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Practice comment

Using general nurses to fill health visitor gaps puts children at risk


As health visiting suffers a recruitment crisis, unprepared staff are being asked to work with vulnerable families. This raises child welfare concerns, say Yvonne Crome and Val Thurtle 

While the public sector prepares for severe financial constraints, the health visiting service is already at a low point. Cutbacks in resources, poor workforce planning and insufficient recruitment to educational programmes mean that in many areas practitioners cannot provide the service needed.

But it is not morally acceptable for those of us working as health visitors and educators to allow continual plugging of gaps in the service by staff inadequately prepared for their role.

Health visitors are highly skilled and trained to provide a public health service, with an emphasis on prevention. The Laming Inquiry into the death of Victoria Climbié emphasised how important health visitors are to protect children. The emphasis was on highly trained, skilled professionals, not nurses without any further training.

While there is concern about child maltreatment, there are also claims that many children are starting school with a range of undiagnosed developmental problems. Early intervention and preventing child maltreatment from poor parenting is vital to improve children’s outcomes in later life. The loss of dedicated health visitors is linked to a marked rise in mental health problems in children.

At a time when there are concerns about child health, the number of qualified health visitors is at its lowest ebb, with a drop of nearly 13% in whole time equivalents since 1998. The DH recognises the need for more qualified health visitors but action is slow to follow. Health visitor vacancies continue to be filled with nurses and nursery nurses, a source of particular concern for safeguarding children.

Skill mix does have its place within health visiting teams; nursery nurses have expertise in child management and mental health nurses’ skills are often beneficial. Nonetheless, workers coming into a health visiting team should be appropriately educated and prepared.

Nurse education does not prepare newly qualified nurses for preventive child and family public health work. Community staff nurses and nursery nurses are not currently prepared to work with children and their families to promote resilience and positive health. To expect them to work with extremely vulnerable families, deal with child and family mental health problems and child abuse in an over-stretched service is an experiment with people’s lives that we cannot afford.

The loss of dedicated health visitors is linked to a marked rise in mental health problems in children

All staff in health visitor teams should be systematically prepared through suitable educational programmes so they share the ethos of prevention and health promotion as well as partnership and community development.

If the government is committed to ensuring that “every child matters” then it must demonstrate its commitment to health visiting. The DH should make it a priority to ensure that strategic health authorities have enough qualified health visitors. There is also a need for a clear strategy for educating health visitors.  

As Nursing and Midwifery Council registered practitioners we are accountable for actions and omissions in our practice; in health visiting this is currently questionable. Hence we feel the need to speak out. The NMC must recognise that health visiting is a unique occupational group and that nursing skills are not automatically transferable. It needs to consider whether having a mix of staff unprepared in family public health protects the public.

The health visiting service is being delivered by staff who are inappropriately prepared, or barely delivered at all. This leads to inequality, something health visiting, public health and this government has sought to address. It is now time for action before the demise of the service is permanent and we can only look back and reflect on what has been lost.

AUTHORS Yvonne Crome and Val Thurtle are senior lecturers at Anglia Ruskin University and the University of Greenwich respectively, and members of the United Kingdom Standing Conference on Public Health Nurse Education


Readers' comments (16)

  • I totally agree with this article, as a health visitor myself I am disgusted that our priority is now paperwork! meaning that precious time is spent on proving we are worth the money when we could be out there delivering the services. As a consequence a number of health visitors are considering leaving the profession or moving to areas where paperwork is not yet the top of the list in priorities. We were technically demoted with Agenda for Change (one of the worse thing to happen to nursing, I know of very few people that did well out of this), unless they increse the level of pay and reward health visitors for the work in child protection that we do, health visited will move back, or out to other sectors. I heard of many vacancies that have Never been filled due to the lack of potential candidates (apart that is from people without the proper qualifications, as all we do is weigh babies!) Train more, over the last number of years there has been a reduction in training places for health visitors at a time when a large number are do to retire.

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  • I am an A and E nurse and I absolutely agree with your statement. I would also like to think that when i have children that it will be someone visting me with the appropriate training and qualifications! As for paper work being top list of priorites this appears to be across every area of nursing! If we only had enough time to deliver the highest level of care and fill in the copious number of forms we had to it would be wonderful but we dont!!!

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  • I am a health visitor and I agree with the above. The service we give now is a shadow of what it used to be. More abuse will go unrecognised due to the paucity of contacts, more children will arrive at school with developmental problems. Agenda for Change was demotion for health visitors. The provider / commissioner split as seen us spend hours working on service level agreements where all that is required is 'what is the minimum contact'. Due to the loss of Trust properties with the provider commissioner split some health visitors are without a proper base, or without a clinic room or health education room. Health Visiting has been treated appallingly by the government and by the PCTs, this shortsightedness can only be described as ignorance.

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  • I too am an experienced health visitor, and totally agree with the other comments. Whilst nursery nurses do a sterling job there is no way that their being allowed to do ALL the developmental assessments as in my area, provides an holistic encounter with the parent and child. Inevitably things will be missed due to the lack of the specialist practitoner actually doing the assessment. We have also had to deal with being seconded and then TUPED over to our local council. As a result morale is at an all time low, those colleagues who were able have voted with their feet and very experienced health vistors are now describing themselves as ' council box tickers'. So severe is the workplace stress that I personally am having to retire before I feel ready to so. I've years of experience to offer and love the job but when one is made to feel utterly worthless professsionally what's the point of struggling on?

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  • What about the US model of the primary paediatric nurse practitioner and child/adolescent psychiatric clinical nurse specialist both with post-graduate degrees?? These work wonderfully - so why on earth isn't the UK utilising them??

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  • I agree. The continuous dumbing down of the HV profession by management - some - who I may add - were once HVs is, quite frankly, appalling. We have some excellent Nursery Nurses where I work - but their role should be to complement HVs not instead of! I am afraid, the Health Visiting service is being decimated up and down the country, with so few home visits now allowed, that the home environment is not seen and a true assesment cannot be made. The number of developmental assesments has been reduced - see the Governments "Healthy Child Programme" - they have some responsibility here - that there is no wonder children are starting school without the basic skills to start their education.
    The commissioners need to take the time to find out about the HV roile as they are the ones commissioning these appalling decimated services, and demand from the providers a better service - BUT, they need to put the finances into the servcie too.
    I am in a position now where I feel embarrassed about the service we are "allowed" to offer, whereas I used to be proud of my job. I feel there is a lack of respect for the profession - no wonder the public thinks all we do is weigh babies - basically that is all the middle class articulate people get to see when they attend clinics and those who get an enhanced service are usually the ones who hide from you as they think you are there to take thier children away.
    What has happened to the principles of health visiting - the search for health needs - pah. The public health work has been totally eroded and the work is now reactive rater than proactive.
    In teh words of Sister Plume - although I am not that old ....." the welfare of our patients is at stake!"

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  • I do not agree with the above. This a dilemma for nursing been an all female profession. The cuts in nursing had always been a gender issue. Likewise where were the leaders in health visiting when things began going pear shape. I realised colleagues do not like rocking the boat and if you do you are the scape goat. Look at Claire Short (MP) and how she was cut off from speaking about her fundamental beliefs about the war, this is no different in nursing or health visiting. Unless we have appropriately trained leaders in health visiting or nursing who are ready to put their fundamental beliefs forward like Florence Nightingalewe can not go far. I think health visitors should start thinking outside the box. Things are not going to go back to the bread and butter health visiting days perharps health visitors should break out as a social entrepreneur themselves as oppossed to been an emploeee just like GP contaractors who safeguard themselves and did not sign up to be NHS emploeees their leaders had insights and forsights in those era and did not go with the crowd.

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  • Maryam Omitogun

    I did not see anything wrong in General Nurses taking up the health visitors role. There is nothing new to learn from health visiting if you are an experienced general nurse. The only important training in health visitijg programme is safe guarding children which I think a short course is enough for a registered nurse to cope with the work.
    To work as an health visitor one need to have excellent communication skills, must know about nutrition and have interest in working with children and families.
    The nursery nurses has taken over most of the job of health visitirs that was why they waste most of their time writing paper work and this has made them to forget most of their role as a nurse.
    All health visitors are nurses and any General Nurse trained can even perform more on this role than trained health visitors.
    Health visitors training should be cancelled and allow Registered General Nurses that have interest working with children and families take up this post.
    Spending a whole year going for a training of all what has been taught as general nurse is a financial waste and time.
    Genearal nurses working in this area should be encouraged and should be placed on the same band as the health visitors.

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  • I agree that only HVs should be visiting and caring for vulnerable families. I also agree that extra training is required and I am currently on the PGdip.
    However, from a personal perspective I know numerous children who were not picked up by their health visitor as having developmental delays and yet it was obvious to me as a childcare provider delivering the EYFS and it was myself and colleagues who alerted the health visitor to these concerns.
    I feel the problem lies not with using nursery nurses, who are extremely aware of developmental issues, but more with the abolishment of the 3.5yr developmental review. Unfortunately it is many of the most vulnerable children who do not access early years provision and therefore are missed.
    The other issue is the lack of suitable practice teachers due to the suspension in training for so long. Many PCTs and educational establishments have funding and spaces on courses but nobody to oversee practice.

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  • Sorry but if you do a good health needs assessment and feel more visits are required you act accordingly. It is a PROGRESSIVE universal service. I would recommend some people reread the healthy child programme, health visiting matters and other more recent government papers. There is no restriction on visits if they are warranted!

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