A Vision for Health Visiting in Wales, Lecture notes of Public Health

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A Vision for Health Visiting in Wales

Table of Contents

A Vision for Health Visiting in Wales

1. Introduction

A Vision for Health Visiting Services in Wales, has been written through discussion and debate with stakeholders across Wales. It lists ten proposals for Welsh Government to consider in order to maximise the contribution that Health Visitors can make in achieving the vision of a service that provides every child with a good start in life to support them in having the best possible chance of living a healthy, happy life and optimising each child’s potential for school readiness.

2. The Vision for Health Visiting

Healthy families are vital to the creation of a prosperous, successful and sustainable Wales^1 and to support this Welsh Government, has developed a statutory legislative framework, committing to taking children and families in Wales out of poverty^2. Welsh Government recognises that health through the life course starts with the principle; children must have a good start in life that supports their long term health and wellbeing, every child and family in Wales deserves the best possible chance of living a healthy and happy life^3. The Health Visiting service will support achieving this through;

2.1 Better Health

 A reduction in health inequalities and social exclusion.  Greater emphasis and focus on public health.  Supporting parents and families of pre-school children.

(^1) Welsh Government (2011) Together for Health: A Five Year Vision for the NHS in Wales. (^2) Welsh Assembly Government (2010) Children and Families (Wales) Measure. (^3) Welsh Assembly Government (2011) The Child Poverty Strategy.

 Promoting infant, maternal and family health.  Reducing ill health by safeguarding children from abuse.  Developing community capacity, with additional Health Visitors in areas of greatest need.

2.2 Access to services for children and families will improve–

 All families with a preschool child will be offered a universal health visiting service delivered in many settings, including the home environment.  All families will be supported through an All Wales Healthy Child Programme.  Families with additional identified needs will have extra support either through targeted and or intensive health visiting led interventions.  Through increased investment, the Welsh Government is supporting families in Wales through doubling the number of families that are eligible for Flying Start^4 ,^5 the number of pioneer sites for Integrated Family Support Services^6 and Family First funding^2.

2.3 Better service safety and quality will improve health outcomes-

 All children and families will be treated with dignity and respect.  Health Visiting intervention will be evidence based and reflect current research.  Families will have individual comprehensive health assessments completed by a qualified health visitor, which will be reviewed at key stages throughout a child’s early years; this will be underpinned by a common assessment.  Utilising community capacity to improve health.  Excellent communication and IT links to ensure that clinical staff have safe and secure access to information.  Using information to improve the quality and outcomes of services.

(^4) Welsh Government (2011) Five for a Fairer Future. (^5) Welsh Assembly Government (2009) Flying Start Guidance 2009-2010. (^6) Welsh Assembly Government (2010) Integrated Family Support Services: Statutory Guidance and Regulations.

Evidence taken from the Marmot Review: Fair Society, Healthy Lives^10 concluded that;

One Quarter of all deaths under the age of one would potentially be avoided if all births had the same level of risk as those to women with the lowest level of deprivation.

4.2 Expectations are continually rising

The needs of children, families and communities are becoming increasingly more complex. These complexities are at individual and family level and include, promoting child attachment and development, safeguarding children, the emotional impact of children exposed to domestic abuse, children with complex health needs, deprivation, teenage parents and substance abuse, as well as at a community level with poverty, housing, unemployment etc.

It is also important to consider the challenges of delivering services to children and families who live in rural areas. Rurality may often bring about different vulnerabilities, such as access to services and isolation.

In addition there are areas in Wales that have are experiencing significant increases in local birth rates which has impacted on Health Visitor workload without extra resourcing.

To be able to fulfil public, local partners and commissioner expectations, health visitors will have to adopt different ways of working.

4.3 Staffing is becoming a real limitation on our service

Creating a sustainable workforce is an increasingly difficult challenge for Health Visitors services in Wales. The pressures of an aging workforce, the financial economic climate, in addition to the development of early years initiatives has depleted the available generic Health Visitor workforce. This has resulted in core

(^10) Marmot Review Team (2010) Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England post -2010.

Health Visitor caseloads and levels of work load increasing to unacceptable levels in some areas^11 ,^12.

4.4 Funding is limited

Although the Government is facing unprecedented financial constraints, through their manifesto there is a commitment to double Flying Start from 18,000 to 36, children under the age of 4 years,3,4^ and to extend the pioneer sites for Integrated Family Support Service^5. The challenge will be how core Health Visiting Services will respond to safe and sustainable services across Wales.

5. The next phase

The purpose of Health Visiting will be to empower and support children, individuals, families and communities to reach and achieve their fullest health and wellbeing potential.

There is compelling new evidence in relation to early infant mental health^13 , neurological development in infants and attachment and bonding. The research states that if children and families receive the right support at the right time they will have better outcomes. However with current demands on the Health Visitor, increasing caseload numbers and workforce availability, as training only occurs once every academic year, ensuring that children and families have access to the right and timely support is becoming increasingly more challenging and unsustainable, without reviewing existing roles and responsibilities.

To be able to fulfil public, local partners and commissioners expectations, health visitors will have to adopt to different ways of working.

5.1 Improving health outcomes

(^11) Unite/Community Practitioners’ and Health Visitors’ Association Omnibus Survey 2008 (^12) The Protection of Children in England: A Progress Report, The Lord Laming (2009) (^13) HM Government (2011) Early Intervention: The Next Steps. An Independent Report to Her Majesty’s Government, Graham Allen MP.

Action 3 Welsh Government to consider implementing the Family Nurse Partnership Programme alongside existing programmes to support teenage mothers.

5.2 One system for Health

To meet the health needs of children, families and communities in Wales, services must interact and engage effectively to be able to meet demand and expectations, while continuing to provide local sustainable services.

Future service delivery and successful health visiting teams will continue to be dependent on having collaborative working arrangements with their Primary Care colleagues (GP’s and Practice Nurses), Midwives^16 and School Nurses^17. Each has a unique and interlinked role to ensure that children and families have smooth transitions in and out of services, with clear communication pathways and joined up working delivered through a team around the child approach. The Health Visitors role with young children and families will be to coordinate an All Wales Healthy Child Programme. The Healthy Child Programme for early life stages will focus on a universal preventative service, providing with a programme for screening, immunisations, health and development reviews, supplemented by advice around health, wellbeing and parenting^18. This will be achieved through continual assessment and review using a common assessment tool, recognised by both Health and Local Authorities.

Protecting and safeguarding children is an area of statutory responsibility for multiagency partners and partnership working is key to making a difference to the most vulnerable for children and families in Wales^19. The role of the Health Visitors is crucial in terms of safeguarding and protecting children, through the provision of assessments, health promotion, identifying risks and delivering support that can prevent maltreatment occurring.^20

(^16) Welsh Government (2011) A Strategic Vision for Maternity Services in Wales. (^17) Welsh Assembly Government (2009) A Framework for a School Nursing Service in Wales. (^18) Department of Health (2009) Healthy Child Programme. Pregnancy and the first five years of life. (^19) All Wales Child Protection Procedures (2008). (^20) NSPCC (2011) All Babies Count: Prevention and Protection of Vulnerable Babies.

ACTIONS

Action 4 The Welsh Government will support the development of 3 initiatives, that will be implemented across Wales:  All Wales Healthy Child Programme of which child health surveillance will be component part.  All Wales common assessment tool for Health Visitors and their teams.  All Wales Parent Held Child Health Record.

5.3 Health Visiting for the 21st^ Century

The Health Visitor’s primary focus will be on prevention, early identification and intervention in relation to a population’s health and social need as opposed to “treatment”.

In Wales, a universal Health Visiting Service will be provided to the total population of young children aged 0-5yrs and their families within their local community. This population will receive access to appropriate, high quality services, irrespective of where they live, their ethnic group, their language or their social circumstance^21.

Health Visitors are trained to identify families that require enhanced or intensive support; by using their clinical and professional skills and judgment they will work with families to develop individual plans. The Health Visiting service will offer families with additional needs;

 Targeted Interventions, this maybe short or longer term interventions (e.g. maternal mental health).

(^21) National Service Framework for Children, Young People and Maternity Services in Wales (2005) Welsh Assembly Government.

5.3.2 The role of the Registered Nurse (Band 5)

Registered nurses will be recruited to support delivery and improve sustainability of services to preschool children and families.

However it would be detrimental to presume that a Registered Nurse could assume the role of a Registered Health Visitor (who will also be a Registered Nurse) as the education and training programme to qualify as a Health Visitor equips them with significantly different and additional skills and competencies. The Registered Nurse will work under the direction of a qualified Health Visitor and will;

 Manage defined and explicit situations  Provide relevant and current health information based on individual and family needs.  Identify opportunities for health promotion and provide appropriate advice and support.

5.3.3 Health Care Support Workers

Across Wales support worker roles have been developed, but there are variations in skills, competencies and educational attainment. The role of the support worker is to deliver on delegated tasks as directed and supervised by the qualified Health Visitor^24. It is expected that the Support Worker possess or is at least working towards a relevant NVQ or equivalent qualification.

5.3.4 Administration

To deliver the health visiting service admin support is essential.

(^24) NMC (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives.

5.3.5 Management Infrastructure

A robust professional management infrastructure will be vital to support the strategic and operational delivery of this vision.

Their role will be to provide or ensure;

 Clear strategic and operational direction, both locally and nationally.  Strong clinical leadership.  Safeguarding the public in terms of NMC accountability.  Professional standards are adhered to.  A robust clinical governance framework supports clinical practice.  Appropriate education and training is offered through continual professional development.  Recruitment and retention of staff.  Appropriate supervision and support  The Health Board develops and delivers their strategic public health agenda to meet local need.

5.3.6 Health Visitors and skill mix within Flying Start

The role, function and skills of a Health Visitor working with preschool children and families will be the same regardless of if they are working in a generic health visiting service or Flying Start; therefore the principles will be the same. However Flying Start has a prescribed Health Visitor component which is non-negotiable with Health Visitors providing enhanced services with reduced caseloads of no more than 110 children.

It is recommended that skill mix within the Flying Start setting would have a wider remit, compared to that described for the generic service. Flying Start is delivered by a multiagency team, with other disciplines, which may include Social Workers, Speech and Language Therapists, Dieticians, Midwives as well as Health Visitors. It would therefore be expected, where appropriate that registered nurses or Agenda for Change Band 3/4, support workers would support the multiagency team in addition to Health Visitors. To accommodate this, the role of the Health Visitor would be to ensure that registered nurses and support workers that have delegated tasks receive

a longer term plan to introduce electronic records. Action 8 Health Boards need to ensure appropriate accommodation is provided for Health Visiting services, which could be in a number of settings including Primary Care. 5.4 Aiming at excellence

The Welsh Government recognises, it is what parents do, as being more important than who they are, especially in a child’s earliest years. The right kind of parenting is a bigger influence on their future than wealth, class, education or any other common social factor. So the future Health Visiting service will be evidence based and reflect current scientific advances, particularly in relation to neuroscience and child development, improving parenting capacity, in addition to supporting and delivering on the public health agenda for this population (see attached evidence based Interventions). Activity will focus around:

 Assessment (of all relevant family members).  Regular developmental assessments of all children focusing on social and emotional health.  Attachment and positive parenting.  Parenting support.  Evidence based parenting programmes.  Health education and health information.  Public health challenges.  Community development.  Safeguarding and child protection issues.  Advocacy to meet the rights of the child.^25

The Health Visitor component of Flying Start through reduced caseloads is to deliver on the above. To achieve this the Government has committed to training additional Health Visitors and are working with the NLIAH and Education providers to increase the number of Health Visitors that will be trained over the next three years.

ACTIONS

(^25) United Nations Rights of the Child (1989/2004)

Action 9 Health Boards to work with NLIAH to develop an appropriate staffing and workforce tool to deliver safe and effective Health Visiting services, based on workload and caseload profiling. Action 10 Welsh Government will continue to work with NLIAH, HEI’s and Health Boards to ensure that the agreed commitment for Flying Start is delivered in terms of Health Visitor workforce, including the additional Practice Teachers. Action 11 Health Boards to ensure that all Health Visitors and their teams have appropriate levels of safeguarding training and clinical supervision to work in partnership with the multiagency framework of the Local Safeguarding Boards.

5.5 Absolute transparency on performance

Historically the health visiting contribution to improving the health of a population has been very difficult to measure. It is therefore essential that service delivery is outcomes based with performance managements systems built in. The success of the future Health Visiting Services will be measured by their contribution to improving the health outcomes of the defined population.

To support this approach standard assessment tools are needed to be able to accurately benchmark across the Local Health Boards of Wales.

ACTIONS

Action 12 Welsh Government to identify key performance outcome measures for Health Visiting Services. Action 13 Health Boards to adequately resource Health Visitor Teams to be able to meet the agreed outcomes.

Families First. Welsh Government’s priorities are described in the Programme for Government 2011^29

7. Making it happen

This vision is based on current scientific knowledge, evidence based interventions, government policy and the views of stakeholders and professionals, with the aim of reducing child poverty and health inequalities which is one of the main priorities of the Welsh Government.

The accountability and responsibility for planning effective and safe services lies clearly with Local Health Boards. The Government’s role will be to hold local organisations to account for delivering services. By setting out a clear vision for the health and wellbeing of children in Wales, the Welsh Government will ensure that those areas where health visitors have much to offer are given greater emphasis by NHS Wales and Local Authorities. Health Visitors and their teams have universal access to all young children and families, public health expertise, knowledge of local communities and access to the disadvantaged groups and have a great deal to offer in the planning and the commissioning process, and should be actively engaged and encouraged to do so.^30

7.1 Every Preschool Child and Family

For children and families in Wales health professionals are often the only contact that they have with services. Health Visitors and their teams are in a unique position because not only do they provide a universal service, this is often provided in the child and family home.

(^29) Welsh Assembly (2011) Programme for Government. (^30) The Governments response to Facing the Future: A review of the role of health visitors (2007).

Local Health Boards and other partners that lead, plan and deliver services are crucial to improving the life chances of children.

The Welsh Government, the NHS, its partners and the public, have a responsibility to support children, families within the communities in which they live.

8. A continuing challenge

Decades of late intervention from health, education and social services has failed, early intervention is critical. A range of well-tested programmes, low in cost, high in results, can have a lasting impact on all children, especially the most vulnerable. If we intervene early enough we can give children a vital social and emotional foundation which will keep them happy, healthy and achieving throughout their lives and, above equip them all to raise children of their own, who will also enjoy higher levels of well-being^31.

(^31) HM Government (2011) Early Intervention: The Next Steps. An Independent Report to Her Majesty’s Government, Graham Allen MP.