As the dust settles on the Baby P scandal and the child health strategy looks set to be finally unveiled, Helen Mooney puts the government’s pledges on the role of health visiting under scrutiny
In November 2008 we learnt that Baby P - a child who had been on the child Haringey Child Protection Register, had died after suffering more than 50 injuries. His mother, her partner and another man were convicted of involvement in his death.
While the Healthcare Commission investigates the health service’s position in the case of Baby P, questions will no doubt be asked about health visitor involvement and whether lack of staffing played a part.
Just two months before the case came to public attention, a Unite/Community Practitioners and Health Visitors’ Association survey of health visitors in England found that individual caseloads of more than 500 children were commonplace for 40% of health visitors and that one quarter of HVs feared that ‘another Victoria Climbi駠case could happen in their PCT.
Almost exactly a year before the government had officially acknowledged health visitor shortages in England. But Angela Mawle, chief executive of the UK Public Health Association, says the picture has become even bleaker. The 500-children caseload figure is now seen as low in some areas, she said. ‘There are many places especially in London and the South East with 800-1,200 pre-school children to one health visitor,’ she warned.
She also said that a lack of numbers was forcing some PCTs to implement ‘emergency cover’. ‘This includes Saturday clinics to which new mothers are being invited because there are too few health visitors to visit them at home and in some places staff nurses are being substituted for health visitors to carry out new baby visits,’ she said. ‘The unseen child and family is always the highest risk, there is no way of predicting what will be found when visited, which is why this form of substitution is not safe practice,’ she added.
Latest figures also suggest that, while recruitment is a problem, PCTs are failing to fund posts in vulnerable areas. As of last week, there were 131 health visitor vacancies on the NHS jobs website but only 25 were within 20 miles of London, which is particularly struggling with heavy caseloads.
The most up-to-date statistics on HV numbers from the NHS Information Centre refer to 2007. Despite the paucity of official data and the severity of the situation in some areas, however, even if that information were available, it would not necessarily reach those who most need it.
For example, Briony Ladbury, NHS London lead for safeguarding children, told Nursing Times that she did not hold information on health visitors for London. ‘As safeguarding lead, I don’t immediately link into the statistics of provider agencies,’ she said.
Since 1997, the year in which the Labour government came to power, the number of health visitors has steadily declined. Over the last decade to 2007 numbers have dropped from 12,410 to 11,569 - lower than the 1997 baseline figure. The number of whole-time equivalent health visitors is even lower. In 1997 the figure stood at 10,025. By 2007 this had dropped to 9,056. According to Unite/CPHVA this represents a health visiting job lost every 27 hours.
Nursing Times has collated the latest available data on health visitor numbers to build up a geographical picture of where they are most under pressure. According to a Freedom of Information request by the Family and Planning Institute in 2007, six of the top 10 PCTs in England with the fewest health visitors per child under five are in or on the edge of London.
At the time, HVs in Redbridge PCT, now NHS Redbridge, had the heaviest caseloads with more than 1,000 children under five each - 10 times higher than Doncaster PCT - while those in Enfield and Sutton and Merton all had caseloads over 600, and those in Hackney, Camden and Newham far more than 500.
Redbridge told Nursing Times that it has managed to get its caseloads down but the average is still 650. A spokesperson said: ‘We recognise that there is a pan London recruitment issue.’
Another hotspot is Coventry. Both Warwickshire PCT and Coventry PCT appear in the institute’s top 10 with caseloads of 720 and 597, respectively. But this is disputed by Jane Williams head of children, young people and families at Wawickshire PCT. ‘The figures for South Warwickshire PCT were applied to Warwickshire PCT incorrectly as the PCTs had just merged.
The most up-to-date figures which are correct at this time are 408 children under five per health visitor,’ she said. This dataset does not include 10 PCTs, which failed to provide figures, including two more in London - Barnet and Hounslow PCTs - and two in Essex.
Hounslow PCT is one of five examples cited by Unite/CPHVA as where children are at increased risk of poor health because of a slump in HV numbers. According to the union, the number of whole-time equivalent health visitors there had fallen from 37 in 2001 to 18 in 2007.
More anecdotal evidence from Unite/CPHVA appears to tie in with the institute’s league table. It has issued warnings about health visitor numbers in Enfield, Barking and Dagenham, and Waltham Forest.
One anomaly is the health visitor service in Peterborough, which does not appear in the league table but which the union said was ‘heading towards disaster’ last year. Further regional analysis of latest NHS workforce figures by Nursing Times shows that strategic health authorities in the North West and East of England have reported drops in whole-time equivalent health visitor numbers of more than a 100 between 2005 and 2007 (Click here for a map detailing the changes in WTE health visitor numbers 2005-2007).
Only one SHA, NHS West Midlands, reported an increase in health visitor numbers over the period. So why exactly is the crisis in health visiting still being ignored? There seemed much to be positive about in the government’s long-awaited review of the role of the profession and its radical proposals.
Facing the Future, published in June 2007, recognised the highly skilled work of health visitors. It called for them to head up multi-skilled teams and to focus on the most complex cases and vulnerable children - leaving general nurses and nursery nurses to carry out the more straightforward elements of the job.
The review appeared to acknowledge the need for early intervention in families and, specifically, the specialist skills of health visitors in leading a preventative strategy. These sentiments were echoed in September that year by health secretary Alan Johnson in his speech to the Labour Party conference. ‘We need more specialist nurses and health visitors to tackle public health issues in deprived communities,’ he stated.
Conservative leader David Cameron went much further in March 2008 when he said: ‘Health visitors are the kind of support that parents want’, and pledged to double their numbers.
So to what extent is child health and safety being put at risk by the erosion of health visitor numbers? Viv Bennett, deputy chief nursing officer for England, cited Facing the Future, the child health protection programme and other initiatives such as Sure Start as confirming the government’s commitment to child safety.
‘The health secretary has stated that we will need to increase the number of health visitors to deliver the key roles for health visitors as set out in the child health protection programme and detailed in the document Facing the Future,’ she said.
A Department of Health spokesperson also told Nursing Times that the DH was currently working with strategic health authorities on a ‘workforce model’ intended to help PCTs as commissioners and service providers estimate the number of health visitors they will need in future.
However, Ms Bennett added that health visitors must be ready to change the way they work to meet emerging health needs. ‘Many health visitors have already identified new and innovative ways of working with local communities to address local health problems. These include working in and leading teams with other health and child care professionals,’ she said.
Such changes, however, may be difficult for a profession that appears to be caught in a vicious cycle of low numbers, poor morale and recruitment and retention problems - a cycle that cannot have been helped by health minister Lord Darzi’s apparent lack of awareness of health visitors’ concerns. As reported by Nursing Times, Lord Darzi was surprised to hear of the health visitor workforce shortage in a private meeting of Labour Party backbenchers last April.
One health visitor who wished to remain anonymous said HVs were ‘no longer able to deliver a proper holistic service’. She said that they now had to ‘firefight’ and prioritise high-risk cases. ‘I think the government’s child health promotion programme is great but in my area the PCT will not allocate extra money to fund it so it’s not going to happen - central government should not be saying that this has to be delivered out of a local pot of money.’
In addition, cases such as Baby P may be compounding recruitment and retention issues. Cheryll Adams, lead professional officer at Unite/CPHVA, said: ‘Many health visitors are telling us that they are leaving the profession, or moving to better staffed areas, as they can’t tolerate the level of risk they are expected to be responsible for.’
This week Nursing Times understands the government is set to publish its delayed child health strategy. As the magazine went to press, the DH was unable to confirm whether health visitors would be mentioned in the strategy. Such an omission would surely put the government’s commitment to child protection into question.
As Ms Mawle said: ‘The birth rate is rising, the number of children with complex and special needs is rising and there is increasing recognition of the public health implications of child maltreatment and threats to health are rising with the ‘credit crunch’ and increasing unemployment.’
Related article: Darzi oblivious to health visitor cuts