Health visitors: an endangered species?

Everyone champions the role of the health visitor, yet as public health and council budget cuts continue, and universities struggle to fill places on health visiting courses, numbers are falling alarmingly low.

Everyone champions the role of the health visitor, yet as public health and council budget cuts continue, and universities struggle to fill places on health visiting courses, numbers are falling alarmingly low.

Health visitor
A number of issues are causing health visitor recruitment and retention problems. Picture: Alamy

In February, former chancellor George Osborne announced that allocations for the next year’s public health budgets in England would be reduced by an average of 3.9% every year in real terms until 2020. Investment in health visiting is already being hit hard by the squeeze on councils’ budgets.

Following the previous coalition government’s health visitor (HV) implementation plan, HV numbers rose from 9,765 in March 2011 to 12,094 in March 2015, Health and Social Care Information Centre figures show. But already the numbers are declining with the current figure at 12,022.

Fears for statutory services

Unite and Community Practitioners and Health Visitors Association professional officer for health Dave Munday fears that numbers could fall to pre-2011 levels. ‘On the one hand the rhetoric is good and we hear about the differences health visitors make to services, while on the other we are moving to a much worse place than we have been in for years,’ he says.

He worries that statutory services – such as the five universal HV checks for all children under the age of two and a half, which are due to expire in March 2017 – could also be cut. Public Health England is currently reviewing whether these checks should continue to be a legal requirement and its findings are expected this autumn. ‘We need strong central instruction for health visiting to be protected because if it is not it will be one of the first things to be cut,’ explains Mr Munday.

He says universities are struggling to fill places on health visiting courses because budget cuts mean local employers are cutting back on the students they take in 2016-17 or not taking any at all. Health Education England (HEE) board papers from May show that, despite planning to commission 1,042 training places for health visiting during 2015-16, it expected to see 12% of those places unfilled. HEE says the previous 2 years of rapid growth in training places has affected 2015-16 recruitment.

Brexit blow?

HEE has commissioned 817 health places for 2016-17, but Mr Munday is doubtful the projections will be met. ‘Some HV graduates do not have jobs to go to,’ he says. ‘Lecturers say they have commissions for 2016-17, but that they are not getting support from local organisations to fulfil them.’

RCN public health forum chair Jason Warriner warns that the Brexit vote to leave the EU could be a further blow to workforce numbers, saying: ‘The numbers are going to fall considerably over the next 2-3 years because of changes to public health funding and health visitors will need to demonstrate the impact of their role.’ The RCN is currently collating best practice to highlight the value of HVs.

A Department of Health spokesperson says councils will receive more than £16 billion for public health over the next 5 years. ‘We believe that local authorities are best placed to decide what is best for the health and well-being of local populations, and they have already made good progress,’ she says.

Named person scheme

In Scotland, HV vacancies are on the rise, giving way to fears that the named person scheme, due to come into effect on 31 August, may be unworkable. The scheme will see every child in Scotland allocated a named person to monitor their welfare. There are 182 vacancies in HV posts in Scotland, compared with 144 in March last year. However, a Scottish Government spokesperson says: ‘The rise in vacancies is partly due to the creation of 500 new health visitor posts between 2014 and 2018, and obviously it takes time to fill these posts.’

Unite and CPHVA professional officer for health in Scotland Gavin Fergie is concerned that boosting the workforce will come too late to fulfil the aspirations of the Children & Young People (Scotland) Act 2014 and says greater recruitment is needed to withstand high attrition rates. ‘We need an investment plan for the next 5, 10 and 15 years,’ he says. ‘If attrition rates remain the way they are, then we will never catch up.’


Council cuts are not the only reason why numbers are declining

The declining number of health visitors (HVs) in England is part of ‘a complex picture’ and not simply due to local authority budget cuts, a leading HV explains.

Institute of Health Visiting executive director Cheryll Adams says not all of the HV workforce problems can be attributed to local councils making cuts in provision. She says a number of issues are causing recruitment and retention problems, including HVs leaving work due to family commitments, not completing courses because of financial reasons or simply because they ‘discover the reality of the challenging aspects of the job… Some people simply did not realise how difficult being a HV can be,’ she says.

Dr Adams says there is wide variation in health visiting across the UK. While there is positive action in Wales and Scotland to improve families’ access to health visitors, England is grappling with recruitment and retention challenges and Northern Ireland is facing issues with low morale.

Regional variations

‘In England, there has not been enough time for the HV implementation plan to embed and have an impact before the numbers started to go down again. The government and researchers need to start drawing on the benefits of HVs based on evidence for when the workforce numbers went up and when numbers were low,’ she says.

Dr Adams recalls how poor HV staffing in England before 2011 coincided with a rise in visits to the GP and emergency departments. ‘There are big issues that need to be sorted fast because otherwise they are going to have a real effect on morale,’ she says.

Meanwhile, a UK-wide study has explored the emotional intelligence and resilience needed to cope with the stresses and heavy workloads associated with being a HV. Janet Garguilo, former HV and now senior lecturer and programme lead for specialist community public health nursing at Wrexham Glyndŵr University, has surveyed 1,000 HVs and students to uncover how emotional intelligence affects their performance in their role.

Selection process

The survey used a combination of questionnaires, including the Health and Safety Executive’s work-related stress analysis tool, to gauge HVs’ well-being and resilience. Ms Garguilo explains how it is difficult for universities and employers to assess people’s emotional intelligence and ability to cope with stress when recruiting to courses or posts. She also envisages that the findings could help her university’s future selection process for HV students and hopes the research will improve work performance as well as reduce HV attrition rates due to work-related stress.

‘HVs’ work today is more stressful than ever before and they need very good coping abilities and interpersonal skills, as well as management qualities. They need to be resilient, but people who are resilient do not necessarily have that emotional intelligence to be able to listen, understand and have insight into the incidents that come up, and be able to cope with the stress.’

Ms Garguilo says the role of the HV is often overlooked due to the preventive nature of the job. ‘Our study will tease out the benefits of HVs more because I feel if you have very strong recruitment, they will be part of the future workforce and will have the skills to speak out more positively about what they do.’

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