Written evidence submitted by Institute of Health Visiting
The impact of COVID-19 on education and children’s services
Submission to Parliamentary Education Committee by: Institute of Health Visiting
Author: Dr Robert Nettleton, Education Lead
Date of submission: Tuesday 30th June 2020
1.1 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 aim 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.
2.1 In our evidence, we wish to assist the Committee to achieve a broadly based perspective on education and children’s services. These services are many and varied, but we wish to draw attention to the capacity of children’s services to support vulnerable children and those who they depend on. This is particularly pertinent to their mental and physical health and safety outside of the structure and oversight of in-person education or other setting or provision outside the home. We will also provide evidence on disadvantaged groups.
Rising levels of need;
Reduction in support available for families and mechanisms for identifying families who might need help; compounded by
Redeployment of health visitors into the wider health service.
4.1 We welcome the opportunity to present evidence on the importance of early childhood for childhood health, development and learning throughout the life course. There is rightly concern COVID-19 ‘lockdown’ measures deny school age children many of the crucial benefits of school. However, there is substantial evidence that the greatest influence on children’s prospects comes from their first 2-3 years of life from conception, most of which is spent in the home environment and community.
5.1 Health visitors are Specialist Community Public Health Nurses registered with the Nursing and Midwifery Council (NMC). Health visitors are nurses or midwives who have undertaken additional public health training at graduate or masters level. Their training equips HVs to use their understanding of public health, the wider determinants of health and impact of health inequalities in their skilful work, recognising and responding to individual needs with the aim of improving health outcomes for every child and family.
“Health visitors are an essential part of the country’s support structure for young children and their parents – especially those who are struggling to cope. But they can only do this if they have the time and capacity to develop good, trusting relationships with families. I am very concerned that the huge pressure on health visitor services is making it harder for them to do this, meaning some vulnerable children are in danger of falling through the gaps.”
Anne Longfield, Children’s Commissioner for England
5.2 Health visiting is the only service that proactively reaches out to all children and families with babies and children under the age of five to systematically assess health and developmental needs and provide support proportionate to that need. The impact of the COVID-19 pandemic has been three-fold:
5.3 The NHS guidance on prioritisation of Community Services drastically reduces the health visitor-led Healthy Child Programme to two of the five minimum mandated contacts in the antenatal period and the New Birth review and more limited targeted support for some families. To comply with the government’s social distancing rules, most health visiting contacts are also largely taking place remotely, unless there is a compelling need for a face-to-face contact. It can already be hard for parents to share personal worries or problems like domestic violence and abuse, mental health or substance misuse with a stranger, and eliciting needs like these will be even harder over the phone, creating an additional challenge if either parent wants to speak privately about the things that are really worrying them and may be placing them and their children at risk. Breastfeeding support and physical assessments for growth or minor illnesses over a telephone or video call are also far from straightforward. This prioritisation of services means that universal health visitor reviews for older babies and toddlers will only take place where there is known risk but, as we shall show, there are increasingly large numbers of children whose health and other needs will remain hidden, especially the most vulnerable or disadvantaged. NB. The Guidance on prioritization was revised on 03.06.2020 to allow limited restoration of community health services for children. However, the impact of COVID restrictions remain significant.
5.4 Altogether, health, education and local authority services are the source of half of all referrals into Children’s Social Care. Without the services having regular contact with children and families there is a real danger that children will fall through the gaps, going without essential help and intervention from social workers, or early help from the wider health visiting and local early years support services for those below the statutory thresholds.
5.5 For babies there is no substitute for proactively seeking out those who missed checks or haven’t been seen; nor for identifying parents who are struggling with mental health or other issues that impact on their parenting capacity without support. The needs of these babies and very young children may therefore remain hidden for a considerable time or remain unknown and therefore unmet.
6.1 Concerns around the needs of ‘hidden’ children have been exacerbated by the pandemic. Last year the Children’s Commissioner drew attention to the large numbers of ‘hidden’ vulnerable children, estimating that in total 2.3 million children are living with risk because of a vulnerable family background. Within this group more than a third are “invisible” (i.e. not known to services) and therefore not getting any support. At the most extreme end of the spectrum, as in previous years, currently the highest rate of homicide for any age group is in babies under the age of 1 . Now, under COVID-19 restrictions, far more children are ‘hidden’.
Figure 1: Percentage of health visitors reporting they work with each of vulnerable groups (iHV survey, 2019):
Looked After Children
Families of concern
Families with children subject to a Child protection Plan
Refugees/ Asylum seekers
Perinatal mental health
Adults/ children with disabilities
People with drug/ alcohol problems
People who need interpreters
Children with speech, language and communication needs
6.2 The above table demonstrates that within health visitors’ work with all families the many faces of vulnerability and disadvantage are mainstream to their work. The health visiting service is recognised as important to both safeguarding and child protection “because it safeguards all children”. This is because health visiting, uniquely reaches out, proactively, to every family with a child under the age of five in order to identify need and provide or facilitate support across the full spectrum of need.
6.3 Our survey provides a snapshot of the experiences of health visitors that highlights their overriding concern that the needs of children and families may be overlooked unless the focus of the national response is broadened to include the secondary impact of COVID-19, alongside the immediate treatment of COVID-19 infected patients. Similar warnings have been raised by leading academics throughout the world who are following the course of this pandemic in other countries. Early evidence from China, France and Italy suggests that the lockdown conditions created by the pandemic, particularly the isolation of families, could lead to the doubling of the number of victims of domestic abuse at a time when there is a significant scaling back of the services available to support victims. A similar pattern is emerging in the UK, with the National Domestic Abuse helpline reporting that it has already seen a 25% increase in calls and online requests for help since the lockdown.
6.4 The World Health Organisation (WHO) has reported that the coronavirus pandemic is also inducing a considerable degree of fear, worry and concern in the population:
“In public mental health terms, the main psychological impact to date is elevated rates of stress or anxiety… levels of loneliness, depression, harmful alcohol and drug use, and self-harm or suicidal behaviour are also expected to rise.”
6.5 The impact of COVID-19 will be felt across the population as a whole but is likely to have the most detrimental effect on those who are already disadvantaged and, in particular, our most vulnerable infants and children whose needs are at risk of being hidden from sight. A recent paper from Jack Shonkoff warns that:
“We cannot lose sight of the massive consequences of these threats to the health and development of our most vulnerable children and their families - now and for years to come… As we pull out all the stops to prevent broader infection, we must also remain vigilant in caring proactively for those who are especially vulnerable to the threat and consequences of social isolation.”
6.6 Our survey also highlights risks to the capacity of the health visiting service to meet these concerns both now and as the longer-term outturn of the pandemic unfolds. There is a risk that the capacity of the health visiting service will be further reduced due to COVID-19 related workforce issues. Health visitors redeployed from health visiting services may not return due to a combination of disillusionment that their specialist skills as health visitors are not valued or their position is not secure; feeling burned-out from their redeployed role and the well-documented stress of working in an emergency pandemic scenario; or concerns that returning to a significantly depleted health visiting service with dangerously high caseloads will leave them unable to deliver the care for which their professional education has prepared them. In addition, the numbers of newly qualified students entering the profession will be reduced as many HV training programmes have been interrupted during the pandemic.
7.1 There is evidence of the impact of COVID-19 lockdown on families from increased calls to help-lines for child abuse, domestic violence and mental health concerns. These three factors combine to form a ‘toxic trio’ of risk to the physical and mental health of children including babies. Paradoxically, however, there is a reduced rate of referral to statutory children’s services for child protection and safeguarding. The universal health visiting service acts as a gateway to other levels of health visiting provision, promoting, supporting and safeguarding the wellbeing of children through its interagency and referral work. Under COVID-19 lockdown conditions the capacity of health visiting services to identify and facilitate help to the hidden children and their parents is severely compromised.
8.1 Health visiting is now operating under PHE guidance for prioritisation and risk reduction. This means that the five mandatory minimum contacts, for which best practice would be home visits, are now reduced to one antenatal and one New Birth virtual contact, normally by phone. Paradoxically, this has improved the achievement for these contacts as ‘key performance indicators’: an ‘improvement’ in efficiency at the expense of effectiveness – a case of ‘ticking box, but missing the point’. This is both a drastic paring back of the universal health visiting service offer and a major change in working practices. It is not, however, inevitable. For example, in Blackpool and enhanced programme of 8 contacts is being maintained of which two are home visits, even under COVID-19. However, this is the exception. In order to inform alternative practices, the Early Intervention Foundation has undertaken a rapid review of the evidence relating to the virtual and digital delivery of interventions for children and young people. The review underlines the key precondition to the uptake of virtual methods of a trusting relationship and ‘therapeutic alignment’. This accords with the core practices of health visiting. What parents most value about health visiting is the opportunity for a trusted and knowledgeable practitioner who is readily accessible to them. This particularly applies to the most disadvantaged families who are less likely to access formal or centre-based services. To be effective, services need to be built around the needs of infants, children and their families, with relationships at the core of all health visiting provision. Continuity of relationships with a known health visitor and collaboration with other services are essential to the early identification of need and the provision of effective support for families with young children and should be a priority for the rebasing of the service as the strictest requirements of social distancing are eased.
9.1 In November 2019 we surveyed frontline health visitors working with families and communities. Our survey, the latest of six conducted annually from 2014, indicates the impact on the quality of the service available to families, and workforce capacity and morale from sustained reductions in funding. It found:
9.2 Key to delivering an effective, quality service is a well-trained professional workforce in sufficient numbers that is well motivated and supported to provide a personalised public health approach to families with young children. In our ‘State of Health Visiting’ survey in 2019 we describe the increase in health visitors’ caseload size due to service cuts. This is due to the fall in the numbers of NHS employed health visitors in England since 2015, see Figure 2 below. (An increasing minority of health visitors are now employed by Local Authorities or independent providers. Anecdotal evidence suggests that the downward trend is steeper outside the NHS).
Figure 2. Fall in the numbers of NHS employed health visitors in England since 2015 and before COVID-19*
Data source: NHS Digital: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics
9.3 Redeployment of health visitors for COVID has drastically reduced the service further in many locations to support the capacity for the NHS to meet the COVID-19 demand. We are concerned that an already very serious gap in provision and overstretched workforce is being reduced to 50% or less. Prior to the pandemic in 2019, 29% of health visitors we surveyed were already responsible for 500-1000+ children (iHV, 2020). The recommended maximum number of children per health visitor is 250.
10.1 The COVID-19 pandemic has exposed how fragmented the service landscape is for our youngest children whose health, development and learning are not determined by specific agencies, settings or other categories but the way they combine and support their key relationships and experiences at home and beyond.
10.2 It is widely recognised that reducing inequalities requires a whole-system, integrated approach as prevention and intervention cut across a range of stakeholders working with children and their families. This is also affected by wider determinants of health like poverty, housing and government policy. Health visiting is part of a “system” – we maximise the impact of the service by working collaboratively with partners. Effective strategic leadership across the system is needed to ensure place-based co-ordination across those responsible for the wider determinants of health to enable integrated pathways to:
11.1 The health visiting service should provide an important part of the solution to numerous current national priorities including:
12.1 The COVID-19 pandemic has highlighted the weaknesses of the rather fragmented and short-term policies for babies and young children in recent years, particularly in England. It is time for a bold shift in national policy which prioritises the needs of babies, young children and their families which are frequently hidden from sight.
12.2 Health visitors play an important role as part of this solution, providing invaluable universal support to all families and intensive support to those that need it the most. It is imperative that we have a national strategy to rebuild this important service.
12.3 Immediate actions
NB. The publication of revised guidance on the restoration of community health services for children goes some way towards these immediate actions.
12.4 Medium term actions
12.5 Medium to long term actions
We set out our recommendations in detail in our Vision for Health Visiting (2019). The COVID-19 pandemic priorities in the light of the COVID-19 pandemic include:
 Characteristics of Children in Need, 2019, Table C2
 Children’s Commissioner (2019) Childhood vulnerability in England 2019. https://www.childrenscommissioner.gov.uk/publication/childhood-vulnerability-in-england-2019/
 Office for National Statistics (2018) Homicide in England and Wales: year ending March 2018. https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/homicideinenglandandwales/yearendingmarch2018
 Public Health England (2017) National Health Visitor Programme: Benefits realisation. http://qna.files.parliament.uk/qna-attachments/804278/original/PHE%20Benefits%20Realisation%20Report.pdf
 World Health Organisation (Europe) (2020) Mental Health and COVID-19 http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/novel-coronavirus-2019-ncov-technical-guidance/coronavirus-disease-covid-19-outbreak-technical-guidance-europe/mental-health-and-covid-19
 Shonkoff J (2020) Stress, Resilience and the Role of Science: Responding to the Pandemic. https://developingchild.harvard.edu/guide/a-guide-to-covid-19-and-early-childhood-development/
 Black M, et. al. (2019) Learning across the UK: a review of public health systems and policy approaches to early child development since political devolution. Journal of Public Health. https://doi.org/10.1093/pubmed/ fdz012
 Public Health England (2019) PHE Strategy 2020-25. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/830105/PHE_Strategy__2020-25__Executive_Summary.pdf