Over the past eight years, there has been a 40 per cent decline in the health visiting workforce.
Data published by NHS England shows a fall from 11,192 full-time equivalent health visitors in October 2015, to 6,688 in April last year.
A lack of career progression for health visitors, low pay and high caseloads are key drivers behind challenges in recruitment and retention for the sector, according to the Institute of Health Visiting (IHV).
Staff shortages
An IHV survey of health visitors found almost nine in 10 believe there are not enough people in the role currently. Health visitors also report that one in five children are missing out on vital health reviews due to staff shortages.
The government’s NHS Long Term Workforce Plan pledges to boost the health visitor training intake from 2022’s figure of 768 to 1,339 by 2031. While welcoming the plan, health visiting leaders say it is not ambitious enough – 2021 research by University College London estimates a shortfall of around 5,000 health visitors in England.
The IHV has published a career pathway for health visiting designed to make it easier for health professionals to take up roles and tackle staff shortages.
“Rebuilding the workforce will take time,” the plan states.
“The solution rests on building worthwhile and attractive career opportunities in health visiting at all levels – whether practitioners are just entering the field or looking to progress in the profession to more senior roles,” explains Dr Karen Whittaker, education and workforce lead at the IHV.
Breaking barriers
In publishing its careers plan the IHV says it aims to set out clear “possibilities for movement towards a health visitor qualification and beyond”.
It lays out solutions to increase both the recruitment and retention of health visitors by opening up pathways for transition from other professions which contribute to the role.
From September 2024, health visiting will require a postgraduate diploma on top of a degree in a related subject.
However, the pathway recognises “the different job roles contributing to health visiting provision and maps these against levels of practice that reflect registration status, educational development, expertise, and responsibility”.
Whittaker explains that the pathway is designed to be used by NHS trusts as a resource for workforce planning and looks at how to help those in non-registered roles support health visiting services and consider if they want to work up to the role themselves.
Those working as nursery nurses, assistant practitioners and support workers often feel “blocked” from becoming health visitors due to the need for a postgraduate qualification, she says.
“We want there to be some thinking about where these people go,” Whittaker says. “Are they even encouraged to have appraisals to consider their career?
“Asking these questions is important because it might be that some people are thinking that they’d like to be a health visitor but they’re not quite ready for it. So there needs to be some parallel learning available which means they are still able to progress.”
She adds that the pathway encourages NHS trusts to move towards “skill mixed” health visiting teams which focus on joint working across at all levels to “enable the health visitor to do the best job they can and support the health actions”.
Allowing all members of a team to see what is required to take on a higher role through development opportunities should help all professionals “feel more invested in the services and future oriented,” Whittaker adds.
“We know that when people feel more invested in, they are more likely to commit to a service and work in a more appropriate way which is particularly important when working with families and dealing with really sensitive and important stuff,” she adds.
Career progression
The career pathway is also designed to lower retention levels by increasing career progression for senior staff.
Whittaker explains that while highly skilled nurses and midwives are often interested in taking on additional training to become a health visitor, lower pay bands for senior staff act as a barrier.
As part of the pathway, the IHV is calling for the introduction of advanced health visitor practitioner and advanced health visitor consultant roles.
“I speak to health visitors who are saying how frustrated they are, because they feel hampered by the level of health visitor opportunities despite their experience,” Whittaker adds.
“That’s why we’re suggesting that we should be formally identifying practitioners that are eligible to develop as advanced practitioners. Advanced practice is now quite commonplace within nursing, but also other disciplines in the health service, and we see no reason why that shouldn’t be the case in health visiting as well.”
The IHV pathway is designed to make it clear to both practitioners and workforce planning leads what level of experience would be needed to reach each role.
The most senior level would require advanced continued professional development in health visiting alongside a PHD or equivalent.
Meeting targets
The NHS long-term workforce plan states: “The health visiting workforce is fundamental to improving the health and wellbeing of families from pregnancy to starting school by promoting health, preventing ill health and reducing inequalities. And by providing support in the community, they help alleviate pressures on hospital care.”
It says that to meet its goal of almost doubling health visitor intake by 2031, training and education opportunities must increase by between 32 and 74 per cent over the same period (see graphic).
In a briefing on the plan, published in July, the IHV calls for greater detail on training and education opportunities.
“The plan is light on detail for health visiting but includes important commitments to improve retention through career development initiatives, flexible working and improved staff wellbeing – this is essential, otherwise we will keep filling a leaky bucket,” it states.
Meanwhile, Whittaker describes hitting the target is “critical” to enabling health visitors to meet increasing demand for services.
“We need organisations to be thinking and planning now,” she adds, noting simply that the only way to boost health visitor numbers at a time when child poverty levels are rising alongside an increase in developmental issues among the youngest children is to create more opportunities for people to enter the profession and greater reasons for experienced practitioners to stay.
