Written evidence submitted by the Institute of Health Visiting (CYP0051)

About the Institute of Health Visiting

The Institute of Health Visiting (iHV) was established with the support of the Cabinet Office and Department of Health in 2012. We are a charity self-funding through our membership scheme, professional development/training programmes and successful partnership work. Our purpose is to strengthen the quality and consistency of health visiting services for the benefit of all children, families and communities and to reduce health inequalities.

Our evidence in summary

The most sensitive and formative period in setting the foundations for child and adolescent mental health is before school and the most powerful influence is the home, positively and negatively. It is this age group and setting that is systematically ignored by current mental health policy and practice. Health visiting and the Healthy Child Programme provides an evidence-based systematic public health approach available to all families that is led by experienced and trusted professional health visitors. However, the health visiting workforce and its capacity has been severely depleted by around a third of the workforce since 2015 when public health budgets were cut and the commissioning of this worker’s services was moved to local authorities.

Prevention and early intervention can only be taken seriously with recognition that:

• A blueprint for a child’s future mental health is laid down in the first 1000 days from conception[1].

• Mental health services should therefore not focus exclusively on schools or be limited to any ‘setting’.

                Review of policy on the mental health needs of children and young people (CYP) should take cognisance of the Early Years Healthy Development Review led by the Rt Hon Andrea Leadsom to underpin a seamless child and family approach to mental health.

• They need to focus on where children live, learn, play and study, wherever that may be.

• Mental health and physical health should be assessed and supported holistically by integrated services.

• Universal approaches are needed to avoid the greatest volume of need remaining ‘hidden’.

• Forthcoming reform of the NHS should enable these principles to be put into practice by enabling closer working between services commissioned by the NHS and those commissioned by local authorities.

                Health visiting workforce capacity and sustainability needs to be rebuilt as a part of a wider recovery plan to strengthen support for families as they develop emotional wellbeing in their children.

1. Government progress on children and young people’s mental health since 2017 Green Paper

Three years ago the Institute of Health Visiting welcomed the Green Paper on Children and Young People’s Mental Health Provision and we wrote to the then Secretary of State, the Rt Hon Dr Jeremy Hunt to make some points which we believed would strengthen the positive proposals in the Green Paper to give due weight to the prevention of suffering of children and their families where there are mental health problems. We recognise that there has been investment and progress since then, raising the profile of mental health needs and developing school-based capacity to respond to them.

However, we pointed out then that there is extensive evidence that:

• the roots of mental health difficulties commonly lie in early childhood[2];

• that the opportunities for prevention and mitigation of mental health issues are most effective when they occur at the earliest opportunity – both in the aetiology of problems (true early intervention) and at the youngest age[3] [4];

• that effective reduction in the incidence of mental health problems recognises that the causes are a) widespread within the general population and b) arise from the experiences / environment to which children are exposed (notably ‘Adverse Childhood Experiences (ACEs[5]));

and that, therefore:

• services should be universal to identify mental health needs, providing the basis for graded levels of proportionate preventative support or treatment (Marmot, 2010[6], 2020[7]).

Three years later, we recognise that the progress made has not taken into account this evidence and that the C-19 pandemic has highlighted some critical limitations of current strategy which continues to have a ‘blind spot’ that renders children’s mental health before school invisible.

2. Provision of mental health support in schools – and BEYOND

2.1.        Mental health beyond the school

A strength of the Green Paper was that it helped to normalise mental health needs and make services accessible and inclusive for all school age children and young people by shifting the focus for services towards the context of schools. Regrettably, this was also a major weakness of the proposals that has been exaggerated by the C-19 pandemic. Effective transformation of mental health service provision for children should be focussed around children and their families, not the configuration of services as such, whether or not in schools. The C-19 crisis has highlighted:

a)      increased mental health needs and educational disadvantage amongst children while they are unable to access school; and

b)      inequalities that are broadly reflective of the social and material circumstances of their families.

It has become glaringly obvious that children’s home circumstances are key to their mental health and educational attainment. It is a mistake for policy to focus exclusively on schools or be limited to any ‘setting’; rather it needs to focus on where children live, learn, play and study, wherever that may be.

Health visitors are Specialist Community Public Health Nurses (SCPHN) with advanced training for the work they do leading child and family public health. They work with SCPHN School Nurses who lead CYP’s public health with the school age population.  Public Health England has highlighted the strength of school nurses as the single biggest workforce specifically trained and skilled to deliver public health for school-aged children (5-19) through their clinical and public health nursing training and their direct work with CYP and schools[8]. They are focused on school-age children in and outside of school with emotional and mental health being a key priority area. CYP appreciate their accessibility, confidentiality and independence of school structures but express their wish that they were more visible[9]. This could have been rectified and built upon had mental health policy for children invested in this service rather than developing new ones.

2.2.        Home Learning environment

We now have definitive evidence of the harm this time out of school has caused children. Anne Longfield, Children’s Commissioner 17.02.2021[10].

The variation of impact of Covid on school age children does not arise from their school but what they experience outside of school. In response to Anne Longfield, Dame Louise Casey said:

“If a child is in need, look to what is happening in the rest of the family… policy, practice and delivery should look to both the child and the family.”

This is true for the development of mental health and particularly in preschool children who are not in school and are primarily in the care of their parents, at home. We now know this is most important in the first 1000 days[11]. The evidence is that early childhood mental health needs to be understood in terms of the quality of relationships between babies, children and their parents and wider carers.

2.2.1               Early speech, language and communication (SLC) skills as a mental health indicator

2.3.        Early intervention and prevention

We fully support a shift in policy and practice towards early intervention and prevention. In order for prevention to be effective it needs to start early enough in the seedbed of mental health difficulties. This will only be the case for children and young people’s mental health difficulties when provision encompasses infancy; childhood and adolescence\young people, reflecting the foundations of mental health being established from conception (WAVE Trust, 2013, 2015[14]). We agree with the many other members of the 1001 Days movement[15] that CYP’s mental health policy has a blind spot when it comes to early childhood when there is overwhelming evidence that exposure to health risks and wider ‘adverse childhood experiences’ (ACEs) make CYP vulnerable to mental health difficulties. In contrast, the experience of nurturing care and responsive relationships in the home and beyond lay the foundations for health including mental health, maximising educational potential and having a protective effect when difficulties are encountered at a later stage – sometimes described in terms of ‘resilience’. This blind spot seems correlated with the policy focus on what schools provide rather than what children need and when they need it.

According to Public Health England (PHE, 2015) ‘early childhood experiences have been found to have a lasting impact upon a child’s mental wellbeing. Initiating improvements in the mental wellbeing of this age group may thus deliver tangible improvement across their whole life course.’ (PHE, 2015: 4[16]) and significantly help NHS expenditure.

Adverse childhood experiences (ACEs) embed social disadvantage biologically due to the impact on the developing brain of ‘toxic stress’, for example due to exposure to domestic violence; while sensitive and responsive care from primary care-givers, parents & others within the family circle, shape a sturdy architecture of brain development and secure attachment.  This is the foundation for healthy social and emotional development essential for readiness for learning in the school age years and future mental health.

Infant mental health can be defined as, ‘the healthy social and emotional development of a child from birth to 3 years’ underpinned by a growing field of research and practice devoted to the:

• Promotion of healthy social and emotional development;

• Prevention of mental health problems; and

• Treatment of the mental health problems of very young children in the context of their families.

http://www.zerotothree.org/child-development/early-childhood-mental-health/

This definition can also appropriately encompass prenatal experience. The emphasis on the first three years of life reflects the critical formative importance of early childhood experiences in these ‘foundation years’ (Field, 2010[17]). The strong evidence that an anxious mother may produce an anxious child also highlights the importance of support being available early to mothers during pregnancy as well as beyond to mitigate against this (Glover, 2014[18]).

This is why health visitors are unique within the wider system in proactively reaching every family to promote and support perinatal and infant mental health, having the knowledge and skills to assess and identify difficulties, provide support and facilitate access to further specialist help as needed.

3. Eating disorders – mental and physical health

The attention given to mental health after long periods of neglect is very welcome. However, separation of physical and mental health in childhood is not helpful at any stage from infancy to late adolescence. Eating disorders are serious mental health issues that have a serious physical dimension. For example, obesity is a serious physical health issue often associated with anxiety, depression and relationship difficulties. Sexual health and substance abuse also have important implications for both physical and mental health. It is therefore important that children of all ages should have access to services that can assess health holistically in the context of the child’s living circumstances encompassing the home, family and, as applicable, educational or care setting. Children’s relationship to food and food consumption is subject to many and varied influences throughout childhood. However, the primary significance of food is established before school by the infant’s first experiences of food and especially the social, emotional and moral associations given to food – for example whether food is used as a reward or punishment, a source of comfort or has positive associations with social relationships.

We develop the implications of a more integrated approach to mental and physical health in the section (5) on services.

4. Addressing capacity and training issues in the mental health workforce

“A robust health visiting service delivered by highly trained skilled professionals who are alert to potentially vulnerable children can save lives”.

Lord Laming. 2003[19]

The number of health visitors in England has fluctuated wildly over the last 20 years. A period of decline in the 2000’s was challenged by Lord Laming’s report into child protection[20] and a significant correction was made from 2011 – 2015. The ambitious target was set by the coalition government to increase the number of health visitors by about 50% from 8,000 by 4,200 full time equivalent health visitors in four years. A monumental effort was made to recruit and train these new health visitors. Unfortunately, the peak of numbers achieved in 2015 declined as rapidly as it had risen coinciding with the transfer of commissioning of HV services from the NHS to local authorities alongside drastic reductions year on year of the Public Health Grant. Figure 1, below, demonstrates this change relative to other areas of nursing practice.

Figure 1: Change in registered nursing workforce by work area (index 100 = June 2010), June 2010 - June 2020[21]

Demoralisation of the profession is an unsurprising consequence, with many leaving. This leaves vacancy rates high, imposing further pressures on those remaining.

At the same time, there is great NHS demand for qualified nurses. The 2019 Conservative Manifesto committed the government to increasing the number of nurses in the NHS by 50,000 from 2019 to 2024-25. Therefore any attempt to increase the number of health visitors could be hampered by ‘fishing in the same pond’ while the NHS and Health Education England[22] puts significant energy and investment into this target. Any additional initiative to increase the numbers of health visitors should seek to avoid ‘competing’ with this target for nurses[23].

Figure 2: below indicates the growth in hospital nursing at the expense of community nursing and health visiting workforce growth, despite repeated policy calls for ‘care closer to home’ and, in the NHS Plan, a call for a ‘radical upgrade in prevention’.

Figure 2: Change in adult hospital nursing and community nursing/health visiting in the NHS in England (index 100 = June 2010), June 2010 - June 2020[24]

5. Improving access to mental health services 

The NHS Long Term Plan for England committed to improving access to specialist services for all children from 0-25. It stated that “over the coming decade the goal is to ensure that 100% of children and young people who need specialist care can access it”[25]. The Green Paper set in motion services and pathways embedded in schools that have started to improve access to mental health services for children with the exception of pre-school children. However, the Covid-19 pandemic has further increased risks to infant mental health, widened inequalities and depleted services. In a survey of professionals working with families in the first 1001 days, 98% of respondents said babies their organisation works with had been impacted by parental anxiety/stress/depression affecting bonding/responsive care. This was widespread with 73% of respondents reporting that many of the babies they work with were impacted.[26]

The mental health of babies and preschool children is affected by many factors but pre-eminent is the availability of a consistent, nurturing and responsive adult, notably a parent. Progress has been made in developing specialist perinatal mental health services for parents suffering with perinatal mental health difficulties and supporting maternal / paternal mental health is critical to good mental health outcomes for their young children. However, there is no equivalent investment in the mental health needs of young children for their own sake.

The Healthy Child Programme (HCP)[27] provides the framework for health visitor-led mental health promotion in pre-school children. However, year on year cuts to the Public Health Grant and service reductions mean health visitors have become increasingly challenged in their capacity to lead and deliver the full HCP to assess and promote infant mental health, establishing infant mental health pathways to specialist services and reducing later demand on CAMHS.

The iHV surveys health visitors annually. In December 2020 we reported[28]:

5.1               A reduction in the capacity of the service to support families.

Health visiting entered the pandemic in an already depleted state, with its capacity to support families further reduced due to the redeployment of over 50% of health visitors in some areas

The NHS categorised the health visiting service as a “partial-stop” service in the Community Prioritisation Plan. The needs of vulnerable children known to the service were hence prioritised. Only 17% of health visitors were able to offer all families a 9-12 month review themselves this year, and this dropped to 10% for the 2-2.5 year review.

5.2               Unmanageable caseloads:

Health visitors provide a universal “safety-net” for vulnerable babies and young children. Their capacity to support families and identify vulnerability is dependent on their ability to work with families and build trusting relationships to elicit need and broker engagement in early intervention:

• 65% of health visitors had caseloads with over 300 children under 5 years.

• 29% of health visitors report caseloads of 500+ children.

• Worryingly 12% of health visitors report caseloads of over 700 children (one health visitor reported a caseload of 3000 children).

N.B. the optimum maximum caseload for effective practice is 250 children, and less in areas of high vulnerability.

• A third of health visitors surveyed feel they are ‘stretched and there may be a tragedy in our area at some point’.

5.3.               Solutions to improving access, prevention and early intervention

We have set our findings out in detail in ‘Health visiting in England: our vision for the Future’[29]. This is not just about health visiting but how this service is a foundation stone for children’s mental and physical health and development. Government needs to find a way to protect this vital workforce into the long term so that its activities are no-longer at risk from policy changes by subsequent governments.

In our submission to the planned Comprehensive Spending Review (iHV 2020[30]) in the autumn, we set out our recommendations to the Government:

1. Government funding for health visiting should be increased by £206m a year to increase the number of health visiting substantive posts in England by 5,000 to 13,000. This will reverse the over 31% reduction in health visitors since 2015, with a further increase to ensure an average recommended caseload size of 250 children aged 0-5 years per WTE health visitor. The benefits of an effective health visiting service accrue to numerous government departments through its contribution to many key national priorities, which if unaddressed carry a significant fiscal burden, and by providing a vital safety net for vulnerable babies and young children who are often hidden from other statutory services. Increasing the health visiting workforce will ensure families receive additional universal and targeted support as recommended by the Health and Social Care Committee.

2. Additional government funding of £218m is needed to train 6,000 health visitors over the next four years to offset the current national shortage of health visitors and projected 20% shortfall in the future due to retirements and attrition.

3. To strengthen health visiting leadership capability, an additional expenditure of £4m is required to provide a leadership development programme for health visitors to help transform models of care in the way that the Government is due to outline within its existing commitment to refresh the health visiting model for England and the Healthy Child Programme.

In light of our survey findings on the impact of working in a pandemic on the wellbeing of health visitors, we set out the following additional recommendation:

4. A clear plan of support is needed for all publicly-funded health visitors, regardless of whether they work in the NHS or not, to restore and maintain staff wellbeing during the ongoing pandemic and recovery phase.

6.                How services should adapt to strengthen a child’s future emotional wellbeing 

We have set out a vision for health visiting in England[31] that places mental health in wider context of child and family health and development within a community public health approach. Health visiting is effective as a crucial place-based connector between every family and the wider system of primary and secondary care, local communities and services (voluntary and statutory). It functions within a 0-19 service with our School Nursing colleagues.

An example of good practice for CYP’s health is the whole town approach adopted by Blackpool: see https://resiliencepathway.co.uk/about-us

With respect to preschool children and their families, Blackpool has strengthened health visiting[32] as a keystone service within it’s A Better Start model of service transformation on the basis of high-quality evidence. Mental health practice adopts a trauma-informed approach to supporting parents and uses a range of evidence-based tools antenatally (e.g. Baby Steps) and subsequently (e.g. Video-interactive Guidance) to support parent-infant relationships providing the basis for secure infant attachment and mental health.

Blackpool has already been visited select committees:

• First 1000 Days of Life Inquiry – Health & Social Care Committee – UK Parliament

• Evidence Based Early Years Intervention Inquiry – Science & Technology Committee – UK Parliament

What is now needed is the political will to overcome the unwarranted variations in service provision to best practice approaches across the country as a whole.

Conclusion

In conclusion our evidence-based view is that improving children’s mental health and any development of services around that must start pre-school and ideally pre-birth where the greatest impacts can be made.  The CAMHS service is in crisis and has been for many years.  Any improvements will come from a total change of strategy rather than continuing to invest in a philosophy of essentially addressing illness rather than its roots.

Health visitors are the appropriately skilled professionals in these very early days but cannot play their part in reducing the flow of children to CAMHS without re-investing to place the service on an adequately resourced and sustainable footing.

Dr Robert Nettleton

Education Lead

February 2021