Institute of Health Visiting – Written evidence (PRT0083)

1. Background and context

The Institute of Health Visiting (iHV) is an independent charity, professional body and Centre of Excellence - established to strengthen the quality and consistency of health visiting practice so that health visitors and their teams can effectively respond to the health needs of all babies, children, families and communities, enabling them to achieve their optimum level of health, thereby reducing health inequalities.  

Health visitors are Specialist Community Public Health Nurses (SCPHN), with a clinical background as registered midwives or nurses and further specialist training at master’s level in public health. They provide a universal service to all families with babies and children from preconception and pregnancy and through the first five years of life. They lead the Healthy Child Programme (0-5 years)[i] which is the national policy blueprint for preventative public health, based on the principles of proportionate universalism, whereby all families receive five universal mandated contacts with extra targeted and specialist support provided to families with additional needs. Health visitors are in a unique position to be able to offer universal early intervention and support to new parents, and potential parents, in the interpregnancy period, regardless of their socioeconomic status.

It is important to recognise the indisputable evidence that:

• The first years of life provide a foundation for future health and wellbeing [ii].
• Babies are our most vulnerable citizens – disadvantage starts early, the effects are cumulative and impact health, child safety, educational attainment, and success across the life course[iii].
• Inequalities are not inevitable – much of the health-related adversity in the UK is preventable[iv]. Inequalities are widening, and the late identification of clinical and safeguarding vulnerabilities in babies and young children is a national concern[v].
• Babies who are born preterm are at heightened risk of poor outcomes – whilst some babies will have their additional needs recognised during their stay in the neonatal unit, many health and developmental impacts will only be identified through robust follow-up and monitoring of progress over time.
• Health visitors’ Unique Selling Point (USP) is that they are the only service which proactively and systematically reaches all families with babies and young children – they are the most trusted source of advice by families due to their legitimate health functions, providing support for all families and an important safety-net for the most vulnerable.
• Health visitors are a vital part of the health service; however, the health visiting service has been steadily eroded over the last nine years. Cuts to the health visiting service in England have had knock-on consequences across the system, impacting numerous clinical pathways for pregnancy, postnatal and neonatal care, immunisations, oral health, A&E attendances for minor illnesses and the identification and support for families with babies and children with SEND, to name just a few.
• Investment in prevention and intervention in the earliest years of life is the most cost-effective means to improve health and reduce inequalities, yielding high return on investment compared to the long-term costs of reactive health and social care. When families are supported, babies thrive and the whole of society benefits[vi] .

2. The health visitor's role with preterm babies and their families

1. Prevention

Health visitors have a key role in the promotion of health and early identification of risk and future needs. The antenatal contact as part of the Healthy Child Programme provides an ideal opportunity to promote health. This includes the identification of risk factors for preterm birth as highlighted by the National Institute for Health and Care Excellence (NICE)[vii] and NHS England (NHSE)[viii].  However, since the reduction of health visiting capacity due to cuts in the public health grant, the delivery of antenatal contacts has been subject to a postcode lottery. The most recent published annual data highlights that only 152,238 pregnant women received the antenatal contact, out of around 530,000 who would have been eligible for this review (although no national denominator is provided)[ix]. 

During the interpregnancy period, the health visiting service plays a crucial role in supporting the prevention of preterm birth and preparing for a healthy pregnancy Within each of the mandated contacts, the health visitor can provide advice specifically on preconception care, interpregnancy spacing, and health promotion. Funded by Public Health England (PHE), the iHV developed a programme of training to increase health visitors' knowledge and understanding of the need for interpregnancy advice and safe pregnancy planning. A gap in practitioner knowledge was identified through a national survey of health visitors, and the project developed training and resources to address this knowledge gap and enhance professional practice.[x].

The iHV has been granted funding consistently since 2016 by The AIMS Foundation to offer education to health visitors, aiming to enhance their understanding of the significance of maintaining a healthy weight and nutrition. This includes highlighting the effects of diet and weight on fertility, promoting safe pregnancies, and ultimately reducing the risk of preterm birth.[xi].

Making health changes is difficult in the complex and messy real world. To support health visitors’ work with families on the four main risk factors for poor pregnancy outcomes (known as the SNAP risk factors – smoking, nutrition, alcohol consumption and physical inactivity), the iHV has partnered with the Centre for Parent and Child Support (King’s College London, South London and Maudsley NHS Foundation Trust and King’s Health Partners) to develop a blended training programme based on the evidence-based “Family Partnership Model” – this is to support better partnership working with families and uptake of health promoting messages.

Without an increase in health visitor workforce capacity to ensure that all families receive these key contacts delivered by practitioners with the expertise and skills to support behavioural change, these opportunities to promote health and reduce preterm birth risk factors will sadly be missed.

2. The health visitor's role in neonatal long-term care and family support, including postnatal care and psychological support for women who have given birth preterm, can improve outcomes.

Health visitors have a key role in needs assessment, care coordination and support for these families and their babies during the neonatal and postnatal periods. 

Babies who are born preterm are at much higher risk of poor outcomes and health complications linked to prematurity. All preterm babies should be offered targeted support as directed by the health visiting and school nursing service delivery model[xii] which sets out the national policy blueprint for these services. This should start as soon as the baby is born and include both the universal mandated contacts and the additional targeted support proportionate to the family’s needs. Health visitors are routinely notified of the birth and offer a personalised programme of care to meet the immediate need while the baby is still on the Neonatal Unit (NNU), and continue to provide long-term care, through to the transition to school. Ideally, the health visitor will have met the family antenatally and have started to build a relationship with them – this has been shown to improve the identification of need and success of health visiting interventions. The health visitor is then able to support the family at different stages of their child’s journey including offering enhanced support for transition to school where the child has ongoing needs, whilst ensuring reviews take place as per NICE guidance[xiii] and promoting immunisation uptake.

The iHV is aware that communication between maternity services and health visiting is not always adequate, and health visitors have reported[xiv] that they do not know a baby has been born preterm or the family are still on a neonatal unit (NNU); in some tragic cases, health visitors have not been informed that a baby has died[xv]. NICE and Bliss[xvi] highlight the importance of care coordination and support when babies are discharged from the NNU, however, families report this is not always in place and is dependent on local capacity.  This lack of coordination is evidenced in research and recent reviews of maternity care[xvii] [xviii].

When sufficiently resourced, health visiting services would be able to offer this support to all families, with wider system benefits. Some areas have developed clear local communication pathways between maternity, health visiting and GPs which should be translated across all services. However, the pregnancy and postnatal care pathway is fragmented. In particular, guidance on the transition to health visiting services and the health visitor’s role across the postnatal pathway is not clear or mandated, and there are no system levers to ensure equity of provision across England[xix].

Promotion of perinatal mental health of all parents is a key part of the health visitor’s role. Having a preterm baby is a significant risk factor for perinatal mental illness and health visitors, as part of their universal role, should be assessing the needs of these families using relevant NICE guidance. The health visitor can then offer tailored support and connection to wider support services for families identified as requiring this.

3. Training needs of health visitors

Currently, health visitor pre-registration training does not give sufficient attention to the specific needs of preterm babies and their families. Continuous professional development opportunities for health visitors are determined locally, and this has led to a gap in the workforce’s ability to deliver high-quality consistent support to these families.  

The iHV, working in partnership with Tiny Lives Trust, identified a gap in support from health visiting services for families of babies who were born preterm or sick, based on direct feedback of parents and carers in the Northeast of England. Tiny Lives Trust supported the iHV to deliver a programme of work to gain a better understanding of the needs of parents and carers who experience neonatal care, and the training needs of health visitors. The insights gathered (see North East Project Insight Report) highlighted that: 

• Parents and carers did not understand the role of the health visitor, had not received support, and felt that health visitors did not understand their needs as parents of preterm and sick babies.
• Health visitors reported they had not had specific training and did not feel equipped to meet the needs of these parents and their babies.

Whilst this project was based in the Northeast of England, the project contains significant transferable messages and key points of learning which are relevant to all areas. The insights reflected the feedback the iHV received from practitioners, and from the national charity Bliss.

In collaboration with parents with lived experience, the iHV coproduced a training programme with the aim of supporting health visitors and their teams to better understand the needs of preterm babies and their families. The training programme was named “Surviving to thriving” - this was a direct quote from a parent with lived experience when they described the potential impact that a supportive and trained health visitor could have on the family’s journey. 

The programme of training focused on:

• Understanding of prematurity risks, impact and prevalence.
• The needs of the baby: recommended follow-up, feeding and growth, developmental needs.
• Understanding of emotional wellbeing and perinatal support for families including parents/ carers and siblings.
• Care coordination including local pathways, the role of the health visitor, and transitioning between services, i.e.to home from the NNU, and to school.

The training programme has been co-delivered with parents with lived experience across the Northeast and nationally in two areas, with over 100  health visitors now trained as Local Ambassadors for Neonatal Families. As part of their role, the health visitors, as placed-based leaders,  are expected to connect with their local NNU, support the development of local pathways, and provide an awareness session to their teams. The programme has evaluated positively, with all health visitors reporting increased confidence and understanding of the needs of these families and their babies, which can be seen in our end of project report.

The training programme and supporting materials, including bespoke e-learning for health visitors, were initially funded by Tiny Lives Trust. However, extending the training offer to all health visitors will require funding to support national rollout and programme sustainability.

We also recommend further research into the impact of the training on the care of the family and baby and have applied for funding from National Institute for Health and Care Research (NIHR) without success. 

3. Recommendations to the review panel

The iHV strongly believes that the needs of families with preterm babies will not be addressed unless:

• There is funding to reinstate the public health grant that funds the health visiting services - which has been significantly cut by almost £1bn since 2015 (this has been the biggest driver for health visitor cuts).
• We address the needs of the workforce: Delivery of the NHS workforce plan for health visitors (this covers student health visitor placements), alongside funding for substantive posts.
• Improvements in the consistent quality of health visitor provision across England – with robust system levers to end the unjustified postcode lottery.

Specifically, consideration should be given to:

• A national training programme to ensure that all health visitors have the knowledge, skills, and confidence to meet the unique needs of preterm babies and their families.
• The development of a national standard care pathway to support the ongoing care of preterm babies and their families from maternity to community care – alongside a robust postnatal pathway for all families.
• Further research to gain a deeper understanding of the needs of families following discharge from neonatal care to inform future care delivery and training of the workforce.

14 May 2024