Phil Wilson, Professor of Primary Care and Rural Health at the University of Aberdeen tells us why he thinks the new Universal Health Pathway for Health Visiting is a cause for celebration.
October’s announcement of the refreshed universal health visiting pathway by the Chief Nursing Officer and the statutory implementation of the Named Person role are real causes for celebration. After over a decade during which most Scottish families with young children did not know who their health visitor was, at last we have a firm policy commitment to personal continuity of care and regular universal access to preventive child development support in the very early years.
Our other cause for celebration is that the ‘ordinary’ flexible and proportionate health visiting service has received a ringing endorsement from a trial which showed beyond reasonable doubt that it is at least as good as, and much cheaper than, the excellent Family Nurse Partnership which has been shown to produce tremendous benefits in high quality US trials.
Scotland’s health visitors and the families they support have suffered many well-intentioned but damaging policies since 2000. These include:
- Nursing for Health 2001. This moved the focus of the health visiting workforce towards a poorly defined public health and community development function. The title of health visitor went into cold storage and we saw a new generation of public health nurses emerging with little or no child development content in their basic training. We are still struggling to reverse the damage that this policy caused.
- The Review of Nursing in the Community 2006. This proposed the end of health visiting as a profession in favour of the introduction of a generic community nurse role. Although the worst recommendations of this review were never fully implemented, the damage to professional morale was grave. Health visiting courses were cut and many HVs left the profession, never to return.
- The 2005 Scottish ‘Hall 4’ implementation framework following the Health for All Children1 Hall 4, which contained much good sense, was misguided in its basic propositions that risk to children could almost always be identified very early in life2 3, and that families would seek help if children’s development or parental mental health gave cause for concern4-6. The framework was interpreted by many health boards as supporting the view that families considered to be at “low risk” did not require any health visiting input after 8-16 weeks.
- The 2007 Glasgow review of health visiting. In its original form, this set of policies advocated removal of health visiting from attachment to general practices (a process which, regrettably in my view, has been implemented in many areas of Scotland), management of the profession by social work services, ending of HV involvement in immunisation, and introduction of skill-mix teams. Of course, many HVs don’t think that immunisation is something that needs a postgraduate qualification, but in the context of Hall 4, it was the only contact they had with most families after babies reached 8 weeks of age. A petition to Holyrood, led by GPs but with strong support from some bold HV colleagues, gathered 22,000 signatures in 10 days, and the policy was greatly diluted: but it again caused great damage to the profession. Many Glasgow HVs took early retirement, moved to other areas or left the profession.
- The development of HV skill mix teams, while appearing to offer a rational approach to cost containment, was poorly handled in Scotland and paid insufficient regard to the importance of continuity of relationships, both between HVs and families and between HVs and primary care teams including GPs. These relationships are crucial, not only in the process of assessment of family needs7 but also in the process of inter-professional communication about the needs of children8.
- The fashion for commercial ‘evidence-based programmes.’ Some readers will find it surprising that an academic like me appears to be calling evidence-based service delivery into question, but many millions of pounds has been spent on commercial ‘evidence-based’ programmes which do not work any better than ordinary health visiting. In Glasgow a gross figure of over £7M was spent on the Triple P parenting programme which failed to deliver any improvements in child wellbeing. Health visitors were pressurised into meeting targets for referring families into the programme, often against their professional judgement. Had those implementing Triple P studied the huge quantity of evidence in depth, they would have seen that most of it came from volunteer Australian families with degree-level education, and that while mothers generally reported that Triple P group interventions were better than nothing, the published work was full of biased and generally poor reporting, as well as hidden financial conflicts of interest9. There was no convincing evidence that Triple P interventions work across the whole population or that any benefits are long-term10. It simply didn’t work in Glasgow11 and we can now say with some confidence that the millions could have been better spent on ‘ordinary’ health visiting.
- The Family-Nurse Partnership is a structured quality-assured programme of support for first-time teenage mothers who book sufficiently early in pregnancy. Family nurses have a maximum caseload of 25 families, get regular supervision and support, and are able to offer complete continuity of care. What’s not to like about that? Given all the other bad things that had happened to the HV profession over the years, who wouldn’t want to retrain as a Family Nurse and be able to offer a high quality service to a manageable caseload? So, many HVs left the profession, causing further demoralisation.
What lessons should we learn?
None of these policies were intended to damage good quality preventive nursing care for children, but all did so to a greater or lesser extent. As a non-health visitor with a very strong admiration for the difficult work done by the profession, it seems to me that HVs proved to be their own worst enemy. In some areas there was a climate of fear; for example many HVs in Glasgow were afraid to speak out about the 2007 HV Review and it was in the end GPs who defended the profession most effectively. It may be that the end of the Health Visiting Association and the dispersal of allegiances between three representative organisations with much ‘bigger fish to fry’ may have contributed, but there may be deeper explanations rooted in the origins of the profession. The lack of senior HV academics, unafraid to speak the truth without fear of losing their funding may be another factor. The high-profile, diverse and inclusive Baby in the Bathwater campaign has proved a great boost to the HV profession but it’s about time that HVs gained a strong voice of their own.
Much of the damage could have been mitigated by a commitment to honest and robust evaluation. Had the impact of any of the policies been properly evaluated, we would have known much earlier that they weren’t working and damage could have been limited. It’s not good enough to put tiny amounts of funding into L’Oréal-style evaluations where 100 women are asked if their service is nice and some process evaluation is carried out. The Scottish evaluation of the Family-Nurse Partnership appeared to produce positive outcomes but we now know definitively from a huge and robustly designed UK trial12 that FNP is no better than ordinary health visiting. We should stop investing in pointless evaluations that don’t tell us whether policies are working or not. And we should immediately disinvest from FNP and divert the resources into the flexible ‘ordinary’ health visiting service.
So what next?
The health visiting service is in a better place now than it has been since the turn of the century. There are huge challenges in terms of restoring professional morale, training the whole workforce in child development science, providing administrative and IT support, professional supervision and quality assurance mechanisms.
Big changes are about to take place and we must put ourselves in a position to establish how well they have worked, and for whom, and in what settings. This means a commitment to serious evaluation, ideally using a stepped-wedge randomised controlled trial design13 focussed on child-based outcomes. It is only by producing hard evidence for the effectiveness of health visiting that we can secure its future and avoid the mistakes of the past.
- Hall DMB, Elliman D. Health for all children Fourth Edition. Oxford: OUP, 2003.
- Wright CM, Jeffrey SK, Ross MK, et al. Targeting health visitor care: lessons from Starting Well. Archives of Disease in Childhood 2009;94(1):23-27.
- Wilson P, McQuaige F, Thompson L, et al. Language Delay Is Not Predictable from Available Risk Factors. The ScientificWorld Journal 2013;2013:Article ID 947018, 8 pages.
- Sim F, O’Dowd J, Thompson L, et al. Language and social/emotional problems identified at a universal developmental assessment at 30months. BMC Pediatrics 2013;13(1):206.
- Thompson L, McConnachie A, Wilson P. A universal 30-month child health assessment focussed on social and emotional development. Journal of Nursing Education and Practice 2012;13(1):13-22.
- Wilson C, Thompson L, McConnachie A, et al. Matching parenting support needs to service provision in a universal 13-month child health surveillance visit. Child: Care, Health & Development 2012;38(5):665-74.
- Wilson P, Barbour R, Graham C, et al. Health visitors’ assessments of parent-child relationships: a focus group study. International Journal of Nursing Studies 2008;45(8):1137-47.
- Wilson P, Mullin A. Child neglect: what has it to do with general practice? British Journal of General Practice 2009;60:5-6
- Eisner M, Humphreys D, Wilson P, et al. Disclosure of financial conflicts of interests in interventions to improve child psychosocial health: A cross-sectional study. PLoS ONE 2015;in press.
- Wilson P, Rush R, Hussey S, et al. How evidence-based is an ‘evidence-based parenting program’? A PRISMA systematic review and meta-analysis of Triple P. BMC Medicine 2012;10(1):130.
- Marryat L, Thompson L, McGranachan M, et al. Parenting Support Framework Evaluation August 2009 to December 2013: FINAL REPORT http://www.gla.ac.uk/media/media_374977_en.pdf. Glasgow: University of Glasgow, 2014.
- Robling M, Bekkers M-J, Bell K, et al. Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. The Lancet 2015; published online http://dx.doi.org/10.1016/S0140-6736(15)00392-X
- Craig PD, P.; Macintyre, S.; Michie,S.; Nazareth,I.; Petticrew,M. Complex interventions guidance www.mrc.ac.uk/complexinterventionsguidance MRC, 2008.
All comments expressed above are the views of the author.