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Gaining evidence on the value of health visiting

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Health visitors are crucial to establishing the foundations for a healthy child. This value needs to be gathered through evaluation and monitoring


Health visitors are leading the development of the Healthy Child Programme (HCP). Indicators of effective delivery of the programme include parental satisfaction and public health outcomes such as breastfeeding. Proxy measures include delivery of universal HCP assessments.

Citation: Fuller S (2014) Gaining evidence on the value of health visiting. Nursing Times; 110: 48, 20-21.

Author: Sabrina Fuller is head of health improvement, NHS England.


Pregnancy and infancy are recognised as crucial periods for child development, but parental influences extend well beyond the early months of a child’s life. A growing body of research suggests good parenting skills and a supportive home learning environment are positively associated with children’s early achievements and wellbeing. Interventions to improve the quality of home/family life have long-term benefits including greater social mobility (Economic and Social Research Council, 2012).

Parents want the best for their children, but do not always realise the full impact of their role on their children’s future. For the NHS and commissioners of health services, the desired outcomes for children are good physical, social and emotional wellbeing, now and in the future.

Local authorities, interested in ensuring economic growth, know the importance of the early years to improve the percentage of children ready for school. Readiness for school enables a child to learn effectively and includes having listening skills and an ability to pay attention, communicate and interact with adults (Ofsted, 2014). Those who are ready for school will go on to gain financial independence, providing economic security for local communities in years to come.

Evidence shows mothers’ weight, smoking, alcohol and substance use, and whether they breastfeed, may influence whether children have long-term conditions and premature mortality in later life (Public Health England and UCL Institute of Health Equity, 2014). Reading to children, and talking and listening to them are shown to be vital to developing improved cognitive, social, emotional and language outcomes which, in turn, are the foundations for educational achievement and attainment of economic security in adulthood (PHE and UCLIHE, 2014). Benchmarked data shows how all of these behaviours and outcomes - or their absence - cluster in different communities (PHE, 2014a).

The day-to-day relationship between the child and primary carer is crucial (Wave Trust, 2013). An early secure attachment relationship with positive parental mental health pre- and postnatally and throughout childhood significantly affects children’s outcomes; it is also key in safeguarding children from abuse and neglect.

Children with multiple risk factors are especially vulnerable to poor outcomes. In pregnancy and the first few months of life, factors such as maternal stress, inadequate nutrition for mother or child, and alcohol or drug misuse, can jeopardise their physical and intellectual development.

Role of health visitors

Health visitors (HVs) lead the delivery of the evidence-based Healthy Child Programme (HCP) (Department of Health, 2009). This is a preventive service, giving families screening, immunisation and health and development reviews, supplemented by advice and interventions around health, wellbeing and parenting. HVs have a key role in supporting the achievement of future health and in promoting children’s readiness to learn.

Commissioning of public health services for children aged 0-5 years, including health visiting, will move from NHS England to local authority commissioning from October 2015. This could put the profession at the heart of the early years strategy - not just in terms of future health and wellbeing but also in how it helps achieve the social, economic and fiscal outcomes that matter to local authorities.

Demonstrating effectiveness

Service-user satisfaction is a highly sensitive indicator of progress. A recent review of the literature on health visiting includes mothers’ testimonies on the service’s value (National Nursing Research Unit, 2013). NHS England’s core national health visiting service requires a validated questionnaire, such as the Friends and Family Test, to be used with clients, and its findings to be fed back to inform local service development. Further work is planned to develop a validated user satisfaction tool specifically for health visiting.

Public health outcomes for 0-5s are set out in the Public Health Outcomes Framework (PHE, 2014b). PHE’s Child and Maternal Health Network and NHS England’s health visiting team collaborated to identify the public health outcomes that could be influenced by HVs working with early years services and primary care. They developed an early years profile and guide covering the key indicators for 0-5s (PHE, 2014c). The profile gives benchmarked local authority-based data and is supported by a guide that sets out how to interpret the outcomes and effective action required to improve them.

Demonstrating child development will depend on consistent implementation of the Ages and Stages Questionnaire 3 assessment. This is parent-led and assesses development in communication, motor skills, personal/social skills and problem solving. There is an expectation that providers will move towards implementing this and reporting results nationally.

Some public health outcomes can be affected relatively quickly; breastfeeding, immunisation and vaccination rates and maternal smoking are examples. Others, such as obesity in four-year-olds, are slow to change and will do so only as a result of evidence-based interventions by a range of agencies. These will include policy, environment, building local communities’ capacity to support the parents of children, giving information and actively supporting clients and patients in change. Proxy measures must, therefore, be used to provide evidence of effective change focusing on inputs, outputs and shorter-term outcomes.

Proxy measures of success

Inputs include setting up infrastructure to enable the delivery of evidence-based interventions: for example, more full-time equivalent HVs or those with accredited training in motivational interviewing or development of evidence-based local pathways, such as that focused on maternal mental health. This type of data is collected via the performance management framework of the health visiting service specification. Some is collated and used locally; some is collected qualitatively at a national level. The findings demonstrate health visiting services’ progress in providing leadership towards improving health and wellbeing outcomes for 0-5s.

Outputs include HV activity. NHS England is collating data on the percentage of the eligible population that has received HCP assessments. These make up the mandated elements of the HCP for local authority commissioning from October 2015. Analysis of national and regional data shows that almost all families receive a newborn visit but, while there have been improvements in the delivery of other checks, regional variations persist.

However, measuring HCP assessments does not provide evidence of health visiting services’ success in delivering evidence-based interventions to meet the need identified. Local measurement of delivery, such as Parents Early Education Programme, use of the Parent-Infant Interaction Observation Scale and the Neonatal Behavioural Observation screening tool can demonstrate the effective implementation of local early attachment pathways.

High-impact outcomes

The DH, PHE, NHS England and Health Education England, have developed six high-impact areas to show the impact of HVs (DH, 2014) (Box 1). Local and national monitoring and evaluation is proposed for each area, split into access, effective delivery, outcomes and user experience.

Box 1. High-Impact Areas

  • Maternal mental health
  • Early attachment
  • Breastfeeding
  • Healthy weight
  • Child development at two years
  • Managing minor illness and preventing accidents

Source: Department of Health (2014)

Case studies are another rich source of information on what works, and are effective in showing success to managers and politicians. However, they need to focus on what matters: better health and wellbeing outcomes. They may be small scale but need to set out clear objectives, baselines and the use of meaningful indicators and reliable instruments for collecting data.

Looking at the national or regional picture does not tell us the whole story. There are stark inequalities nationwide in health, wellbeing and attainment outcomes. Inequalities affect communities within, as well as between, local areas; for example there are big differences between clinical commissioning group areas in both initiation and maipracttenance of breastfeeding.


Making the case for health visiting shows the influences on health-related behaviour are complex and change takes place over the medium or long term. We must be clear that our inputs and outputs address need, are evidence-based and recorded accurately. Implementation of the national maternity and children’s data set from summer 2015 will support this. This has been developed by the Health and Social Care Information Centre to help achieve better care outcomes for mothers and children.

Key points

  • Pregnancy and infancy are crucial periods for a child’s future development
  • Health and social care services aim to ensure children’s current and future health and wellbeing
  • Successful outcomes include improvements in parent satisfaction and indicators from the Public Health Outcomes Framework
  • NHS England is using various measurements to demonstrate the impact of health visiting
  • Commissioning of public health services for children aged 0-5 years will transfer to local councils so health visitors must continue to provide evidence of their contribution
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