but other areas, such as London, are still under-staffed according to several professional bodies and research institutions. Munday fears the “postcode lottery” could worsen under local authorities, which arguably have a longer history of using devolved powers than the NHS, with its tradition of more centralised control. His RCN counterpart, Smith, is less concerned about this aspect of the move. “There’s considerable variety… even in the NHS,” says Smith. She adds: “The local authority may have had longer, in terms of experience, of working in different ways and commissioning in different ways, but the same [variation] is true in many areas of healthcare.”
A move to more devolved decision-making, with potentially greater scrutiny and freedom over service contracts, has employment implications too, even though the transfer does not in itself change the organisations that health visitors work for. Re-tendering and contracting out to the private sector has been a day-to-day part of council business for many years, and this readiness to consider alternative providers may provide discomfort to staff who are employed by the NHS and wish to stay within the public sector.
Any staff transferring to a private provider would have to be moved under Transfer of Undertakings (Protection of Employment) Regulations – meaning their terms and conditions would be retained, says Munday. But “there’s nothing to stop that company on day one from renegotiating [contracts],” he highlights. This could prove a challenge for dissenting staff if the private company has no collective bargaining process.
Alongside concerns associated with the financial and human resources impacts of the transfer, there are also those who challenge the principle that local authorities are the best fit for health visitors. If it makes sense to move away from the NHS because the service is more naturally aligned with other services for which councils have a responsibility, what will the change mean for NHS services provided by GPs, and child and adolescent mental health teams? “The same argument must exist [regarding the risk of increasing silos] by taking it out of the rest of health. The logic doesn’t follow,” says Munday.
Inevitably, some local authorities will decide that if health visitors are working more closely with non-NHS services, they will need to be based in children’s centres rather than, for example, GP practices. Dr Pearson is “absolutely sure” councils will increasingly want to look at this.
Uren agrees, on the basis it helps to “encourage the notion of one workforce working with families”.
In the short term, health visitors may not see any drastic changes. Commissioning budgets for future years are still unclear, and some local authorities are still wrangling over this year’s allocation. The DH has stated in its finance factsheet related to the policy decision that: “Stability of the transformed and expanded service is a priority.”
Civil servants and service managers have been working through the challenges of changing the physical boundaries of health visiting services so that they serve local authority resident populations as opposed to GP practice registered populations. But the issue is not regarded as earth-shattering, and there is an expectation that service delivery should take precedence over any boundary disputes.
Time will tell whether local authorities opt to expand health visiting services or see them as easy targets for funding cuts. Adams says: “There’s a responsibility for health visitors themselves.”
In order to be more “conspicuous” staff should invite commissioners to shadow them in order to demonstrate the subtleties of their work; provide case studies, and ensure they are represented at important meetings as much as possible. It’s incredibly helpful and powerful if the health visitors get the opportunity to articulate their roles directly,” she stresses.