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Council plans to radically shake-up of public health nursing roles across Cumbria

  • 5 Comments

Cumbria County Council has outlined plans for radical changes to children’s public health services, which would reduce the number of health visitors, scrap the traditional school nursing service and shut down the family nurse partnership scheme.

The authority hopes to save a total of £900,000 this year and next by redesigning key health services for children and young people from birth to 19 and combining them with other early intervention work.

“[These are] devastating proposals for children and young people’s outcomes”

Sharon White

Those behind the plans say they will mean a more streamlined and effective service for children and families, as well as making savings.

However, critics warn the changes could have a “devastating” impact on children’s welfare and on hard-pressed health professionals.

Health visiting and other expert nursing services are currently delivered by Cumbria Partnership NHS Foundation Trust, which would continue to do so under a new contract to start in April next year.

The first phase of the radical service redesign would involve reducing the number of health visitors in 2017-18 and increasing caseloads, council papers show.

There are currently about 80 health visitors who deliver standard health checks across the county supported by three clinical practice tutors.

Cumbria County Council

Cumbria plans radical shake-up of public health nurse roles

Source: PawełS

Cumbria

Under the plans, this would reduce to 71 health visitors with caseloads increasing from 250 to 340 – exceeding national guidelines recommending a caseload of around 300. Meanwhile, three health visitors/clinical practice tutors would handle caseloads of 150.

Instead of getting five core health checks, young children may just get four with health visitors no longer seeing them at 2.5 years and there would be fewer health visitor clinics with the priority being children aged up to one.

The local authority report – from Colin Cox, the council’s assistant director for health, care and community services – warned that reduced health visitor contact with families “increases the risk of issues and concerns not being recognised and identified a timely way”.

However, a new safeguarding team would take on the more complex cases and less contact with health visitors would be balanced with greater support from other early help services, it said.

But it also goes on to caution that job cuts and increased workloads could affect staff morale and make it harder to recruit nurses.

The proposals would also involve scrapping the family nurse partnership scheme – currently delivered by six specialist health visitors.

Instead, the six nurses would move into new specialist safeguarding roles in multi-agency teams to “provide expert supervision and training”.

The papers show the family nurse partnership scheme in Cumbria has not always met targets for reaching vulnerable families.

“The aim is to work with 150 families county-wide, however, the average number routinely being worked with is 90,” stated the document. “This makes the cost per client very high”

“There needs to be a bold redesign of service provisions that puts children and families at the heart of multi-disciplinary teams”

Colin Cox

The council would need to ensure “transition plans” were in place for families currently getting support if the programme is decommissioned, it added.

The proposals also advocate the decommissioning of the traditional school nursing service in favour of a new service delivered by “school-aged health co-ordinators”.

The current school nursing service is provided by 11 full-time equivalent school nurses with a number of staff working part-time and term-time only.

The report said the current set-up was “not sustainable” and the service was “significantly under-resourced, therefore ineffective”.

“Our school nurses work hard to deliver an excellent service. However, due to this limited capacity the service struggles to deliver fully either on the individual care for children that schools would like or on the public health role they could be playing,” said the report.

The new service would mean less face-to-face interaction between nurses and children, with the development of web and text-based communication.

Six clinical school-aged co-ordinators would be based in the county council’s children’s services to do wider children’s health improvement work across groups of schools and in other sectors.

Cumbria County Council

Cumbria plans radical shake-up of public health nurse roles

Colin Cox

The report acknowledged there were potential risks to children’s health if schools could not access expert advice from nurses and fewer direct assessments of children are carried out.

In response, Sharon White, professional officer for the School and Public Health Nurses Association, described the proposals as “nothing short of a devastating”.

The plans were “devastating proposals for children and young people’s outcomes, school nursing, health visitors and the family nurse partnership in Cumbria”, she said on the social media site Twitter.

However, the council board report said the new model had been shaped through consultation with staff, parents and young people, as well as discussion with service providers.

A second phase due to be implemented in 2019 would involve even greater integration of services, it noted.

“If Cumbria County Council aims to achieve a fully integrated approach to early help services, there needs to be a bold redesign of service provisions that puts children and families at the heart of multi-disciplinary teams that can fully identify and respond to a range of needs and help children and families achieve their full potential,” said the report.

“This means the removal of organisational boundaries and a move towards integrated teams with shared line management, consisting of health visitors, social workers, early help practitioners and targeted youth workers and others,” it said.

The current plans are due to be considered by the county council’s cabinet at a meeting on 20 October.

School and Public Health Nurses Association/SAPHNA

Cumbria plans radical shake-up of public health nurse roles

Sharon White

Nursing Times asked the council for further comment on the plans, but it was unable to respond in time before publication. However, a response is expected in due course.

The council said it was unable to tell Nursing Times whether the proposals would mean the loss of nursing posts.

Nursing Times also asked the council for further clarification on the plans, including its proposals for increasing health visitor caseloads, stopping the family nurse partnership and new school roles (see box below for full responses).

Central to the future provision of the reshaped health visiting and family nurse services was the creation of a new specialist team to support vulnerable families, suggested a council spokesman.

It would pick up both some of the staff and also some of the families currently involved with the family nurse partnership service, he said.

He acknowledged that caseloads for health visitors providing universal support would increase, but the numbers of vulnerable families they worked with would decrease under the plans.

Nursing Times asked Cumbria County Council a series of further questions on its plans

NT: Will nurses/health visitors be made redundant?

CCC: This is question for the current provider of the service.

NT: The plans will mean significantly increased caseloads for specialist health visitors, health visitors and clinical practice tutors? How will you ensure staff can cope with increased caseloads?

CCC: The proposals include the development of a ‘Strengthening Families’ team, who would support Cumbria’s most vulnerable families. Specialist health visitors will be part of this team and have much lower caseloads than health visitors providing universal support. Caseloads for health visitors providing universal support will increase, but this is deemed acceptable, because the numbers of vulnerable families they work with will decrease (as this support will be provided by the Strengthening Families team).

NT: How will you ensure the welfare of vulnerable families currently involved in the Family Nurse Partnership scheme?

CCC: We have been working very closely with the current provider of FNP to support clients to leave the programme in a safe and positive way, whatever stage of the programme they have reached. The provider has used a Risk and Vulnerability Tool to risk assess each individual client, and to refer to the most appropriate existing service according to need. However, many of the clients will be picked up through the new Strengthening Families team and the nurses who have previously delivered FNP will form a crucial part of that team. Therefore, some clients may continue to work with the same nurse. This work follows guidance from the National FNP Unit.

NT: How will the new clinical school-aged co-ordinator scheme work and how will the council ensure school age children’s health needs are identified and met with far less face-to-face contact with school nurses?

CCC: These new roles have been designed to encompass a more strategic public health approach, with a focus on prevention and early intervention. We have not yet defined the detail of these posts, because we have agreed to co-produce the service with existing nurses and managers, this is expected to take place in the next few months. School aged children’s health needs will be identified through a partnership approach with schools, and families underpinned by our Joint Strategic Needs Assessment. Through our JSNA we know the priorities for our school age children are emotional resilience and healthy weight and this team will be a particular focus for the work of this team.

NT: How has the current workforce reacted to the plans and how much consultation has there been with nurses and health visitors?

CCC: A series of briefings with nursing staff have taken place during August and September 2016. These briefing were used to outline the proposed changes to staff and comments were invited and were delivered jointly between ourselves and the provider. We have been careful not to define the detail of how the new services will work and have invited staff to help shape this, via a series of Design workshops which will take place over the coming months (Dec 2016 – Feb 2017).

The design workshops will provide the opportunity to explore feedback from staff and ensure their views influence how the services are further developed.

  • 5 Comments

Readers' comments (5)

  • michael stone

    Just a 'general' comment.

    'Those behind the plans say they will mean a more streamlined and effective service for children and families, as well as making savings.'

    Well, they almost always do - at the time the money is saved, rarely do the people saving the money say 'the service might be worse': that is more often admitted a decade or two later, when problems have resulted and somebody is changing things again.

    I can't comment on whether I think in this case, they will be able to save money and not damage the service provision (not an area I know anything about) - but as a cynic, 'fingers crossed'.

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  • Cumbria will see its ring fenced public health budget from the Department of Health reduce by nearly a million pounds a year over the next two years. It already receives one of the smallest allocations in the country. Frontline staff work hard to deliver services across a large rural area.

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  • Natalie Jewell

    The irony of changing from five health visitor checks to four - we all know early intervention is critical. This is just saving up problems for the school nursing age. Oh wait - they are reducing the scope of that service too.

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  • The responsibility for Public Health, in Wales, has not been devolved to Local Authorities. I thought that this was a missed opportunity, because I could see the benefit of inegrating the Community Protection functions of Local Councils, with what were the formerly, NHS Public Health arrangements. The same goes, for example, with Health Visiting with Child Social work.

    Well run, single management structures reduce duplication, in nearly every respect and improve communication, offering the benefit both of efficiencies and improved outcomes for service users.

    These proposed Cumbria County Council service changes seem to reflect these ideas about integrated working; but in the Q&A above, comparative Outcome Audit planning was not discussed; also I'm not clear whether the money "from Health" has been reduced by the NHS, or if it is being invested, by the Council, into a different design of a service, aimed at the client group currently being served.

    Change is a permanent fact of professional life; and practitioners and local managers should not protect the status quo, for its own sake. So often though, proposals and plans for change aren't backed by a reasoned hypothessis or published evidence; nor are the effects of significant and very disrupting organisational change, sytematically audited and reported, as part of Public Health and Local Government reporting.

    An evidenced hypothesis should form part of this consultation process. So often, this is not the case.

    One thing, though, that my instinct/experience and some evidence seems to support (because the reliability and availability of Change evidence is so poor) is that we reduce the amount face-to-face family contact with Fully Qualified Health Visitors, at our peril. This might be the same with School Nurses. If this instinct/experience based assumption is correct, I hope that we don't discover this, in the time-served, sad. way... Such an outcome would also damage Local Authority run Public Health services.

    I hope, in due course, it turns out that I'm wrong, and that my instincts, therefore are/were incorrect; and this proposed new arrangement turns out to provide audit-based evidence, good enough to provide a blue print for more effective protection and care for, and within, young families.

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  • The responsibility for Public Health, in Wales, has not been devolved to Local Authorities. I think that this was a missed opportunity, because I can see the benefit, for example, of integrating the Community Protection functions of Local Councils, with some of what were the formerly, NHS Public Health arrangements. The same goes, for example, with Health Visiting and Child Social work.

    Well run, single management structures reduce duplication, in nearly every respect and improve communication, offering the benefit both of efficiencies and improved outcomes for service users.

    These proposed Cumbria County Council service changes seem to reflect these ideas about integrated working; but in the Interview Questions, above, comparative Outcome Audit planning was not sufficiently discussed; also I'm not clear whether the annual money "from Health" has been reduced by the NHS, or if it remains the same and is being invested, by the Council, into a different design of a service,but for the same client group.

    Change is a permanent fact of professional life; and practitioners and local managers should not protect the status quo, for its own sake.

    So often though, proposals and plans for change aren't backed by a reasoned hypothesis or published evidence; nor are the effects of significant and very disrupting organisational change sytematically audited and reported, as part of Public Health and Local Government reporting.

    A detailed, summarised and evidenced hypothesis should form part of every consultation processes. So often, this is not the case.

    One thing, though, that my instinct/experience and some evidence seems to support (because the reliability and availability of Change evidence is so poor) is that we reduce the amount face-to-face family contact with experienced Health Visitors and Social Workers, at our peril; and practitioner competences in the two professions, whilst overlappping, are not completely interchangeable. In other words, until new and realistic hybrid practitioner training evolves, enough workers from both professions are required. The need for continued face-to-face activity, with children, might be the same for School Nurses.

    If this instinct/experience based assumption of mine is correct, I hope that it's not discovered in the now time-served, sad. way...Poor outcomes will also damage Local Authority run Public Health services.

    I hope, in due course, that it turns out that I'm wrong; that my instincts, therefore are/were incorrect; and that this proposed new arrangement turns out, eventually, to provide audit-based evidence, good enough for these proposals to become a blue print for more effective and value-for-money protection and care of the children in our UK communities.

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