Dr Gabriella Conti and Abigail Dow, University College, London PSC0024 – Written evidence (PSC0024)

Call for evidence: The role of public services in addressing child vulnerability

Summary

-          Health visitors are a vital component of the workforce supporting vulnerable children, through their role in identifying and supporting these children, referring children to services, and addressing the roots of child vulnerabilities.

-          Health visiting services, however, are under severe strain due to years of funding cuts, redeployment of staff during the pandemic and increased demand due to the secondary impacts of COVID-19 and the lockdowns.

-          Health visiting staff (as emerged from an online survey we conducted) were particularly concerned about vulnerable children slipping through the cracks and having their needs missed during the first COVID-19 wave. 

-          We welcome the updated Public Health England guidance on the Healthy Child Programme (Public Health England, 2021) which introduces two additional universal health visiting contacts.  However, given that we find a prevalence of worryingly high caseloads across the country, more funding is urgently needed to deliver the current five health visitor contacts, let alone two more.

-          We recommend an increase in the public health grant to local authorities, based on local need for services, training of new health visitors and emergency funding to help health visiting services address the backlog of missed appointments due to the NHS England COVID-19 prioritisation.

Introduction

Dr Gabriella Conti is Associate Professor in Economics in the Department of Economics and the Social Research Institute at University College London. Dr Conti is also co-Investigator of the National Child Development Study, and Research Fellow at the Institute of Fiscal Studies, Centre for Economic Policy Research and IZA Bonn. Dr. Conti’s research draws on both the biomedical and the social sciences with the aim of understanding the developmental origins of health inequalities, the role of child development as input in the production of lifecycle health and the behavioural and biological pathways through which early life shocks, investments and policies affect well-being throughout the life course.

How is child vulnerability best defined?

1.     A child can be vulnerable for numerous factors, or combination of factors. The Children’s Commissioner’s Office identified 70 groups of vulnerabilities (Clarke, Chowdry and Gilhooly, 2019). Examples of factors of vulnerability include:

a)    Having special educational needs, disabilities, and/or poor mental or physical health.

b)    Being at risk of neglect, abuse, or serious harm.

c)     Due to their home environment - children living in homes with domestic abuse, in poverty, in unstable or poor housing, with financial stress.

d)    Due to their parents – lack of nurturing parenting, use of drugs/alcohol, mental health problems.
 

2.     A child’s vulnerability may be formally recognised by the state (e.g. children in care). Yet many vulnerable children may not meet the threshold for accessing services or they may have ‘hidden’ vulnerabilities that are not recognised by the state.
 

3.     Health visitors are a vital agent for vulnerable children of all forms, not only those where vulnerabilities are manifest. They identify and refer children to formal services, and they monitor and support children with hidden vulnerabilities and those under the threshold.

How well do public services address underlying causes of child vulnerability within families, such as domestic abuse, mental ill health, and addiction?

4.     Health visiting teams are key in identifying and addressing the underlying causes of child vulnerability. First, as health visiting is universal in England, health visitors are in the unique position of being able to access all babies and new parents. They are best placed to identify children at risk of vulnerability. 
 

5.     Health visitors address the driving causes of vulnerability by checking the child’s health and development to see if they are developing and growing as they should be and providing information to address parents’ concerns around topics such as feeding, crying, sleeping and postnatal depression. Health visitors also act as a support, they provide encouragement and try to empower parents. Furthermore, they act as a referral agent; they can steer vulnerable families to the necessary health and social care services.
 

6.     Research shows that nurse home visiting programmes are effective at targeting causes of child vulnerability. Vulnerable mothers in Australia who received nurse home visits saw reductions in postnatal depression scores and were more likely to have better maternal-infant attachment (Armstrong et al., 1999). Hirani, Sievertsen and Wust (2020) show that Danish mothers that miss a nurse home visit in the initial months of the child’s life are more likely to have contact with a psychologist or psychiatrist in the child’s first four years. The U.S. Nurse-Family partnership (NFP), a home visiting programme for low-income teenage mothers, resulted in fewer cases of child abuse and neglect (Olds et al., 1986; Olds et al., 1998) and reductions in smoking, alcohol and marijuana use (Olds et al., 2010). Olds et al. (2019) also found significant reductions in the costs of publicly provided benefits to mothers after 18 years. The German Pro Kind programme was effective at reducing maternal depression and prescriptions of psycholeptics (Sandner et al., 2018), and improving the quality of mother-daughter interactions (Conti et al., 2021).
 

7.     Nurse home visiting programmes also lead to short and long-term improvements for the child. Hirani, Sievertsen and Wust (2020) show that missing an early nurse home visit results in increased regular and emergency GP visits for the child. Whereas research on historical programmes in Denmark found that providing nurse home visits leads to increases in infant survival rates (Wust, 2012), and in Norway, increases in school attainment and lifetime earnings with more pronounced effects for lower socioeconomic status children (Buetikofer, Loeken & Salvanes, 2019). NFP nurse home visits led to better outcomes for children too – participants had fewer childhood injuries and healthcare episodes (Kitzman et al., 1997). Researchers also found positive effects on children’s emotional and behavioural development (Olds et al., 2004), and long-term effects of reduced involvement in crime (Olds et al., 1998; Eckenrode et al., 2010). In the U.K., Robling et al. (2021) found significant improvements in school readiness.

Do vulnerable children, parents, guardians and families receive sufficient support from early intervention and preventative services? If not, how might such support be improved? Can early intervention and prevention deliver more efficient and effective public services?

8.     In England, health visiting services are under severe strain after years of public health funding cuts, which have constrained health visitors’ ability to address the sources of child vulnerability.
 

9.     Before COVID-19 struck, in 80% of local authorities, caseloads were greater than 250 children per full-time equivalent (FTE) staff, the maximum caseload size recommended by the Institute of Health Visiting. In 22% of local authorities, caseloads were greater than 500 children per staff; and in 10% of them, caseloads were greater than 700 children per staff (Conti & Dow, 2020b).
 

10. COVID-19 has only made matters worse, due to the redeployment of health visiting staff to support COVID-19 efforts, the increased demand for health visiting services arising from the knock-on impacts of the pandemic and lockdowns, and the limiting of face-to-face contact.
 

11. Widespread redeployment of staff in health visiting teams occurred (both health visitors and clinical skill mix staff such as nursery nurses and community nurses). 65% of local authorities redeployed at least one FTE member of health visiting staff. Redeployment of FTE health visitors ranged from 0% to 63%, with 11% of local authorities losing over 25% of their FTE health visitors. Redeployment of FTE clinical skill mix staff ranged from 0% to 100%. 13% of local authorities redeployed over 50% of their FTE clinical skill mix staff (Conti & Dow, 2020b).
 

12. The level of redeployment varied greatly across local authorities (figures 1 and 2) (Conti & Dow, 2020b). This variation in redeployment means that vulnerable children received different levels of care and support based on where they lived, an inequitable outcome that undermines the universality of health visiting in England.

 

13. Redeployment of staff began around the time of the first Government imposed lockdown, from 19 March 2020, and was sustained, until at least 1 September. In 95% of local authorities that redeployed staff, redeployment started before May. This means that vulnerable families weren’t all receiving support from health visitors during the challenging first lockdown period.
 

14. Redeployment meant that in many cases the number of children a health visitor was responsible for increased. Our survey of health visiting professionals (n=740) during the first COVID-19 wave reveals that 38% of respondents reported an increase in the number of children they were responsible for between 19 March to 3 June 2020 (Conti & Dow, 2020a).
 

15. Even after staff returned, health visiting services would have experienced higher workloads because of increased demand for support, repercussions of limited face-to-face contact and a backlog of missed appointments due to the NHS England COVID-19 community health services prioritisation[1] (during which, 3/5 mandated Healthy Child Programme contacts were paused).
 

16. Face-to-face contact is fundamental for health visitors to identify vulnerable children. Survey respondents raised the challenges of limited face-to-face contact for vulnerable families: “I have always thought that when we visit families it’s not so much what they are telling us it’s what they aren’t telling us i.e. the body language the non-verbal cues. I think this is an important part of health visiting and we have missed all that”, “Vulnerable families that we may have picked up at clinic previously obviously weren’t seen and identified”, “These are hard to reach families that are hard to engage and unwilling to participate in virtual health checks”, “I am concerned my safeguarding cases have used Covid to refuse contact”. A few responses indicated that “no one is seeing these children”.
 

17. So, unsurprisingly, a large proportion of health visiting staff we surveyed were worried about vulnerable children having their needs missed during the first lockdown[2]. 96% of respondents were concerned about domestic violence and abuse, 86% about child safeguarding, and 82% about child neglect (Conti & Dow, 2020a).
 

18. The funding cuts to health visiting coupled with the COVID-19 induced shocks and impacts mean that vulnerable children and families across the country have not all received sufficient support. Health visiting services need increased funding in order to identify and meet the needs of vulnerable children.
 

19. Health visiting is not the only preventative, nurse visiting service that has experienced cuts.  The Family Nurse Partnership (FNP) programme, an evidence-based intensive home visiting programme for first-time teenage parents, has seen services decommissioned across the country since 2015. In many cases, there hasn’t been an alternative programme to catch FNP mothers.
 

20. Health visitors and Family Nurses are best placed to support vulnerable children and parents, through their preventative role supporting families in the early years. Early intervention of this nature is effective, as highlighted by the evidence on nurse home visits set out above.    
 

The Government has stated its ambition to ‘level-up’ underperforming regions. How could the Government’s ‘levelling-up’ agenda address regional and local disparities in children’s education, health and wellbeing outcomes?

21. The Government cannot address geographical disparities in children’s outcomes if their funding for public health does not accurately and fairly reflect the needs of local families.
 

22. At present, public health funding for local authorities is not determined based on need for different services (including health visiting) in the local population. Funding is largely a function of historic trends and has not been updated to account for the transfer of children’s 0-5 public health services to local authorities in 2015[3].
 

23. We support a return to the use of a revised ACRA[4] public health formula, a needs-based approach to estimating funding for public health services.
 

Policy recommendations

24. We support the addition of two new universal health visiting contacts, recently announced by Public Health England. Based on our findings, however, with existing resources it does not seem feasible for health visiting teams to deliver more contacts.
 

25. First and foremost, increased funding for health visiting services to boost workforce size is necessary. The Government must increase the public health grant beyond the allocations for 2021/22 to counteract the funding cuts of 2015-2020. Between 2015/16 and 2021/22 there has been a 24% cut in real terms, equivalent to £1 billion[5]. Funding must also go beyond this shortfall given the erosion to health visiting services and consequences of COVID-19. The 2021 budget made no mention of children nor community healthcare.
 

26. Training student health visitors is a necessary for increasing the health visiting workforce size. We recommend hiring and training sufficient health visitors to meet a safe caseload size of 250 children per FTE health visitor (as recommended by the Institute of Health Visiting) across all local authorities.
 

27. The Government must provide additional emergency funding to local authorities to help health visiting services address the accumulation of missed appointments, built up during the NHS England COVID-19 prioritisation plan. Funding should account for the level of redeployment in a local authority, given that we find significant variation.
 

28. We advocate for the reintroduction of the revised ACRA public health formula, as stated in paragraphs 21-23.

March 2021

References

Armstrong, K.L., Fraser, J.A., Dadds, M.R., and Morris, J. (1999). “A randomized, controlled trial of nurse home visiting to vulnerable families with new-borns”. J Paediatric Child Health. Jun;35(3):237-44.

Bütikofer, A. & Løken, K. & Salvanes, K. (2019)."Infant Health Care and Long-Term Outcomes", The Review of Economics and Statistics, MIT Press, 101(2), May: 341-354.

Conti, G. and Dow, A. (2020a). “The impacts of COVID-19 on Health Visiting in England (first results)”. Unpublished manuscript, University College London. Available at: https://discovery.ucl.ac.uk/id/eprint/10106430/8/Conti_Dow_The%20impacts%20of%20COVID-19%20on%20Health%20Visiting%20in%20England%20250920.pdf

Conti, G. and Dow, A. (2020b). “The impacts of COVID-19 on Health Visiting in England: FOI Evidence for the First Wave”. Unpublished manuscript. Available at: https://dl.orangedox.com/HEALTHVISITINGFOINEW

Conti, G, Poupakis, S., Sandner, M. and Kliem, S. (2021). “The effects of home visiting on mother-child interactions: Evidence from a randomized trial using dynamic micro-level data”. Child Abuse & Neglect. 115.

Clarke, T., Chowdry, H. and Gilhooly, R. (2019). “Trends in childhood vulnerability: Vulnerability technical report 1, July 2019”. Children’s Commissioner for England. 

Eckenrode, J., Campa, M., Luckey, D.W., Henderson, C.R., Cole, R., Kitzman, H., Anson, E., Sidora-Arcoleo, K., Powers, J., Olds, D. (2010). “Long-term Effects of Prenatal and Infancy Nurse Home Visitation on the Life Course of Youths: 19-Year Follow-up of a Randomized Trial”. Arch Pediatr Adolesc Med. 164(1):9–15.
 

Hirani, J. L.-J., Sievertsen, H. H. and Wüst, M. (2020). “Missing a nurse visit”, IZA DP No. 13485.

Kitzman, H., Olds, D.L., Henderson, C.R., Hanks, C., Cole, R., Tatelbaum, R., McConnochie, K.M., Sidora, K., Luckey, D.W., Shaver, D., Engelhardt, K., James, D., Barnard, K. (1997). “Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial”. JAMA. Aug 27;278(8):644-52.

Olds, D. L., Henderson, C. R., Chamberlin, R., and Tatelbaum, R. (1986). “Preventing child abuse and neglect: A randomized trial of nurse home visitation”. Pediatrics. 78, 65–78.

Olds, D., Henderson, C.R., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., Pettitt, L., Sidora, K., Morris, P., and Powers, J. (1998). “Long-term Effects of Nurse Home Visitation on Children's Criminal and Antisocial Behavior: 15-Year Follow-up of a Randomized Controlled Trial”. JAMA. 280(14):1238–1244.

Olds, D.L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D., Henderson, C., Hanks, C., Bondy, J., and Holmberg, J. (2004) “Effects of nurse home visiting on maternal life-course and child development: age-six follow-up of a randomized trial”. Pediatrics. 114:1550-9.

Olds, D.L, Kitzman, H.J.,Cole, R.E., Hanks, C.A, Arcoleo, K.J, Anson, E.A., Luckey, D.W., Knudtson, M.D., Henderson, C.R, Bondy, J. and Stevenson, A.J. (2010). “Enduring Effects of Prenatal and Infancy Home Visiting by Nurses on Children – Follow up of a Randomized Trial Among Children at Age 12”. Arch Pediatr Adolesc Med. 164 (5):412-418.

Olds, D., Kitzman, H., Anson, E., Smith, J., Knudtson, M., Miller, T., Cole, R., Hopfer, C. and Conti, G. (2019). “Prenatal and Infancy Nurse Home Visiting Effects on Mothers: 18-Year Follow-up of a Randomized Trial.” Pediatrics. 144 (6).

Public Health England. (2021). “Healthy child programme 0 to 19: health visitor and school nurse commissioning”. Available at: https://www.gov.uk/government/publications/healthy-child-programme-0-to-19-health-visitor-and-school-nurse-commissioning
 

Robling M., Lugg-Widger F., Cannings-John R., Sanders J., Angel L., Channon S., Fitzsimmons, D., Hood K., Kenkre, J. Moody, G., Owen-Jones, E., Pockett, R., Segrott, J. and Slater, T. (2021). “The Family Nurse Partnership to reduce maltreatment and improve child health and development in young children: the BB:2 6 routine data-linkage follow-up to earlier RCT”. Public Health Res. 9(2).

Sandner, M, Cornelissen, T., Jungmann, T. and Herrmann, P. (2018). “Evaluating the effects of a targeted home visiting program on maternal and child health outcomes.” Journal of Health Economics. 58: 269-283.

Wüst, M. (2012). “Early interventions and infant health: Evidence from the Danish home visiting program”. Labour Economics, 19(4): 484-495.

Annex

Data collection:

1. We collected data through Freedom of Information (FOI) requests to the providers of health visiting services across all Upper-Tier Local Authorities (UTLA) (n=151) in England. The first FOI requests were submitted on 19-20 August 2020, and the remaining between 2-7 September. Responses were received between August 27 and January 26. We have received complete data on FTE staff numbers and redeployment of staff for 140 local authorities (93%).
2. We collected primary survey data between 19th June to 10th September 2020 on a sample of adults working in the health visiting profession in England (n=740) who are on the membership and wider profession email databases held with consent by the Institute of Health Visiting.