Universal Health Visiting Pathway evaluation - phase 1: main report - primary research with health visitors and parents and case note review

Executive summary

Early years experiences and outcomes have long term impacts. Health and wellbeing pre-birth and during the first three years of life affect all aspects of health and wellbeing, social and emotional development and future learning and attainment. The early years (pre birth to age three) also provide the greatest opportunity to influence a child’s development. Health visitors are uniquely positioned to improve outcomes for all children and families and drive sensitive, responsive, care giving.

Historically, the role of health visitors has varied across and even within Health Boards in Scotland. To ensure consistency and maximise the impact of the service, in 2013 the then Chief Nursing Officer for Scotland, directed all Health Boards to enhance the specialist role of health visitors towards the delivery of preventative and targeted interventions, delivered by a health visitor workforce, better equipped to address the specific needs of children and families, in the first five years of life. Following the directive, the service has now been enhanced to follow a routine pathway for delivery (Universal Health Visiting Pathway (UHVP) and includes:

• a more structured home visiting service and refocused role from 0-5
• an increased number of home visits of at least eleven visits before the child enters school, with eight in the first year of life, including three child health reviews
• adaptation of the relevant post graduate education Specialist Community Public Health Nursing (SCPHN) to support the refocused role
• additional training of existing health visitors to support the new educational components
• sustainable recruitment of new health visitors.

In order to facilitate such significant changes in the service, the Scottish Government made an investment of £40 million over four years to enable the number of health visitors in Scotland to increase by at least 500 whole time equivalent (WTE) staff by the end of 2018. The Scottish Government then set a timeline for ensuring all families received the pathway, this was set as 1 Jan 2020. These substantial changes in the service model and increased investment in health visiting have necessitated an evaluation to assess the impact of the UHVP on outcomes for children and families and to enable identification of areas for improvement in the future.

To address the goals of the evaluation, a logic model was developed with stakeholders to outline the processes and relevant outcomes of the UHVP delivery. Following this, four main evaluation components were identified to assess the implementation processes and outcomes achieved over a 4 year evaluation period, across two phases. This included qualitative evaluation with parents and health visitors, a case note review, surveys with parents and health visitors and routine data analysis (findings from the routine data analysis will be published in separate reports). This publication reports the main findings from the primary research for Phase 1, where data collection occurred between May 2019 and September 2020. A total of 55 parents and 50 health visitors took part in one-to-one interviews and a further 33 health visitors took part in focus groups. A case note review was also undertaken which reviewed 73 health visitor records. In the survey, 554 health visitors and 550 parents responded.

This was a nation-wide evaluation across all Health Boards in Scotland. However, the qualitative evaluation and case note review were undertaken in five case study Health Boards (NHS Ayrshire and Arran, NHS Borders, NHS Grampian, NHS Lothian and NHS Tayside).

Below are the key findings of the primary research conducted as part of the evaluation are:

• All Health Boards in Scotland have adopted the UHVP, however the implementation of the pathway varied between Health Boards.
• By 1 January 2020 all Health Boards were delivering the pathway to new parents, and most were delivering all aspects of the pathway to their caseload.
• Almost all health visitors who responded to the survey said they were delivering the UHVP, with around half (47%) delivering it for one to three years.
• The majority of health visitors said they felt confident (90%) and skilled (91%) in their roles.
• As well as pathway visits, it was clear from the case note review that health visitors were providing a substantial number of additional visits to some families, often leading to increased paperwork and workload, which is concerning.
• Some additional visits seem to cluster at certain points between pathway visits, particularly, between the 3/4 month and 8 month home visits; and between 13-15 month and 27–30-month child health reviews, indicating a possible gap in the pathway between visits, which may need to be addressed.
• The majority of parents surveyed felt they developed a positive and trusting relationship with their health visitor. They found their health visitor to be approachable, non-judgmental, and professional and as a result, they felt very comfortable approaching health visitors with questions or concerns.
• The main aspects of the pathway attributed to building positive and trusting relationship with families are the frequency of visits (particularly within the first 6 months), the antenatal visit, and the continuity of care and carer model.
• In the survey, more than a third (36%) of health visitors said that the pathway they were delivering enabled them to identify concerns about a child at an early stage ‘very well.’ A further 57% felt the pathway did this ‘fairly well’ while 4% said it did not do this ‘very’ or ‘at all’ well.
• Eight in ten parents (81%) agreed that their health visitor listens to their concerns either ‘very’ (51%) or ‘fairly’ (30%) well. This is positive for the pathway.
• The survey examined the extent to which parents felt their health visitors had provided them with information about certain topics. A high proportion (77%) of parents felt well informed and knew ‘a great deal’ or ‘a fair amount’ about how to manage their own mental health and wellbeing.
• In the survey, half (50%) of the health visitors felt that the UHVP has had a positive impact on providing opportunities to work with other agencies, 43% felt it had made no difference one way or the other while 5% felt the impact had been negative.
• Health visitors who were positive that the pathway created more opportunities to work with other agencies explained in the qualitative interviews and focus groups that the frequent visits embedded within the pathway promoted timely and appropriate referrals to relevant agencies.
• The frequency of the pathway visits facilitates timely referrals to relevant services. However, in some instances, services for onward referrals such as speech and language therapy may not be available or accessible to families, and this appears to be a challenge that the needs to be addressed.
• The COVID-19 pandemic (COVID-19 is a respiratory disease caused by SARS-CoV-2, a new coronavirus discovered in 2019) led to a series of national lockdowns in Scotland. The first lockdown started on 23^rd March 2021 and relaxation of lockdown restrictions began on 29^th May 2020. The survey of parents took place between 12 August to 17 September 2020. Positively, around two thirds of parents (69%) were satisfied with the health visiting service they had received before the onset of the COVID-19 pandemic, with 37% saying they were very satisfied and 32% fairly satisfied. Just over one in ten parents (12%) were dissatisfied with the service they had received (7% ‘fairly’ and 4% ‘very’) while 18% were neither satisfied or dissatisfied and 2% said they did not know.

The following areas may require further consideration:

• The antenatal visit should be prioritised in the pathway schedule, because of its role in building positive and trusting relationships between families and health visitors, as well as facilitating the earlier identification of concerns relating to maternal mental health.
• The pathway should be considered in terms of perceived gaps in the visit schedule. Additional visits could be introduced at 6 months and 18 months.
• The substantial number of additional visits health visitors provide to families outside the core visits should be adequately monitored and incorporated into their workload planning.
• At times services for onward referrals such as speech and language therapy may not be available or accessible to families. It might be helpful to develop robust referral strategies in conjunction with such services to ensure families receive timely support.
• More efficient ways of reducing or simplifying documentation and paperwork should be explored.