All families with young children should get an extra health visitor check at age three, according to an influential group of MPs who have called for a major refresh of public health services for under fives.
It also highlights the importance of extra support for the most vulnerable families through initiatives like the Family Nurse Partnership scheme, which has been wound down in many parts of the country.
In addition, it emphasises the need to address staffing shortages, highlighting concerns that dwindling health visitor numbers and unmanageable caseloads meaning many families are not getting the support they need at a crucial time in their child’s development.
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The recommendations come in a report, published today by the Commons’ Health and Social Care Select Committee, which looks at the first 1,000 days of life.
Under the Healthy Child Programme, which became the responsibility of local councils in 2015, all families in England are entitled to five visits from health visitors.
However, the committee heard this often did not happen with wide variation in all aspects of the programme across the country, including in the percentage of statutory health visitor checks completed.
According to the Institute of Health Visiting nearly two thirds – 65% – of families do not get a formal visit from a health visitor at all, after their baby is aged six to eight weeks and may instead see early years workers with less training in identifying potential problems.
“Government must now show inspiring leadership to help children get the best start in life”
Even when checks or “contacts” are recorded as having taken place, this may mean a family simply got a letter instead of a visit in person, the committee heard.
Other concerns about current delivery of the programme include the fact many health visitors are struggling with caseloads that exceeded the 250 children per health visitor recommended by the Institute of Health Visiting.
“While we have not seen strong evidence for a particular ratio, there has been consensus from the evidence we have heard during the inquiry that there are currently too few health visitors, and many have too many families on their caseload,” said the report.
According to the report, the first priority should be ensuring all families actually get the five mandatory checks. These should be carried out by health visitors with a minimum number involving a home visit, said the document titled – First 1000 Days of Life.
Meanwhile, it called for the programme to be extended to offer a further health visitor check at age three to three-and-a-half to ensure children are on course to reach the level of development needed to start school.
Currently, the last mandated visit by a health visitor occurs at age two to two-and-a-half and involves a review of a child’s development.
But in some areas an additional visit is carried out about a year later to assess children’s school readiness, helping identify those who may need extra help at this crucial stage.
The committee said an extra mandatory visit at this age should be available to all, pointing out that families in other UK nations get a higher number of mandated visits.
In Northern Ireland there are currently seven checks but there are plans to increase that to nine. In Wales families get nine reviews while in Scotland there are 11.
“All we are seeing are cuts to health visiting, children’s centres and increasing child poverty”
Both Scotland and Wales specify which reviews must be carried out by a qualified health visitor rather than another team member.
Overall, the committee highlighted the need for a complete refresh of the Healthy Child Programme in England, with a greater emphasis on the wellbeing of the whole family.
“All health professionals, and particularly health visitors, need to understand a child’s health and development in the context of the family environment,” said the report.
Meanwhile, support for families should start before women conceive, the committee concluded with help for parents planning a pregnancy including those who may have struggled first time round.
This work should begin at school with a focus on healthy relationships and pregnancies, including advice about smoking, alcohol and substance misuse and parenting.
The report also emphasised the importance of continuity of care and says the revised Healthy Child Programme should feature an explicit goal to try and ensure families see the same midwife and health visitor at each appointment or visit.
When it came to the most vulnerable families, the report highlighted the need for targeted, intensive support provided through services like the Parent Infant Partnership scheme, which provides specialist infant mental health services, and the Family Nurse Partnership programme.
The committee heard families across the country – including those affected by mental health issues like postnatal depression – currently face a “postcode lottery” for this kind of specialist help.
While Family Nurse Partnership schemes, which see vulnerable first-time mums supported by specially trained nurses and midwives, are being rolled out and extended in other UK countries, many have been shut down in England due to an apparent lack of evidence that they made a real difference.
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At its peak in 2016, the Family Nurse Partnership programme was delivered in 132 local authority areas in England but is now believed to operate in just 77.
A government-commissioned trial of the partnership programme found no evidence of a positive impact on key goals including reducing smoking, second pregnancies and visits to A&E.
However, the health and social care committee report states that the interpretation of these findings “has been widely questioned”, with organisations like the Early Intervention Foundation concluding there is evidence of long-term positive impact on children’s outcomes.
The Family Nurse Partnership programme is currently undertaking a new piece of work designed to build on the learning from the trial and make improvements.
A previous inquiry the Science and Technology Committee concluded commissioners should await the results of this initiative before deciding to withdraw funding – a stance supported by this latest investigation.
“Staffing shortages impact heavily on the time midwives have to spend with women and their families”
The health and social care committee said it wanted to see government working with local areas and the voluntary sector to develop a programme that children and families who need targeted support could be referred to drawing on the experience of Family Nurse Partnership schemes in Scotland, Northern Ireland and parts of England and the Flying Start scheme in Wales.
It said commissioners should continue to look at the evidence for Family Nurse Partnership and other early intervention schemes “and consider investment or disinvestment accordingly”.
The committee went on to emphasise the importance of having people with the right knowledge, skills and experience to work with parents and children.
However, it said staffing shortfalls across universal, targeted and specialist services were getting in the way of providing high quality support to families.
“Shortfalls across universal services, particularly health visitors, midwives and GPs have drastically cut the time professionals spend with parents and families,” said the report.
Figures from the Institute of Health Visiting suggest the number of health visitor employed by the NHS has fallen since 2015 from just over 10,000 to just under 8,000 as of April 2018 – although this does not include those working for non-NHS providers.
In addition, the committee heard that specialist roles – such as midwives and health visitors specialising in perinatal mental health – did not exist in many areas.
“A shortage of specialist skills means that some specialist services are not commissioned locally, which in turn acts as a disincentive for professionals to specialise,” said the report.
It stressed qualified professionals “should not be substituted for low-skilled staff”. However, it said a broad skills mix – that can include deploying volunteer peer mentors – can enhance local provision.
“The government must take this report seriously or we will continue to fail to give children the best start in life”
Crucially, it said it was vital to involve staff in shaping services such as in Blackpool’s Big Lottery funded Better Start scheme, which was visited by the committee.
Investment in early intervention services had “helped create headroom for staff, such as health visitors, to engage in transforming the way services are delivered locally”, said the report.
“For example, local health visitors were actively engaged in the changes which has led to Blackpool offering three additional visits on top of the five mandated ones,” it added,
However, the report acknowledged “engaging staff in transformation is difficult”.
“Workforce shortages and rising demand mean that staff are under pressure to implement service changes while maintaining business as usual,” it said.
The committee called on the government to come up with a long-term, cross-government strategy for the first 1,000 days of life, with councils, NHS and voluntary services working together to implement that strategy locally.
It also said the government should publish “a holistic workforce plan”, setting out how the government and national bodies will support areas “to enhance the capacity, capability and skill mix of staff including voluntary staff”.
Dr Paul Williams, Labour MP for Stockton South and a practising GP who led the committee for the inquiry, said it was clear there was a need to invest in early support services.
“But all we are seeing are cuts to health visiting, children’s centres and increasing child poverty,” he added.
“Government must now show inspiring leadership to help children get the best start in life,” said Dr Williams.
“If our country is serious about prevention and reducing health inequalities then we must make massive investment and drive co-ordinated action right at the start of life,” he said.
The report has been welcomed by health and early years bodies.
The Royal College of Midwives said it was especially pleased with the emphasis on the continuity of carer.
“Evidence shows us that continuity of carer works. It works for women and it enables midwives and their maternity colleagues to deliver safer care,” said RCM chief executive and general secretary Gill Walton.
“We are pleased that as part of a refresh of the Healthy Child Programme that there is a commitment that those families will see the same midwife and the same health visitor for their appointments,” she said.
She noted that the report also highlighted the damaging impact of shortages of midwives and other staff, including specialists in perinatal mental health.
“Staffing shortages impact heavily on the time midwives have to spend with women and their families and this in turn impacts on their ability to provide the quality of public health advice and support which would particularly benefit vulnerable and at risk families,” she said.
“Therefore, the RCM cannot stress enough how important is that we have the right levels of staff, in the right places to deliver safe, high quality maternity care,” she added.
The Nuffield Trust think-tank described the report as “a step in the right direction”.
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“The government must take this report seriously or we will continue to fail to give children the best start in life, with consequences that will haunt them and our public services for years to come,” said chief executive Nigel Edwards.
Jo Casebourne, chief executive of the Early Intervention Foundation, said the committee had “made a series of sound and welcome recommendations”.
“Over recent months, we have seen two select committees making the case for increased coordination and investment in an early intervention approach to supporting children’s life chances,” she said.
She added: “There is clearly mounting pressure on the government to provide the leadership required at the national level, and the upcoming comprehensive spending review provides the ideal opportunity to recalibrate its approach.”
Ms Casebourne said there was a need for a 25-year plan “to put the issue of children’s wellbeing and livelihoods on the same policy footing as other crucial long-term issues like housing and the environment”.
A Department of Health and Social Care spokeswoman said: “Children’s health is a key priority for this government and we want every child to have the best start in life.
“The NHS Long Term Plan has committed to make the NHS one of the best places in the world to give birth and expand provision of quality mental health support for new and expectant mothers and their families,” she said.
She added: “The health secretary has also set out his prevention vision, supporting good health and support for families to stop problems developing in the first place.”