21st century health visitors for 21st century parents
Wendy Mitchell and Phil Wilson argue that the scope of health visitors is vast and varied and that it is vital to value and invest in their work to ensure the workforce remains motivated, competent and credible.
Health visiting has grown and developed in line with changes in society generally, and has responded to the new challenges and health needs emerging. Health visiting policy in Scotland, nevertheless, had a turbulent entry to the 21st century; the Scottish Government has acknowledged widely-held concerns about the direction of health policy over recent years and has prioritised the early years (The Scottish Government 2007; The Scottish Government 2008) with recognition of the important role of health visiting.
Health visitors are proud of their reputation; they are unusually successful in gaining acceptance by families across society (Robotham and Frost 2005) even among under- served groups such as homeless people, travellers and women with mental health needs. Not only are health visitors widely accepted, their interventions are valued highly by families (Ipsos MORI for PAS 2008; Netmums 2008). Health visitors are also recognised by other professionals, agencies and third sector organisations as central to the support network for pre-school children and their families (Robotham and Frost 2005).
Morale in health visiting has declined following several policy changes. This is a vital workforce and it must be involved in influencing services for children and families. This would re-energise this workforce and achieve an elusive goal: agreement about the role and function of health visiting. 21st century health visiting should build on and improve already successful core functions, including health promotion, prevention, early identification of problems, early intervention, and helping families navigate services. These functions should be the cornerstone of a service offering 'proportionate universalism' - every family feels that support is available but those with most need receive more (Marmot et al. 2010).
Taking the lead
Health visitors should take the lead in providing a pre-school child health programme, responsive to children and their families, incorporating a public health approach. When children and families' needs are increased, health visiting teams must have sufficient resources to meet these or ensure that services are available elsewhere, for example, in the third sector or through health service referrals. Health needs vary, and it may be that support is required for short periods particularly around transitional points such as the birth of a baby, weaning and early toddlerhood (Cowley et al. 2007).
The Acheson Report (Acheson 1998) showed that the population health 'bell-curve' can be moved in a positive direction by investing in children and families, and that health visiting is integral to this. Therefore, the focus of health visitors should be based on the above core functions, as this is where their nursing and public health skills and knowledge can have the greatest impact. For instance, supporting a new mother to breastfeed, followed by weaning and dietary advice can prevent both childhood obesity and poor oral health; further health benefits may continue into adult life and contribute to preventing coronary heart disease or diabetes. Similarly, offering support when there are threats to early parent-child attachment can provide long-term benefits to mental and physical health (Olds et al. 1998).
Parents affect many aspects of a child's life immeasurably, continuing into adulthood. The acceptability to families of health visiting and a professional understanding of the parental role have resulted in a unique ability to assess, support and improve parenting capacity. One of the most significant changes in adulthood is becoming a parent. Increasing expectations, changes in work-life balance and changing family configurations make it difficult to offer families easy and equitable access to support. Whilst it is vital that public services are efficient, effective and evidence-based, sometimes very low levels of informal support can prevent a crisis, and a skilled health visitor should know when and how to intervene in this way.
Proportionality of this kind is the key to an efficient service. While 'manualised' interventions such as the Family Nurse Partnership undoubtedly offer a superb service to families who need it, their focus on young, first-time mothers means that they are only available to a lucky few. In addition, the Family Nurse Partnership does not support proportionate universalism: it is 'all or nothing' and lacks flexibility when needs are not immediately obvious, or for older mothers. With a flexible, professionally-led health visiting service, families with less pressing needs could benefit from lower intensity support which might avoid the necessity for later crisis intervention. Furthermore, by investing in health visiting, costs might be better contained and more equitably provided.
Another economic argument for trusting professional judgement relates to minimising bureaucracy: many health visitors spend considerable time completing paperwork which brings little benefit to families who require minimal support. If we are prepared to invest in training professionals, we should be willing to accept a professional judgement that things are going OK for a family without demanding pages of paperwork to support that judgement.
Supporting new parents
Supporting new parents is complex and varied; health visitors have an important function in calibrating expectations and improving understanding or norms. The health visitor should be able to search for health needs following assessment of parenting, bio- psychosocial, economic and environmental factors (Appleton and Cowley 2003). From this, health visitors can work with the whole family pro-actively promoting health and preventing ill health. Much could be done to improve the professional capacity of health visitors. The shift to a public health focus (Scottish Executive Health Department 2001), largely welcome, led to a shift away from a focus on individual needs. There is a strong case for a renewed commitment to developing health visitors' knowledge of family functioning, child development and infant mental health. Many health visitors strongly support this view (Wilson et al. 2008) and we believe that developing such expertise would also increase professional confidence and respect for the profession among colleagues in health and social services.
Strengthening child health
Health visitors are essential for strengthening child health provision in primary care. Health visitors are often the first contact for parents, and, with their greater knowledge of community facilities and services, are best placed to signpost families towards services. The can find extra support for families because they know what is available. They also simplify access to support because of their ability to work across organisational boundaries. We consider that health visitors and general practitioners have complementary roles in providing support for families. Both health visitors and GPs are well placed to identify vulnerability (Wilson and Mullin 2009) but the 'intelligence' may come through different mechanisms. For example, GPs are more likely to identify issues through their relationships with extended family members or adult-oriented services such as addictions or A&E departments, while health visitors are more likely to make direct observations in the home or hear information about a child's behaviour in a nursery. It is, therefore, essential to foster close working relationships between GPs and health visitors - the only professions in routine contact with every pre-school child. As with trust in professional judgement, face-to-face close working relationships promote efficiency - intelligence can be exchanged quickly without formal referral. Furthermore, low-level concerns can be shared and acted upon without the fear of alienating families; the campaign launched by Netmums (2008) highlights the huge value families place on the support they receive from health visitors.
The scope of health visitor activity is vast and varied. It is vital to value this work and invest in it to ensure this workforce remains motivated, competent and credible.
About the authors
Wendy Mitchell qualified as a registered nurse in 1995 and completed a PgD in Health Visiting/PHN in 2001. Currently, she is a senior community nurse manager within a community heath partnership and is responsible, both professionally and operationally, for health visiting, school nursing, district nursing and specialist nursing.
Phil Wilson is a GP and senior lecturer in infant mental health at the University of Glasgow. He contributed to the Scottish Needs Assessment Programme on Child and Adolescent Mental Health and the HeadsUpScotland Infant Mental Health report, and has published numerous academic papers on early childhood mental health. He is currently involved in evaluating the parenting support strategy for Glasgow and in research designed to improve early identification and treatment of psychological and psychiatric problems in infancy.
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