Heralded by Health Secretary Andy Burnham as the "end of the wilderness years", the Action on Health Visiting Programme unveiled last week represents the government's attempt to address the chronic staff shortages and low morale among the profession.
Health visitors have been arguing that they have been under-resourced for many years. But the plight of the profession was given fresh prominence in March when Lord Laming's report on child protection urged the government to take immediate action to boost health visitor numbers and improve the quality of the service they provide.
With the current number of health visitors standing at 8,764 this year - around 2,000 less than five years ago - some health visitors have been left with caseloads in excess of 1,000 children each, more than four times the amount the Community Practitioners' and Health Visitors' Association (CPHVA) says is workable.
The Conservatives have already pledged to increase health visitor numbers by 4,200 but, speaking at the launch of the programme at last week's CPHVA conference, Burnham says Labour will not be setting such a target. Instead, it will be down to local service providers to decide. "The days of centralised mandates are over in the NHS," he says.
Pressure on PCTs
Burnham believes pressure can be applied to primary care trusts (PCTs) to improve health visiting services by making them publish figures on how many full-time health visitors they employ and list their average caseloads. "Commissioners must give a clear explanation if caseloads are high," he says.
The omission of a target figure for the number of health visitors or any specified sanctions for PCTs that don't invest in the profession has led to concerns that other health services will be prioritised. The issue of funding itself is another bone of contention as no extra cash is offered to boost numbers.
Instead, PCTs will need to use their existing budgets to pay for additional health visitors. Norma Dudley, health visitor and London regional chair for the CPHVA, says budgets in local health services are already tight and, without any clear direction from central government, it could prove difficult to persuade PCTs to divert additional funds to health visiting.
"I'm concerned that, particularly in London, if strategic health authorities and local NHS organisations aren't given guidelines or money is not ringfenced, budgets are going to be spent in other areas," she says.
Elaine Baptiste, a health visitor in east London and CPHVA representative, shares her concerns. "It's all very well producing documents but if there is no money or pressure put behind it to influence it, then these documents are totally useless," she says.
More clarity
Another aspect of the programme involves giving greater clarity to the exact role of health visitors, outlining why they are necessary and where they can make a difference.
Burnham, along with Children's Secretary Ed Balls, believes this can allow pressure to be applied locally by health visitors themselves on PCTs to enhance the case for increased provision.
Meanwhile, a new £2m leadership and training programme will have a "particular focus" on health visitors and school nurses.
A health visitor from Cambridgeshire, who did not want to be named, is not convinced by the content of the programme: "I think in some areas of the country things will improve but in the majority it probably won't. They (the government) need to make sure the money is there and that they can enforce it."
Professor Sarah Cowley, a former health visitor and an expert in community practice development at King's College, says despite reservations about the government's strategy, she feels it can lead to progress.
"It is the best document I have ever seen come out of the Department of Health in 30 years of health visiting. But my worry is it is not going to correct the recruitment problem," says Cowley.
THE PROGRAMME
- The programme has four sections. Two contain a definition of the role and how health visitors should go about their work. A third gives evidence of the benefits of early intervention, with the final section focusing on increasing numbers
- The first section states that health visitors should lead on and deliver the Healthy Child Programme, and act as the named health visitor in Sure Start centres
- They should also support vulnerable families, use specialist skills to protect children and create and develop effective teams- A series of requirements are outlined that call on health visitors to, among other things, contribute to the design of evidence-based services
- A collection of relevant evidence has been collated to allow health visitors to impress the value of the role on commissioners
- The final section details variables that should be considered when arriving at caseload calculations such as demographics, indicators of inequality, workforce profiles, skills mix and desired outcomes
